Case Report: Optimizing Wound Care — Tailored Nutritional Strategies with Immune-Modulating Enteral Nutrients
Summary: Published March 13, 2026 in Frontiers in Nutrition (Clinical Nutrition section, impact factor 5.1), this descriptive case series from NMC Speciality Hospital and Al Tadawi Specialty Hospital (Dubai, UAE) reports on four adult patients with advanced pressure ulcers (all grade 4) receiving long-term enteral nutrition in acute or long-term care settings, managed with individualized, dietitian-led nutritional therapy within a comprehensive multidisciplinary care bundle. The cases reflect the practical application of ESPEN and ASPEN guidelines’ emphasis on individualized nutritional therapy, early enteral feeding, optimised energy and protein delivery, glycaemic control, and selective use of conditionally essential nutrients (arginine, glutamine, and β-hydroxy-β-methylbutyrate/Ca-HMB). Case 1: a 73-year-old with CVA, diabetes, HTN, and CAD — protein 1.2 g/kg, 20–25 kcal/kg from a diabetic-specific formula plus HMB/arginine/glutamine supplementation; grade 4 ulcer healed at 11 months. Case 2: a 30-year-old with bipolar disorder, severe malnutrition (BMI 15.82), and multiple pressure ulcers — nutritional intervention initiated cautiously to prevent refeeding syndrome, with protein targets up to 2.8 g/kg and energy 50 kcal/kg at peak; BMI increased to 18.11 and ulcers fully healed at 12 months. Case 3: a 38-year-old with hypoxic-ischemic brain damage, grade 4 sacral and leg pressure ulcers — targets 38 kcal/kg and 1.6 g/kg protein; notable improvement and weight gain over 12 months. Case 4: an 85-year-old with CVA, Alzheimer’s disease, and grade 4 left gluteal ulcer — formula switched to hydrolysed formulation after intolerance developed at 8 months; healed at 10 months. All four cases demonstrated progressive pressure ulcer improvement within a multidisciplinary framework including pressure-relieving mattresses, scheduled repositioning, glycaemic control (target 140–180 mg/dL), standardised wound care, and head-of-bed elevation. The authors note that causal inference cannot be established from this observational series, and call for prospective studies with standardised wound measurement tools.
Key Highlights:
- Four cases of grade 4 pressure ulcers in critically ill, long-term hospitalised adults; all achieved healing within 10–12 months with dietitian-led individualised enteral nutrition plus multidisciplinary wound care
- Immunonutrition protocol: each 24 g sachet providing glutamine 7 g + arginine 7 g + Ca-HMB 1.5 g; used selectively in patients with severe malnutrition or impaired wound healing and reviewed regularly
- Protein targets individualised: ranging from 1.2 g/kg (diabetic, stable) to 2.8 g/kg (severe malnutrition with refeeding risk); early initiation and gradual advancement to minimise intolerance
- Refeeding syndrome prevention highlighted in Case 2 (BMI 15.82): electrolyte monitoring (phosphate, magnesium, potassium) with caloric increase over 4–8 weeks — important safety consideration for malnourished wound patients
- Formula adaptation: Case 4 required switch to hydrolysed formula after intolerance at 8 months — highlights the need for ongoing reassessment and flexibility in enteral formula selection over prolonged follow-up
- Limitation: observational design with concurrent interventions; causal contribution of nutrition to wound healing cannot be isolated — prospective RCTs with standardised wound assessment tools needed
Keywords: nutrition wound healing pressure ulcer, enteral nutrition pressure injury, arginine glutamine wound care, HMB wound healing nutrition, immunonutrition critical care wounds, protein energy wound healing
Fiji Antony, Wafaa Ayesh