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Wound care management of vascular ulcers M J Sultan.

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Presentation on theme: "Wound care management of vascular ulcers M J Sultan."— Presentation transcript:

1 Wound care management of vascular ulcers M J Sultan

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3 Wound care: leg ulcers Wound care: leg ulcers Wound care is a high cost area for patients and NHS in terms of prescribing costs, patient QoL and NHS workforce time The evidence base for therapeutics in much of this area is limited Value for money for the NHS is an important factor when choosing treatments Leg ulcers are a common, chronic, recurring condition Prevalence of active leg ulcers is between 1.5 to 3 per 1000 and increases with age. It’s estimated that up to 20 per 1000 people over 80 yrs will suffer from a leg ulcer Following healing, re-ulceration rates at one year range from 26% - 69% Available treatments can reduce recurrence rates NHS CRD (1997) Effective Healthcare 3 (4), 1-12 SIGN 26 The Care of patients with Chronic Leg Ulcer Clinical Knowledge Summaries_Venous Leg Ulcer

4 Leg ulcer aetiology Venous insufficiency % Other causes: Arterial disease Mixed arterial and venous disease Diabetes Rheumatoid arthritis Systemic vasculitis Lymphoedema Trauma Others including malignancy Clinical Knowledge Summary Venous Leg Ulcers_February 2008 Grey J.E et al. ABC Wound Healing BMJ 2006; 332:

5 Assessment of the patient - history History suggesting venous disease History suggesting arterial disease (c.10-20% patients) Varicose veins, immobility, obesityAnkle Brachial Pressure Index less than 0.8 Proven deep vein thrombosis in the affected leg Ischaemic heart disease, stroke or transient ischaemic attack Phlebitis in the affected legRheumatoid arthritis Previous fracture, trauma, or surgery Diabetes mellitus Family history of venous diseasePeripheral arterial disease/intermittent claudication Symptoms of venous insufficiency: leg pain, heavy legs, aching, itching, swelling, skin breakdown, pigmentation, and eczema Smoking Clinical Knowledge Summary Venous Leg Ulcers Royal College of Nursing Clinical Practice Guidelines

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7 Assessment of the leg - examination Measurement of Ankle Brachial Pressure Index (ABPI) is the most reliable way to detect arterial insufficiency Clinical Knowledge Summary Venous Leg Ulcers CREST Guidelines for the Assessment and Management of Leg Ulcers

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9 Assessment of the ulcer RECORDRATIONALE Size, depth, edges and site of ulcerSerial measures useful for progress Ulcer base: Epithelialisation/granulation/slough/ eschar/necrosis Aid choice of dressing and indicate progress of healing Level of exudate: Minimal/ moderate/ high Will influence dressing choice and frequency of dressing change Signs of infection: Enlarging ulcer, increased exudate, pyrexia, foul odour, cellulitis May indicate infection Pain: Assess level, frequency and duration Treat to relieve distress and aid compliance with treatment Clinical Knowledge Summary Venous Leg Ulcers CREST Guidelines for the Assessment and Management of Leg Ulcers

10 Referral to a specialist clinic before treatment Uncertain diagnosis Suspected alternative causes of ulceration: - Arterial or mixed venous/arterial ulcer. Refer people with ABPI <0.8 for further assessment. If < 0.5 refer urgently. Suspected malignant ulcer or rapidly deteriorating ulcer Suspected rheumatoid ulcer, or ulcer associated with systemic vasculitis People with diabetes with an ulcer on the foot (according to local arrangements) Varicose veins or arterial insufficiency

11 Lifestyle advice Self - care strategies include: Keep mobile with regular walking if possible Elevate legs when immobile Use emollient and examine legs regularly for broken skin, blisters, swelling or redness Lose weight if appropriate Stop smoking Clinical Knowledge Summary Venous Leg Ulcers

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14 Venous leg Ulcer - treatment Venous leg Ulcer - treatment Irrigate the wound with warm tap water or saline, then dry. Strict aseptic technique not required Remove slough or necrotic tissue by gentle washing If debridement is needed, it should be carried out by a trained healthcare professional For uncomplicated, non infected ulcers and where indicated by ABPI, apply compression bandaging - 4 or 3 layer if immobile, or 2-layer if mobile Clinical Knowledge Summary Venous Leg Ulcers SIGN, NICE

15 Uncomplicated venous leg ulcer – Follow up during treatment Assess weekly for the first 2 weeks. If healing underway, assess fortnightly or monthly, then 3 monthly Change dressings at least once a week. Check for healing and compliance with compression therapy and ask about problems e.g. mobility, sleep, mood If delayed or no healing, identify problems which may need further treatment or referral Check for complications Check lifestyle advice is followed If ulcer not healing or deteriorating at 12 weeks, look for signs of arterial disease and repeat ABPI Clinical Knowledge Summary Venous Leg Ulcers

16 Venous leg ulcer - compression bandaging Venous leg ulcer - compression bandaging Below-knee graduated compression is the mainstay of treatment to improve venous return, and to reduce venous stasis and hypertension in uncomplicated venous leg ulcers Graduated compression delivers the highest pressure at the ankle and gaiter area (40 mmHg), and pressure progressively reduces towards the knee and thigh where less external pressure is needed (18 mmHg) High compression multilayer (four layer, three layer) bandaging has improved healing rates over single layer bandaging An appropriately trained person should apply high compression multi-layer bandaging, to avoid the risk of pressure ulceration over bony points Clinical Knowledge Summary Venous Leg Ulcers Cochrane review NICE, SIGN

17 Venous leg ulcer - preventing recurrence Graduated compression stockings should be used for at least 5 years after ulcer healing Educate and explain to the patient the importance of preventing recurrence through lifestyle changes and use of hosiery Accurate measurement of limbs for compression hosiery is essential Follow up with 6-monthly Doppler ABPI checks Class III (high) compression stockings are associated with less recurrence than Class II (medium) compression stockings, but may be less acceptable to the patient Clinical Knowledge Summary Venous Leg Ulcers CREST Guidelines for the Assessment and Management of Leg Ulcers

18 Arterial leg ulcers Caused by reduced blood supply to the lower limbs either by a block in the artery or narrowing of the arteries resulting in hypoxic damage, ulcer formation and necrosis Arterial ulcers account for 10% - 15% of leg ulcers Typically occur over toes, heels and bony prominences of foot Can take months or years to heal, are painful and often become infected Men over 45 years and women over 55 years are more likely to have PVD, (peripheral vascular disease) and so are prone to arterial leg ulcers Modifiable risk factors: smoking, hyperlipidaemia, hypertension, obesity, diabetes, decreased activity Grey J.E et al. ABC Wound Healing BMJ 2006; 332:

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20 Arterial leg ulcers Infection can cause rapid deterioration of an arterial ulcer It is not appropriate to debride arterial ulcers as this may produce further ischaemia and formation of a larger ulcer (specialist only) Compression bandaging should not be applied as severe damage to the leg can result Choice of dressing is dictated by the nature of the wound Treatment options include reconstructive surgery or angioplasty Grey J.E et al. ABC Wound Healing BMJ 2006; 332: Nelson EA et al. Dressings and topical agents for arterial leg ulcers. Cochrane Database of Systematic Reviews 2007, Issue 1.

21 Diabetic ulcers

22 Co-Morbidity in DU Peripheral vascular disease occurs in 11% of diabetic patients Peripheral neuropathy occurs in 42% of diabetic patients PVD is associated with delayed ulcer healing and increased rates of amputation

23 Treatment of DU: What Works Surgically debride ulcer to allow healingMust keep pressure off the ulcers to allow healing Orthopedic shoes: drop recurrence rate from 83% to 17%SandalsSplintsCrutches/wheelchairsTotal contact casting Podiatric physician

24 Hyperbaric O2Dermagraft (cultured skin—human)Pinch skin graftPlatelet-derived growth factorU/SElectrical stimulation Other Possibly Helpful Treatments

25 Management of infection in ulcers

26 Physical Examination: what to look for Vital signs – tachycardia, hypotension Signs of volume depletion Cognitive state – delirium, stupor, coma Limb / foot Vascular status Arterial – necrosis, gangrene Venous – edema, stasis, cellulitis

27 Physical Examination Wound Size and depth: necrosis, gangrene, foreign body involvement of muscle, tendon, bone, or joint – inspect, debride, and probe the wound! Presence, extent and cause of infection: purulence, warmth, tenderness, induration, cellulitis, bullae, crepitus, abscess, fasciitis, osteomyelitis Pain, increased discharge, non-responsive

28 Physical Examination Infection should be diagnosed clinically based on the presence of Purulent secretions or At least two of the cardinal manifestations of inflammation (redness, warmth, swelling or induration, and pain or tenderness)

29 Leg ulcers - treating infection All chronic wounds are colonised with bacteria Antibiotics should be used only if there is evidence of cellulitis or active infection (e.g. pyrexia, increasing pain, enlarging ulcer) If there are clinical signs of infection present, clean ulcer with warm tap water or saline before taking a swab Start immediate empiric treatment with an anti-staphylococcal antibiotic Change dressing daily or alternate days to assess if infection is improving Do not start compression therapy if ulcer is infected Clinical Knowledge Summary Venous Leg Ulcers

30 Infected leg ulcer- follow up during treatment Reassessment and follow up frequency is different for uncomplicated and infected ulcers Review the patient within 3 days to assess response to treatment, ideally followed by re-assessment every two or three days until clinical improvement is seen Reassess the ulcer as at initial assessment: dimensions, site, base, odour and exudate If infection is not responding, consider change of antibiotic based on swab results If signs of worsening infection, refer After infection has settled, follow up as for uncomplicated venous ulcers Clinical Knowledge Summary Venous Leg Ulcers SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer

31 Wound dressings Arterial Ulcers - Aim to keep the wound dry Venous Ulcers - Aim to keep the wound moist and warm Control the amount of leakage from the wound Control any smell from the wound Protect the wound from further damage, infection or drying of the wound surface Be comfortable and not restrict movement Not cause pain or further damage to the wound when it is removed for re-dressing Not need frequent changes, maintain humidity, absorb serum, protect granulation tissue

32 Wound dressings

33 Dressings

34 Consider using potassium permanganate 0.01% soak if the ulcer is malodorous For uncomplicated, non-infected ulcers apply a low- adherent dressing & replace weekly. (If heavy exudate - more frequent change) Other dressings may be used if needed - pain (hydrocolloid), heavy exudate (alginate) or slough (hydrogel)

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44 Management of ulcer Compression Simple dressings Pain management Elevation and exercises Removal of slough Skin care

45 Choice of dressing Do not use antimicrobial dressings local costs preference of practitioner/patient

46 debridement

47 Prevention is better than cure

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