# Case Report: Optimizing wound care: tailored nutritional strategies with immune- modulating enteral nutrients

## TL;DR

This case series shows how personalized nutrition, including immune-modulating nutrients, can help heal pressure ulcers in hospitalized patients.

## Contribution

The study demonstrates practical application of individualized nutritional strategies in complex wound care scenarios.

## Key findings

- All patients showed improvement and eventual healing of pressure ulcers with tailored nutritional interventions.
- Optimized enteral feeding and immunonutrition were associated with better nutritional status and wound healing.
- The study highlights the role of dietitians in multidisciplinary care for advanced pressure injuries.

## Abstract

Adequate nutrition and hydration are essential for maintaining skin integrity and supporting tissue repair in patients with pressure injuries. Current ESPEN guidelines emphasize the role of individualized nutritional therapy, including optimized energy and protein delivery and selected conditionally essential nutrients such as arginine, glutamine, and β-hydroxy-β-methylbutyrate (HMB), as part of a multidisciplinary approach to pressure ulcer management. This case series describes dietitian-led personalized nutritional interventions in critically ill, long-term hospitalized patients with advanced pressure ulcers.

This descriptive case series reports four adult patients receiving long-term enteral nutrition in an acute or long-term care setting. Each case illustrates individualized nutritional assessment and intervention tailored to metabolic stress, nutritional risk, wound burden, and tolerance. Nutritional strategies included early initiation and optimization of enteral feeding, progressive achievement of energy and protein targets, glycemic control, and selective use of immunonutrition. Over prolonged follow-up, all patients demonstrated improvement and eventual healing of pressure ulcers within a comprehensive multidisciplinary care bundle. This series highlights the practical application of personalized nutrition in complex clinical scenarios rather than establishing causal efficacy.

Patients were excluded from this case series if they met any of the following conditions: (1) Age below 18 years, (2) Pregnancy or lactation, (3) Patients receiving exclusive parenteral nutrition, (4) Presence of terminal illness or receiving palliative/end-of-life care, (5) Hemodynamic instability preventing initiation or continuation of enteral nutrition, (6) Pre-existing metabolic disorders that could significantly confound nutritional outcomes (e.g., inborn errors of metabolism), (7) Incomplete medical or nutritional records, and (8) Patients with anticipated length of stay are insufficient to assess nutritional intervention outcomes.

Patients were included in this case series if they met the following criteria: (1) Adult patients aged 18 years and above, (2) Admitted to an acute or long-term care setting requiring nutritional intervention, (3) Presence of medical conditions associated with increased nutritional risk, such as critical illness, neurological impairment, psychiatric disorders, or impaired wound healing, (4) Patients who received individualized nutritional assessment and intervention, including enteral nutrition, (5) Availability of complete medical, nutritional, and clinical outcome records, and (6) Patients with a length of hospital stay sufficient to allow assessment of nutritional intervention outcomes.

This case series underscores the importance of individualized, dietitian-led nutritional therapy integrated within multidisciplinary care for patients with advanced pressure injuries. Optimized nutritional delivery was associated with improved nutritional status and wound healing progression; however, causal inference is limited by the observational design. Prospective studies using standardized wound assessment tools are warranted to clarify the independent contribution of targeted nutritional interventions.