Editor's note:This blog post is part of the WoundSource Trending Topics series, bringing you insight into the latest clinical issues and advancement in wound management, with contributions by the WoundSource Editorial Advisory Board.

Pressure injuries (pressure ulcers) claim over 60,000 lives and affect over 2.5 million Americans each year. The US health care system spends $9.1–11.6 billion annually in the treatment of pressure injuries.¹ Aside from the financial cost, pressure injury is a devastating health concern that affects quality of life and well-being. Benchmarked by regulatory agencies as a quality of care indicator, pressure injuries are deemed preventable events. Incorporating evidence-based guidelines of care for the prevention or treatment of pressure injuries and implementing best practices help to lessen the prevalence of pressure injuries.²

Nutrition and Pressure Injuries

Multiple intrinsic and extrinsic factors affect the healing process in pressure injuries. The presence of malnutrition, inadequate diet intake, unintentional weight loss, low weight, and low body mass index have been acknowledged as independent risk factors for both the development of pressure injuries, as well as for delayed wound healing.^2,3 Those patients identified as being at risk for developing pressure injuries should undergo nutritional status screening to identify the need for further nutrition assessment. It is not uncommon for individuals with pressure injuries or at risk for developing pressure injuries to be nutritionally compromised.⁴ Reduced food and fluid intake, a hypermetabolic state secondary to disease process, nutrient loss, and malabsorption are some of the most common factors contributing to a compromised nutritional status. Because many nutrients play a role in the pressure injury healing process, providing individuals who cannot meet their nutritional needs with diet alone with a nutritional supplement is an appropriate intervention.² The use of oral nutrition supplements with a high protein content is common practice in daily pressure injury care.

Arginine: Function and Principles of Supplementation

Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, released in 2014, goes a step further and makes a recommendation for supplementation with high protein, arginine, and micronutrients for adults with a stage 3 or 4 pressure injury or multiple pressure injuries when nutritional requirements cannot be met with traditional high-calorie and protein supplements.² Arginine is a conditionally indispensable amino acid. As such, it is synthesized in healthy humans. Additional arginine is needed during periods of stress and in the presence of injury, including burns, other skin injuries, and certain diseases.

Each gram of dietary protein provides approximately 54mg of arginine. This varies depending on the type of food. Also, arginine loss occurs during cooking. It is estimated that on average, 4g–5g of arginine are consumed through a regular diet on a daily basis. In addition, the kidney synthesizes an additional 2g of arginine per day.⁵ Nitric oxide is generated from arginine. Nitric oxide regulates blood flow. Research supports that the presence of arginine increases blood flow to limbs of healthy and diseased individuals.⁶ Arginine also stimulates the release of growth hormone and insulin-like growth factor, both of which are linked to improved wound healing. Arginine can enhance wound strength and collagen deposition. A recent literature review by Neyens et al.⁷ examined 11 clinical studies. Ten of the studies reviewed supported a positive effect of nutritional supplementation with additional protein, arginine, and micronutrients.⁷

Clinical Application of Arginine Supplementation

As previously mentioned, the presence of pressure injuries can be a devastating health problem. Nutritional status has an impact on pressure injury development and healing. Guidelines of care and recent research support the use of oral nutritional supplements to promote adequate nutrition and wound healing. Selection of a supplement should be individualized to meet the patient's unique needs. As practitioners, we have a wide range of products to choose from. Every protocol should start by providing food interventions first (using fortified foods). Additional commercial supplements should be used when the nutritional needs of the patient cannot be met with diet alone. When selecting an arginine supplement, keep in mind that most of the research trials conducted included a product enriched with protein, arginine, and micronutrients. Oral nutrition supplements utilized in research protocols contained anywhere from 3g to 9g of arginine.⁷

Conclusion

Given the prevalence of inadequate nutrition in patients with pressure injuries, the use of high-protein oral nutrition supplements is common practice in the daily care of these patients. Additional arginine is needed in the presence of injury and therefore is recommended as a component of oral nutritional supplements for patients with pressure injuries.

References

1. Padula WV, Pronovost PJ. Addressing the multisectoral impact of pressure injuries in the USA, UK and abroad. BMJ Qual Saf. 2018;27:171-173.

2. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance, Haesler E, eds. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Perth, Australia: Cambridge Media; 2014.

3. Iizaka S, Kaitani T, Nakagami G, Sugama J, Sanada H. Clinical validity of the estimated energy requirement and the average protein requirement for nutritional status change and wound healing in older patients with pressure ulcers: a multicenter prospective cohort study. Geriatr Gerontol Int. 2015;15:1201-1209.

4. Banks MD, Bauer JD, Graves N AS. Malnutrition and pressure ulcer risk in adults in Australian healthcare facilities. Nutrition. 2010;26:896-901.

5. Brosnan ME, Brosnan JT. Renal arginine metabolism. J Nutr. 2004;134(10 Suppl):2791S-2795S.

6. Booi DI, Debats IB, Deutz NE, Van der Hulst RR. Arginine improves microcirculation in the free transverse rectus abdominis myocutaneous flap after breast reconstruction: a randomized, double-blind clinical trial. Plast Reconstr Surg. 2011;127:2216.

7. Neyens JCL, Cereda E, Meijer EP, Lindholm C, Schols JMGA. Arginine-enriched oral nutritional supplementation in the treatment of pressure ulcers: a literature review. Wound Med. 2017;16:46-51.

About the Author

Dr. Nancy Munoz is the Assistant Chief for Nutrition and Food Service for the Southern Nevada VA Healthcare System. Teaching healthcare practitioners the role of nutrition as a modifiable risk in the development of pressure ulcers is at the core of her practice. Dr. Munoz has authored and served as expert reviewer for books and manuscripts for numerous professional publications, and the Academy of Nutrition Evidence Analysis Library. She currently serves as the Professional Development Chair for the Dietetics in Healthcare Communities DPG, is a member of the Academy’s Positions Committe and the WoundSource editorial advisory board, and is the current Vice President for the National Pressure Ulcer Advisory Panel.