Nutrition, or rather the new USDA Dietary Guidelines, have been in the news this week. It seem apropos to take not of a recent article in the supplement to the January issue of the Plastic and Reconstructive Surgery Journal discussing nutrition and wound healing (full reference below).
The article presents an update on new developments in the field of nutrition and wound healing, not an exhaustive review of the field.
As the authors point out “most operations in well-nourished patients are successful, with uncomplicated healing responses, even if nutritional intake is absent or curtailed for 7 to 10 days.” It’s the patient with trauma, cancer, chronic illnesses, mal-absorption issues where this is most important.
First and foremost, the nutritional assessment should begin with a complete history and physical. The authors reference the second article below for this statistic:
This alone has been found to be 80 to 90 percent accurate in evaluating patient nutritional status, and the addition of multiple or complex biochemical, immune, or anthropometric measurements does not increase greatly the accuracy of nutritional assessment.
Malnutrition should be considered if the history reveals unintentional weight loss (20% weight loss is indicative of severe malnutrition), if the patient appears cachectic with obvious muscle wasting, or if the patient has a history of or reason for alimentary malabsorption. It must also be remembered that Obese Patients are at High Risk for Malnutrition in the Hospitalized Setting.
If the patient is found to be malnourished prior to an elective surgery, this should be corrected. As the authors point out:
Determining who would truly benefit from nutritional supplementation is still a matter of some debate, but there is evidence that preoperative nutritional support reduces infectious complications and anastomotic breakdown in severely malnourished patients undergoing major elective surgery.
Postoperative nutritional support should be considered in patients expected to be unable to eat for a period of at least 2 weeks.
Other key points from the article:
- Enteral feeding is superior to parenteral feeding when possible.
- Fish oil supplements (omega-3 fatty acids) adversely impacts the healing response.
- Vitamin C deficiency, in addition to impairing wound healing, has also been associated with an increased susceptibility to wound infection. Burn victims require as much as 1 to 2 g/day to restore urine and tissue levels to normal.
- Vitamin A deficiency impairs wound healing. Vitamin A, administered either topically or systemically, reverses the antiinflammatory effects of corticosteroids on wound healing.
- The antiinflammatory properties of vitamin E are similar to those of steroids. Vitamin A can reverse the wound-healing impairment induced by vitamin E. Vitamin E has also been shown to affect various host immune functions, often in a negative fashion.
- Zinc deficiency impairs the critical roles each of these processes play in wound healing. Zinc levels less than 100 μg/dl have been associated with decreased fibroblast proliferation and collagen synthesis.
Herbal Supplements and Surgery Reviewed (April 30, 2009)
Local Wound Care for Malignant and Palliative Wounds – an Article Review (September 13, 2010)
Nutrition and Wound Healing: An Update; Kavalukas, Sandra L.; Barbul, Adrian; Plastic & Reconstructive Surgery. 127():38S-43S, January 2011; doi: 10.1097/PRS.0b013e318201256c
Assessment of nutritional status; Jeejeebhoy KN, Detsky AS, Baker JP.; JPEN J Parenter Enteral Nutr. 1990;14:193S–196S.