Hideharu Tanaka and Joseph A. Molnar
RECOMMENDATIONS FOR VITAMIN C TO SUPPORT WOUND HEALING
The combined effect of ascorbic acid on collagen synthesis, antioxidant status, and immunomodulation make it an appropriate supplement for wound repair protocols.
Research provides evidence for the use of low doses of vitamin C in vitamin C deficient individuals, but many practitioners believe larger doses of ascorbic acid in nondeficient individuals are indicated for optimal wound repair. In light of the discussion above, one must also decide if vitamin C is to be provided as an enzymatic cofactor or as an antioxidant.
While the literature is controversial, the authors suggest that to support collagen synthesis and immune function in otherwise healthy individuals with small wounds, such as pressure ulcers or elective small to moderate surgery, doses of 500 to 1000 mg should be given daily in two divided doses. Those with larger injury, such as large body surface area burns and multiple traumas, should be given doses of 1 to 2 g/d.
Proper doses to optimize antioxidant effect remain to be determined. The studies of Tanaka suggest 66 mg/kg/h intravenously for patients with large body surface area burns.84–87,89 For multiple trauma patients Nathens et al. suggest an intake of only 1000 mg/d in three divided doses, as well as vitamin E.28 Inadequate data exist to recommend doses to optimize the antioxidant effect in patients with smaller wounds and less meta-bolic stress. The low risk of toxicity suggests the liberal use of vitamin C.
FUTURE DIRECTIONS
Much of the controversy in the literature on vitamin C in wound healing revolves around the measured endpoints for optimal nutrition. Some studies measure plasma levels, some measure tissue levels, and others measure clinical parameters of vitamin C nutriture. In addition, some look at clinical parameters of collagen synthesis, immune competence, or free radical metabolism. Future studies should concentrate on functional assays of vitamin C deficiency. Serum and tissue levels are of uncertain value, even in healthy individuals, and will continue to be problematic when used to assess nutrition in the critically ill. Development of biochemical assays of collagen metabolism, immune function, and free radical metabolism that could be obtained as a clinical test rather than a laboratory research project would be invaluable to help in the healing of our wound patients.
Although the role of ascorbate in collagen metabolism has long been understood and extensively studied, further research on the other enzymatic cofactor functions
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and on its role in general protein synthesis must be better understood. The effect that these systems have on wound healing must also be elucidated.
Much of the future research in vitamin C will revolve around its use as a free radical scavenger. Its role in protecting against disease as well as in treating injury must be further understood, and proper safe intakes at these pharmacologic levels of ascorbate must be determined in a variety of clinical situations. The interaction of ascorbate and other antioxidants, such as glutathione and vitamin E, must be better understood to allow for the determination of proper clinical doses of vitamin C.
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