A diet enriched in eicosapentanoic acid, gamma-linolenic acid and antioxidants in the prevention of new pressure ulcer formation in critically ill patients with acute lung injury: A randomized, prospective, controlled study

  • Miryam Theilla
    Affiliations
    Department of General Intensive Care, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel

    The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Pierre Singer
    Correspondence
    Corresponding author. Department of General Intensive Care, Rabin Medical Center, Beilinson Campus, Kaplan Street, Petah Tiqva 49100, Israel. Tel.: +97239376521; fax: +97239232333.
    Affiliations
    Department of General Intensive Care, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel

    The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Jonathan Cohen
    Affiliations
    Department of General Intensive Care, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel

    The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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  • Freda DeKeyser
    Affiliations
    Nursing School, Jerusalem, Israel
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      Summary

      Background & aims

      Pressure ulcers are a significant burden in the ICU. Many factors have found to be associated with pressure ulcers including malnutrition. While it has been recognized that high protein diets decrease the incidence of pressure ulcers, the role of lipids as well as vitamins and antioxidants remains unclear. The aim of this study was to evaluate the preventive and healing effects of an enteral diet enriched in eicosapentanoic acid (EPA) and gamma-linolenic acid (GLA) and vitamins (vitamins A, C and E) on pressure ulcers.

      Methods

      One hundred patients with acute lung injury were included in a larger study evaluating the effects of lipids and vitamins on respiratory function. A secondary end point, occurrence and healing of pressure ulcers was included. A diet enriched in lipids (EPA, GLA) and vitamins (vitamins A, C and E) was compared with a diet similar in macronutrient composition. The occurrence and healing of pressure ulcers was evaluated according to the National Pressure Ulcer Panel. Nutritional assessment included calorie intake, resting energy expenditure, levels of serum prealbumin, albumin, vitamins A and E, zinc and copper. C-reactive protein and procalcitonin were also measured.

      Results

      Patient's age, severity of disease and gender distribution were similar in the two groups. The study group had a higher body mass index. At baseline, the pressure ulcer score was similar in the two groups A significantly lower rate of occurrence of new pressure ulcers was observed in the study group compared to the control group (p<0.05). No difference was observed in the healing of existing pressure ulcers in the study as opposed to the control group. There was no significant difference in the nutritional parameters between the two groups.

      Conclusions

      A diet enriched with EPA, GLA and vitamins A, C and E is associated with a significantly lower occurrence of new pressure ulcers in critically ill patients with acute lung injury.

      Keywords

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      References

        • Bouten C.V.
        • Oomens C.W.
        • Baajens F.P.
        • Bader D.L.
        The etiology of pressure ulcers: skin deep or muscle bound?.
        Arch Phys Med Rehabil. 2003; 84: 616
        • Reddy M.
        • Gill S.S.
        • Rochon P.A.
        Preventing pressure ulcers: a systematic review.
        J Am Med Assoc. 2006; 296: 974-984
        • Singer P.
        Nutritional care to prevent and heal pressure ulcers.
        Isr Med Assoc J. 2002; 4: 713-716
        • Ek A.C.
        • Unosson M.
        • Larsson J.
        • Von schenck H.
        • Bjurulf P.
        The development and healing of pressure ulcers related to the nutritional state.
        Clin Nutr. 1991; 10: 245
        • Thomas D.R.
        The role of nutrition in prevention and healing of pressure ulcers.
        Clin Geriatr Med. 1997; 13: 497
      1. Pressure ulcer prevention guidelines and pressure ulcer treatment guidelines. European Pressure Ulcer Advisory Panel (EPUAP) 2001 〈www.epuap.org〉.

        • Schols J.M.G.
        • de Jager-vd Ende M.A.
        Nutritional intervention in pressure ulcer guidelines: an inventory.
        Nutrition. 2004; 20: 548-553
        • Desbeves K.J.
        • Todorovic B.E.
        • Cassar A.
        • Crowe T.C.
        Treatment with supplementary arginine, vitamin C and zinc in patients with pressure ulcers: a randomized controlled trial.
        Clin Nutr. 2005; 24: 979-987
        • Singer P.
        • Theilla M.
        • Fisher H.
        • Gibstein L.
        • Grozovski E.
        • Cohen J.
        Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury.
        Crit Care Med. 2006; 34 (erratum 1861): 1033-1038
        • Knaus W.A.
        • Draper E.A.
        • Wagner D.P.
        • Zimmerman J.E.
        APACHE II: a severity of disease classification system.
        Crit Care Med. 1985; 13: 818-829
        • Farreras N.
        • Artigas V.
        • Cardona D.
        • Rius X.
        • Trias M.
        • Gonzalez J.A.
        Effects of early postoperative enteral immunonutrition on wound healing in patients undergoing surgery for gastric cancer.
        Clin Nutr. 2005; 24: 55-65
        • Mayser P.
        • Mayer K.
        • Mahloudjina M.
        • et al.
        A double-blind, randomized, placebo-controlled trial of n-3 vs. n-6 fatty acid-based lipid infusion in atopic dermatitis.
        J Parenter Enteral Nutr. 2002; 26: 151-158
        • Arnold M.
        • Barbul A.
        Nutrition and wound healing.
        Plat Reconstr Surg. 2006; 117: 42S-57S
        • Singer A.J.
        • Clark R.A.
        Cutaneous wound healing.
        N Engl J Med. 1999; 341: 738-746
        • Van den Berghe G.
        • Wouters P.
        • Weekers F.
        • et al.
        Intensive insulin therapy in critically ill patients.
        N Eng J Med. 2001; 345: 1359-1367
        • Undurti N.Das.
        Essential fatty acids: biochemistry, physiology and pathology.
        Biotechnol J. 2006; 1: 420-439
        • Gadek J.E.
        • DeMichele S.J.
        • Karlstad M.D.
        • et al.
        Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral nutrition in ARDS group.
        Crit Care Med. 1999; 27: 1409-1420
        • Mayer K.
        • Meyer S.
        • Reinholz-Muhly M.
        • et al.
        Short-time infusion of fish oil-based lipid emulsions, approved for parenteral nutrition, reduces monocyte proinflammatory cytokine generation and adhesive interaction with endothelium in humans.
        J Immunol. 2003; 171: 4837-4843
        • Grimm H.
        • Mayer K.
        • Mayser P.
        • Eigenbrodt E.
        Regulatory potential of n-3 fatty acids in immunological and inflammatory processes.
        Br J Nutr. 2002; 87: S59-S67
        • Lee J.Y.
        • Sohn K.H.
        • Rhee S.H.
        • Hwang D.
        Saturated fatty acids, but not unsaturated fatty acids, induce the expression of cyclooxygenase-2 mediated through toll-like receptor 4.
        J Biol Chem. 2001; 20: 16683-16689
        • Mc Murray D.N.
        • Jolly C.A.
        • Chapkin R.S.
        Effects of dietary n-3 fatty acids on T cell activation and T cell receptor-mediated signalin in a murine model.
        J Infect Dis. 2000; 182: S103-S107
        • Tsirogianni A.K.
        • Moutsopoulos N.M.
        • Moutsopoulos H.M.
        Wound healing: immunological aspects.
        Injury Int J Care Injured. 2006; 37S: S5-S12
        • Koch T.
        • Heller A.
        Outcome-effects of parenteral nutrition with omega-3 fatty acids—a multicenter observation in 661 patients.
        Aktuel Ernaehr Med. 2005; 30: 15-22
        • Gercek A.
        • Yildirim A.
        • Konya D.
        • et al.
        Effects of parenteral fish–oil emulsion (Omegaven) on cutaneous wound healing in rats treated with Dexamethasone.
        J Parenter Enteral Nut. 2007; 31: 161-166