Management of Venous Ulcers Ms C Martin. Definition Chronic Venous Ulcer Open lesion between the...
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Transcript of Management of Venous Ulcers Ms C Martin. Definition Chronic Venous Ulcer Open lesion between the...
Definition Chronic Venous Ulcer
Open lesion between the knee and the ankle joint
Remains unhealed for at least
4 weeks
Occurs in the presence of venous disease
Assessment
Varicose veins
Haemosiderin
Lipodermatosclerosis
Atrophie blanche
Oedema
Dermatitis/eczema/Marjolin’s
Joint mobility – calf muscle pump
ArterialABPI over 0.8 - compression therapy is safe
with ABPI under 0.8 - should have referral and
cardiovascular risk factor modification
Assessment
Varicose veins
Haemosiderin
Lipodermatosclerosis
Atrophie blanche
Oedema
Dermatitis/eczema/Marjolin’s
Joint mobility – calf muscle pump
ArterialABPI over 0.8 - compression therapy is safe
with ABPI under 0.8 - should have referral and
cardiovascular risk factor modification
Assessment
Varicose veins
Haemosiderin
Lipodermatosclerosis
Atrophie blanche
Oedema
Dermatitis/eczema/Marjolin’s
Joint mobility – calf muscle pump
ArterialABPI over 0.8 - compression therapy is safe
with ABPI under 0.8 - should have referral and
cardiovascular risk factor modification
Assessment
Varicose veins
Haemosiderin
Lipodermatosclerosis
Atrophie blanche
Oedema
Dermatitis/eczema/Marjolin’s
Joint mobility – calf muscle pump
ArterialABPI over 0.8 - compression therapy is safe
with ABPI under 0.8 - should have referral and
cardiovascular risk factor modification
Investigations
Duplex - arterial and venous
Bacteriology Swabs Only with clinical signs - cellulitis, pain, malodour, increased exudate. Colonisation does not delay healing
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Simple non-adherent dressings are recommended for ulcers.
Systematic review of 42 studies comparing - NA, alginate, hyrdocolloids, hydrogels, foams – no difference in healing when applied under multilayer bandages (ref 45).
NA UltraGranuflex DuoDerm
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Cochrane Review
Silver vs NA – no difference
Silver dressings not recommended in the routine treatment
ManagementDressingsSilverDrugs Cleaning Debridement Larval TherapyManuka HoneyCompressionStockings SurgerySetting
Systemic antibiotics should not be used unless there is evidence of clinical infection.
Placebo controlled studies suggest increased bacterial resistance with antibiotic usage.
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Aspirin insufficient evidence
Mesoglycan insufficient evidence
Zinc insufficient evidence
Pentoxifylline – 400mg tid should be considered improves healing interaction with NSAIDs
ManagementDressingsSilver Drugs Cleaning Debridement Larval TherapyManuka HoneyCompressionStockingsSurgerySetting
Tap water vs sterile water
ManagementDressingsSilver Drugs Cleaning Debridement Larval TherapyManuka Honey CompressionStockingsSurgerySetting
• Use a scalpel
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting
Cochrane Review 19 trials – no benefit
Honey dressing are not recommended in the routine treatment of patients with venous leg ulcers.
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Compression
Cochrane review 7 RCTs comparing compression versus no compression – compression increases ulcer healing rates (Ref 51)
Caution ABPI < 0.8, DM, neuropathic
Compression LevelHighest that maintains compliance.
Reassess within 24-48hrs of application
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting
Multilayer Compression Layer Kit
Wound contact dressing (NA, Tubinet)Layer 1 subcompression wadding bandag (soffban)Layer 2 support bandageLayer 3 compression bandage (K-Plus) Layer 4 cohesive compressive bandage (Coban)
Light Compression 3 Layers Profore or K-Plus = 27 mmHG at the ankle
High Compression 4 Layers K-Plus + Coban = 40 mmHG at the ankle
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Below knee graduated compression hosiery is recommended to prevent recurrence of venous leg ulcers in patients where leg ulcer healing has been achieved.
Strongest compression which they can tolerate and apply (dexterity).
Compression should be worn indefinite during the day.
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting
Compression Class
British (1°) European(2°)
Class 1 14-17mmHg 18-21 mmHgClass 2 18-24 mmHg 23-32 mmHgClass 3 25-35 mmHg 34-46 mmHgClass 4 not available 49-70 mmHgClass 4(s) not available 60-90 mmHg
Brand Activa Medi (FP10)
Management
There is no difference in recurrence between class 3 versus class 2 stocking, however compliance is higher for class 2.
There is variation in the compression afforded between different brands of class 2 and 3 stockings.
DressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
ManagementDressingsSilver Drugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Skin grafting
• – no evidence of benefit
• Bioengineered Products – single layer products – insufficient evidence of benefit
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka Honey CompressionStockingsSurgerySetting
Patients with chronic venous leg ulcers and superficial venous reflux should be considered for superficial venous surgery to prevent recurrence.
Surgery does not improve ulcer healing but does significantly reduce recurrence rates at 12 months.
ESCHAR study – Lancet 2004
ManagementDressingsSilverDrugs Cleaning Debridement Larval Therapy Manuka HoneyCompressionStockingsSurgerySetting
Healing rates are significantly increased within a specialist leg ulcer care setting (Ref 51).
Costs are lower per leg healed within a specialist
clinic compared to costs within a non-specialist clinic.
Larger case load with specialist leg ulcer clinics are recommended as the optimal service for community treatment of venous leg ulcers.
Venous Ulcers – SIGN Summary
Recommended in routine care Not recommended in routine care
ABPI / duplex Silver
Tap water Larvae, Versajet
Simple skin care emollient Manuka honey, zinc
Simple non-adherent dressing Skin grafting
High compression 4 layer bandaging Hyperbaric/electromagnetic/Ultrasound
Pentoxifylline 400mg tid 6 months Antibiotics
B-K graduated compression stocking
Endovenous surgery
Community specialist leg ulcer clinics
Calf muscle exercise
Criteria for referral
Non-healing ulcer – no progress in 12 weeks
Suspicion of malignancy
ABPI < 0.8
Diabetes mellitus
Atypical ulcers
Vascular ulcer clinics
• Royal Surrey alternate weeks
• Farnham Hospital alternate weeks
• Aldershot Centre for health (weekly)
• Brants Bridge ulcer clinic (Bracknell)(weekly)