Contraction 174

Epithelialization 175

Connective Tissue 175

Protein 179

Amino Acids 179

Dextrose and Lipid 180

Micronutrients 181

Electrolytes and Wound Healing 181

Vitamins and Wound Healing 182

Trace Elements 183

Boron 187

Chromium 187

Copper 191

Iodine 194

Iron 195

Manganese 196

Selenium 196

Silicon 197

Silver 197

Zinc 197

Metallothionein 199

Trace Element Implications in Wound Repair 201

Trace Element and Inflammatory Phase Implications 202

Trace Element and Proliferation Phase Implications 206

Trace Element and Remodeling Phase Implications 208

Recommendations for Supplementation and Avoiding Toxicity 210

Future Directions 211

References 211

Wound healing is a complex, tightly regulated process, consisting of three distinct phases. In each phase of wound healing, macronutrients and micronutrients are required. In other chapters of this book, the other macronutrients and micronutrients are discussed, but the complex interaction of trace elements with all other nutrients merits some additional review here. Chronic wounds (such as pressure ulcers) have been extensively investigated as to the risk of development, prevention, and cure. The combination of chronic wounds and malnutrition in the aged is particularly unfortunate. Malnutrition is frequently associated with skin anergy and immobility because of mental apathy and muscle wasting. Further, impaired nutritional intake and the risk of pressure ulcer formation are interrelated.

When considering nutritional support, oral supplementation should be weighed against tube feeding, as the associated morbidity of tube feeding (i.e., insufficient intake because of procedures, aspiration risk, diarrhea, constipation, translocation liability, and restricted mobility) might obscure the favorable effects of adequate nutrition. Total parenteral nutrition (TPN) should be used when the gastrointestinal tract cannot be used or cannot be used enough.

Attention should be focused on early recognition of a depleted nutritional status and an adequate and supervised intake of the following:

• Protein (up to 1 g of oral or enteral amino acids [AAs]/kg/d or up to 2 g parenteral AA/kg/d) with provision of the recommended daily allowances of micronutrients that will usually will require 1 to 1.5 l of any selected enteral feeding formula1

Parenteral nutrition should be reserved for the patient who cannot enterally ingest or cannot enterally eat enough.

Pressure ulcers affect one out of ten patients in hospitals, and older people are at highest risk for decubitus. The correlation between the lack of nutritional intake and the development of pressure ulcers is supported by several studies, but the results are inconsonant. Although it is difficult to draw any firm conclusions on the effect of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers,2 nutrition support intuitively provides precursors for every messenger mediator involved in the healing process and consequently plays a key role in the process of healing.

Primary wound healing mechanisms are contraction, epithelialization, and connective tissue deposition. In turn, micronutrients (electrolytes, trace elements, and vitamins) are intimately related to all of these physiologic responses in wound healing.

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Constipation Prescription

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