Nutrition and Wound Healing | Midwest Sinus and Allergy

MILD MALNUTRITION WT LOSS > 10 % TRANSFERRIN (T1/2=8DAYS) < 175 ALBUMIN (T1/2=20DAYS)< 3.4 PREALBUMIN AND RETINOL BINDING PROTIEN MAY BE OF SOME HELP ANERGY (ASK FOR AN ANERGY SKIN PANEL TO BE PLACED AND READ)

SEVERE MALNUTRITION WEIGHT LOSS > 15%—MUCH HIGHER RISK FOR POST OP COMPLICATIONS TRANSFERRIN (T1/2=8 DAYS) = THE EARLIEST OBJ MEASURE OF PROTEIN ANABOLISM AND CATABOLISM, <100 = SEVERE ALBUMIN(T1/2=20 DAYS) < 2 = SEVERE SERUM LYMPHOCYTES < 800/MM3 = SEVERE

CRITICAL WEIGHT LOSS > 30 % = BRAIN IS RELATIVELY RESISTANT TO STARVATION PRIMARY CAUSE OF DEATH SECONDARY TO MALNUTRITION = INFXN (PNEUMONIA) IF THE GUT WORKS—USE IT DO NOT BOLUS THE DUODENUM ILEUS RETURNS–S.I.(BS)—STOMACH—L.I. (PASS GAS) PROBABLY KEEP ON ZANTAC UNTIL T.F.’S WELL ESTABLISHED KEEP HOB > 30 DEGREES CONSIDER CISAPRIDE 10 MG PT QID PRIMARY COMPLICATION OF TUBE FEEDS = DIARRHEA (CHECK C. DIFF TOX) NEXT COMP IS PROBABLY HYPERGLYCEMIA (DKA VS HOC) CHECK CHEMSTICKS Q 6 OR TID WHEN ON TF’S, SWITCH TO AC AND HS WHEN ON REGULAR DIET (ADA) THE AMINO ACID GLUTAMINE SEEMS TO PROMOTE GI MAINTENANCE ETOH—-FOLATE, THIAMINE=B1, B3(NIACIN), B6, B12, ATIVAN “BANANNA BAG”, ATIVAN OR LIBRIUM IF RENAL FAILURE—USE LESS FLUID, K+, PROTEIN, AND DRUGS (CIMETIDINE/ZANTAC) ALWAYS CHECK ELECTROLYTES—ESPECIALLY MG++ AS THIS IS VERY IMPORTANT—-ALSO PHOS—ATP ALWAYS CHECK THYROID STATUS AND THIS EFFECTS ALL TISSUE RESPONSE ALCOHOLICS USE THE CORI CYCLE–GLUCOSE TO LACTATE INSTEAD OF THE KREBS CYCLE TUMORS DEPEND ON GLUCOSE FOR ENERGY AND CANNOT USE FAT—MUSCLE IS BROKEN DOWN INTO AMINO ACIDS TO SYNTHESIZE GLUCOSE (GLUCONEOGENESIS) CANCER PTS HAVE INCREASED FFA SECONDARY TO AN INCREASE IN HEPATIC KETOGENESIS—FFA IMPAIR TISSUE RESPONSIVENESS TO INSULIN RESULTING IN MUSCLE WASTING—-MOST EVIDENT IN THE QUADRICEPTS AND DELTOIDS CHEILOSIS, AND STOMATITIS AND DRY SCALING SKIN—-SUGGEST VITAMIN DEFEICIENCY GET A DIETARY CONSULT EARLY–-MAY SAVE YOU COMPLICATIONS

HARRISON-BENEDICT EQUATION DETERMINES CALORIC NEEDS—-BASICALLY NEED 50% MORE THAN THEIR BASAL RATE GENERALLY RECOMMEND A MULTIVITAMIN WITHOUT IRON, 500 MG VIT C, AND VIT E REQUIREMENTS: ROUGH ESTIMATE = 35 KCAL/KG/DAY NL ADULT CAN LIVE MONTHS WITHOUT FOOD BURN (HYPER METABOLIC—DIE IN ABOUT 3 WEEKS OF STARVATION) 1 KCAL = AMOUNT OF HEAT NECESSARY TO RAISE TEMP OF 1 KG OF H2O AT 1 ATM PRESSURE 1 DEGREE CELSIUS NITROGEN = PROTEIN GRAMS/6.25 (CATABOLIC PT REQUIRES 120-150 CAL/GRAM OF NITROGEN 1 GM NITROGEN/120-150 NON-POTEEN CALORIES = 1.5-2.0 G/KG/DAY—-CALORIE/NITROGEN RATIO MUST BE ADEQUATE TO RESTORE PROTEIN STORES—-120-180:1 TOO MUCH CARBS CAN MAKE VENT WEANING HARD AND EXASSERBATE COPD

VITAMINS B1/THIAMINE—-BERI-BERI (INFANTILE=TACHY, VOMITING, CONVULSION),(ADULT=DRY SKIN, IRRITABLE, DISORDERED THOUGHT), WERNICKE’S ENCEPHALOPATHY (ENCEPHALOPATHY, OCULAR(NYSTAGMUS,OPTHALMOPLEGIA), ATAXIA—--KORSAKOFF’S PSYCHOSIS (PERMANENT LOSS SHORT TERM MEMORY + FOOT/WRIST DROP, PARESTHESIAS AND AREFLEXIA)

B2/RIBOFLAVIN—DERMATITIS, CHEILOSIS, ATROPHIC GLOSSITIS, GINGIVOSTOMATITIS, DYSSEBACEA B3/NICOTINIC ACID (B3) NIACIN—PELLAGRA (DIARRHEA, DERMATITIS (CASAL’S NECKLACE), DEMENTIA—DEATH)—ANGULAR CHEILOSIS AND GLOSSOPYROSIS(BURNING TONGUE)

B6/PYRIDOXINE—SIDEROBLASTIC ANEMIA, ANGULAR CHELSOSIS—-CNS ABNL—CARPAL TUNNEL SYNDROME

VITAMIN C—COLLAGEN SYNTHESIS, SCURVY(SCORBITUS)—-ONLY DZ WHERE FULLY HEALED WOUNDS CAN DEHISS–BLEEDING AND SWOLLEN GUMS, IRON ABSORPTION (IDA), OXALATE (KIDNEY STONES)—COENZYME FOR PROLINE HYDROXYLASE AND LYSINE HYDROXYLASE (VIT C INCREASES THE ABSORBTION OF ALUMINUM—-BEWARE OR ALUMINUM CANTAINING ANTACIDS)

B12/COBALAMINE—SYNTHESIZED ONLY BY BACTERIA (ANTAGONIZED BY DIPHILIBOTHERUM LATUM (TAPE/FISH WORM))—-NEED R-PROTEIN FROM STOMACH AND ABSORBED TERMINAL ILEUM—CAUSES SUB ACUTE SCLEROSING CORD DEGENERATION—-SECONDARY FOLATE DEFICIENCY—-MEGALOBLASTIC ANEMIA—-GLOSSITIS FOLATE—PRIMARY DEFICIENCE IN USA—STORED IN RBC’S MEGALOBLASTIC ANEMIA, GROWTH FAILURE, PURINE METABOLISM—-PRIMARY DEFEICEINCY IN USA—NEURAL TUBE AND CARDIOVASCULAR ABNL MEGALOBLASTS ALSO INCREASE THE RDW—ANISOCYTOSIS FAT SOLUBLE—MEANS CAN GET TOXIC LEVELS VIT E—FIBROBLAST GROWTH, PMN FUNCTION, NERVE GROWTH, PLATELET FUNCTION, ANTIOXIDANT—–MEGADOSES(>400 IU Q D)—–LEAD TO INCREASED BLEEDING

VIT A—COUNTERACTS THE EFFECTS OF STEROIDS ON WOUND HEALING, IMPORTANT IN ROD FUNCTION (NIGHT VISION)/NYCTALOPIA, EPITHELIAL CELL FUNCTION AND MUCOUS SECRETION (XEROPHTHALMIA)—MAY REVERSE THE ANTI-INFLAMMATORY EFFECTS OF THE STEROIDS AS WELL Wound healing–steroids/vit E—-vit A 25,000-50,000 iu qd, zinc, vit C topical vit a —- -scar contracture

VIT D—CALCIUM METABOLISM (RICKETS/OSTEOMALACIA)
RICKETTES = A PEDIATRIC Dz—PIGEON BREAST, RACHITIC ROSARY (ENLARGEMENT OF THE COSTOCHONDRAL JUNCTIONS—LIKE BEADS OF A ROSARY), BOWED LEGS, LUMBAR LORDOSIS, DELAYED CLOSURE OF FONTENELLES AND EPIPHYSEAL PLATES. OSTEOMALACIA=AN ADULT Dz THE FINAL CONVERSION OF VIT D TO THE ACTIVE FORM IS VIA THE KIDNEY (SO RENAL FAILURE IS THE PRIMARY CAUSE OF DEFIECENCY—LOW CA++ AND HIGH PHOS) ALSO MALNUTRITION, MALABSORBTION (ADEK) AND LACK OF UV (SUN) EXPOSURE PANTOTHENIC ACID—-FATTY ACID SYNTHASE(CAN GET IDA)

VIT K-—HEMOSTASIS, JAUNDICE—LONG TERM ABX CAN LEAD TO POOR VIT K ABSORBTION ESSENTIAL FATTY ACIDS OMEGA 3—LINOLENIC ACID—-MARINE PHYTOPLANKTON (NOT IN FARMED FISH) OMEGA 6—LINOLEIC ACID—PLANTS MINERALS AND TRACE ELEMENTS—COFACTORS IN DETOXIFICATION PATHWAYS IRON (FE+++)—DEFIECENCY GIVES A MICROCYTIC/HYPOCHROMIC ANEMIA—ALSO A RETICULOCYTOSIS AND ANISOCYTOSIS WITH ALL ANEMIAS CHECK INDICES—MACROCYTOSIS—THINK FOLATE/B12—MICROCYTOSIS THINK IRON GLUTAMINE—GI TRACT MAINTENANCE (ENTEROCYTES PREFERENTIALLY OXIDIZE GLUTAMINE)

ZINC–CELL DIVISION, FUNCTION (TASTE/ OLFACTION),COLLAGEN SYNTHESIS (WOUND HEALING)—ZICAM FOR COLDS—-CAN LOOK LIKE CHRONIC ILLNESS—ACRODERMATITIS ENTEROPATHICA—-ANOSMIA—START H&N PTS ON EMPIRICALLY TO AVOID FISTULA

COPPER—-WILSONS—-ZINC LESSENS COPPER ABSORBTION CHROMIUM--GLUCOSE TRANSPORT/METABOLISM—DEFIECENCY CAN LEAD TO A DIABETIC PICTURE, ALSO FATIGUE

FLUORIDE—SOLIDIFY BONE AND TEETH—SUPPOSEDLY STABILIZES OTOSPONGIOTIC LESIONS

ARGININE—+ COLLAGEN SYNTHESIS BIOTIN—DERMATITIS, GLOSSITIS, ANOREXIA, NAUSEA

MG++—VERY IMPORTANT IN CALCIUM METABOLISM—REQUIRED BOTH FOR THE SECRETION AND END ORGAN ACTION OF PTH—-GIVE IV/IM MGSO4 OR PO MG-GLUCONATE SODAS—LEAD TO HIGH LEVELS OF

PO4—WHICH POTENTIATES PTH SECRETION AND OSTEOPOROSIS

WOUND HEALING 3 PHASES: FIRST PRIORITY=HEMOSTATIC PLUG

INFLAMMATORY PHASE (COAGULATIVE, LAG, SUBSTRATE, EXUDATIVE) LAST UNTIL WOUND EPITHELIALIZED (1MM/DAY)—MAY BE DELAYED IN SECONDARY HEALING—PROBABLY GOOD TO HAVE ON ABX FOR ABOUT 5 DAYS IF AN INFECTED WOUND PMN MIGRATION–ANGIOGENESIS AND BEGINNING OF GT—-NOT MUCH INCREASE IN TENSILE STRENGTH ————–3-5 DAYS————–

PROLIFERATIVE PHASE (COLLAGEN, FIBROBLAST) NEOVASCULARIZATION AND COLLAGEN DEPOSITION—-TYPE III COLLAGEN—-KELOIDS AND HYPERTROPHIC SCARS ARE LARGELY TYPE III COLLLAGEN—-INJECT WITH KENALOG (SEE KELOID) STRENGTH UP TO 50% AT 4 WEEKS AND 75% AT 8 WEEKS ————-3-5 WEEKS————-

CONTRACTION PHASE (REMODELING, MATURATION) TYPE III REPLACED BY TYPE I COLLAGEN, CROSSLINKING, CONTRACTURE AND REMODELING–NO NET GAIN IN COLLAGEN BUT THERE IS A NET STRENGTH GAIN—–SCAR SOFTENS LASTS UP TO A YEAR—-WOUND NEVER REGAINS ALL OF ITS STRENGTH BUT PROBABLY > 80%—-CERTAINLY WOULD NOT DO A SCAR REVISION ANY SOONER THAN 6-8 MONTHS WOUND STRENGHT—5% AT 1 WK, 10% AT 2 WEEKS, 25% AT 4 WEEKS, 40% AT 6 WEEKS, 80% AT 10 WEEKS—-NEVER ANY BETTER THAN 80% HEALING ANTAGONISTS: SMOKING/ISCHEMIA, DESSICATION, IFN-GAMMA, INFXN—GREATER THAN 105 MICROBES/GRAM OF TISSUE—-(REMOTE INFXN INCREASES LIKELIHOOD OF WOUND INFXN 3 X)—-CANDIDA SUPERINFXN IS THE BIGGEST REASON FOR DELAYED SECONDARY HEALING, HYPOXEMIA (LOW P02—NOT SAT)—OFTEN THE RESULT OF LOCAL WOUND EDEMA (CONSIDER PRE AND POST OP DECADRON TO LESSEN THIS), DM (POOR CHEMOTAXIS UNRELATED TO SUGARS), AGE, STEROIDS, RADIATION, HYDROGEN CYANIDE IN CIGARETTE SMOKE INHIBITS OXIDATIVE ENZYMES WOUNDS ARE WEAKEST AT ABOUT 5-7 DAYS–MOST LIKELY TO DEHISS EHRLERS-DANLOS SYNDROME–11 TYPES (AUTO D, AUTO R, X-LINKED RECESSIVE) ABNL COLLAGEN BIOSYNTHESIS HYPEREXTESIBILITY OF SKIN AND JOINTS, DELAYED WOUND HEALING--POOR HEALING–DECREASED WOUND STRENGTH-PRONE TO WOUND DEHISSENCE—FORM BROAD SHINEY SCARS RESEMBLING CIGARETTE PAPER, EASY BRUISABILITY 50% ABILITY TO TOUCH TIP OF NOSE WITH TONGUE (VS 10% NL POP)—GORLIN’S SIGN HEALING AGONISTS: HYPERBARIC 02 (HIGH Po2 SEEMS TO HELP—-SAT DOESN’T COUNT), SOME TENSION SPEEDS HEALING (WOLF’S LAW—-ELECTRON INDUCED FIELD—TENSION LEADS TO HYPERTROPHIC SCARS), ZINC (CELL DIVISION, FUNCTION, AND COLLAGEN SYNTHESIS), VIT C (COFACTOR FOR PROLINE AND LYSINE HYDROXYLASE–COLLAGEN SYNTHESIS) ASCORBIC ACID 500 MG P.O. QD, VIT E (FIBROBLAST GROWTH), VIT B 1, 2,6,12 (COFACTORS), VIT A—COUNTERACTS THE NEG EFFECTS OF STEROIDS (RETINOL/VIT A 25.000-50,000 IU P.O. Q D), ARGININE (PROMOTES COLLAGEN SYNTHESIS) TIGHT CONTROL OF SUGARS, MAINTAIN HCT AT OR ABOVE 30, MAINTAIN ADEQUATE THYROXINE LEVELS TRANSFORMING GROWTH FACTOR-BETA–A MACROPHAGE PRODUCT—STIMULATES FIBROBLAST AND KERITINOCYTE MIGRATION AND COLLAGEN DEPOSITION PDGF—SECRETED FROM PLTS DURING THE INITIAL THROMBUS FORMATION PROBABLY A GOOD IDEA TO GIVE MULTIVITAMIN (MVI) 1 PO QD WITH IRON—–SEE SKIN CARE FOR TOPICALS FOR PTS WITH COAGULOPATHIES ECT… MAY CONSIDER AN AUTOLYTIC OR ENZYMATIC CREAM FOR CHEMICAL DEBRIDEMENT FOR INFECTED WOUNDS DEBRIDE WITH 1/4 STRENGTH DAKINS DSG CHANGES FOR ENDORAL LESIONS UTILIZE PERIDEX OR THIRDS SOLUTION RINSES CLEAN WOUNDS HEAL AND EPITHELIALIZE BEST UNDER AN OCCLUSIVE DSG—HOWEVER MUST BALANCE THIS WITH THE RISK OF INFXN—-DRY OPEN WOUNDS HEAL SECOND BEST WITH MUCH LESS RISK OF INFXN—-INFECTED WOUNDS DO NOT HEAL WELL—–IT IS HARD TO BEAT AN OPEN WOUND CLOSED WITH A NON-ABSORBABLE MONOFILAMENT

ALWAYS PROTECT FROM THE SUN NON HEALING WOUND OR FISTULA F—FOREIGN BODY E—-EPITHELIALIZATION T—–TUMOR (THE MOST IMPORTANT TO RULE OUT I—–INFXN (THE MOST COMMON)—REALLY A QUANTITATIVE THING > 100,000 M/O PER GRAM OF TISSUE IMPEDE THINGS D—-DISTAL OBST—-NOT COMMON IN THE H&N IF AT ALL CONCERNED ABOUT WOUND INFXN—-BEST TO USE NON-REACTIVE NYLONS, BREIF COARSE OF ABX, AND LEAVE IT OPEN—-H2O2 AND POLYSPORIN OINT QID FOR 3 DAYS AND THEN JUST H2O2 QID T ½ OF ABSORBABLES CAT GUT 1 WEEK CHROMITIZED CAT GUT 1-2 WEEKS VICRYL (BRAIDED) WEEKS DEXON (BRAIDED) WEEKS PDS (MONO) MONTHS MAXON (MONO) WEEKS TO MONTHS MONOCRYL (MONO) MONTHS

Posted by: on August 22nd, 2013