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Venous Stasis Management and Ulcer Healing Evidence base and expert opinion put into practice Christine Herb, MS, FNP-C, CWON Christine Herb, MS, FNP-C,

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Presentation on theme: "Venous Stasis Management and Ulcer Healing Evidence base and expert opinion put into practice Christine Herb, MS, FNP-C, CWON Christine Herb, MS, FNP-C,"— Presentation transcript:

1 Venous Stasis Management and Ulcer Healing Evidence base and expert opinion put into practice Christine Herb, MS, FNP-C, CWON Christine Herb, MS, FNP-C, CWON Syracuse VA Medical Center June 13, 2014

2 VenousArterialNeuropathic Venous vs. Arterial vs. Neuropathic 1 st it is critical to correctly determine the etiology!

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4 Lymphedema w/ Venous Stasis

5 Diseases Process Bicuspid valve damage due to DVT or heredity results in venous HTN and regurgitation. White cell trapping theory: venous HTN & increased cap pressure trap leukocytes in cap & become activated, thus damaging cap beds. Increased permeability leads to fibrin cuff formation & hypoxemia, which leads to inflammation & tissue loss.

6 Venous stasis / insufficiency disease

7 We should all be more like giraffes!

8 Location

9 VS ulcer Characteristics Irregularly shaped Granular base Edema & lymphedema Hemosiderin staining Varicosities Exudate Stasis Dermatitis Cellulitis Sharp or aching pain Itching sc fibrosis

10 Scope of the problem VIU 1-3% population (Kerstein 2003) Peak at 60-80 yo (Pauqette & Falanga, 2002) 6-7 million Americans have LEVD & 1 million of those develop ulcerations (WOCN Society 2005)

11 $ Costs of Venous Ulcers $ Costs: Lifetime costs of LEVD care est at $40,000/individual Total cost of care of LEVD in US est at $1 billion/year (Simka & Majewski 2003) Ulcer Recurrence: 57-97%, which reflects the chronicity of the problem & also failure to effectively address the underlying etiology (Paquette & Falanga 2002) Repeat hospitalizations, repeat abx Lost productivity (work, hobbies, family care, volunteering) Loss of independence (application of compression garments) Pain, itching, anxiety, social isolation & reduced ability to carry out usual activities reported to be areas of greatest concern by individuals w/ venous disease (deAraujo et al, 2003)

12 WHAT TO DO? Let’s start with the evidence…

13 AHRQ: Treatment approaches for chronic venous ulcers reviewed (Johns Hopkins University Evidence-based Practice Center :Dec 2013)  There is a general lack of conclusive evidence on the benefits and harms of advanced wound dressings, systemic antibiotics, and surgical interventions in the treatment of venous leg ulcers lasting six or more weeks in patients with preexisting venous disease  Some evidence supports:  Antimicrobial dressings (mod str evidence)  Collagen dressings (low str evidence)  Bilayered human skin equivalents (mod str evidence)  Surgical procedures do not improve healing or recurrence (high str of evidence)  SEPS: subfascial endoscopic perforator vein surgery

14 Evidence Based Treatment Compression  Compression for venous ulcers (Cochrane review) 2009 by O’Meara, Cullum & Nelson. 39 RCTs reporting 47 comparisons Author’s conclusions: Compression increases ulcer healing rates compared to no compression. Multi-component systems are more effective than single- component systems

15 Evidence Based Treatment  Inflammatory cytokine levels in chronic venous insuf ulcer tissue before and after compression (2009) J of Vasc Surgery. Beidler et al. 30 limbs untreated CVI ulcers received high compression therapy for 4 weeks. Biopsy of healthy & ulcerated tissue before & after therapy & using a multiplexed protein assay to measure multiple cytokines CONCLUSIONS: CVI ulcer healing is asso with pro- inflammatory environment prior to treatment. Treatment with compression therapy results in healing that is coupled w/ reduced pro-inflammatory cytokine levels & higher levels of the anti-inflam cytokine Il- Ra.

16 Evidence Based Treatment  Skin grafting for venous leg ulcers (Cochrane review) 2007 by Jones & Nelson. 15 trials generally of poor methodology. Author’s conclusions: Bilayer artificial skin, used in conjunction with compression bandaging, increases the chance of healing a venous ulcer compared with compression and a simple dressing. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.

17 Evidence Based Prevention  Compression for preventing recurrence of venous ulcers (Cochran review) 2000 by Nelson, Bell-Syer & Cullum. Author’s conclusions: No trials compared compression with vs no compression for prevention of ulcer recurrence. Not wearing compression (non-compliance in trial) was associated with recurrence in both studies indentified in this review. Recurrence rates may be lower in high compression hosiery than medium compression hosiery and therefore patients should be offered the strongest compression with which they can comply. People are more likely to wear hosiery with moderate rather than high compression.

18 “the integration of best research evidence withbest research evidence with clinical expertise andclinical expertise and patient values”patient values” Sackett, et al. (2000) “...in the context of available resources” DiCenso, et al. (1998) Evidence Based Practice

19 Safe to Compress?  Ankle/Brachial Index (> 1 calcified vessels) ABI of 0.8-1.0 safe ABI of 0.5-0.7 modified compression may be safe  Clinical presentation of adequate perfusion: Palp DP, PT pulses Strong doppler signals Warm Pink color Hair on feet or toes

20 Compression wraps Compression wraps for healing

21 Dyna-Flexvs3M coban

22 What are the essentials of effective ulcer tx? Effective COMPRESSION is essential !!!! Debridement of slough and fibrin Removing scales & moisturizing Reduce the bioburden: antimicrobial topicals Medical grade HONEY Cadexomer iodine paste Mupirocin, bacitracin oint Dakins sol Bioelectric dressings Manage the drainage Start simple and change one thing at a time Progress to the advanced products if failure Collagen, bilayered skin substitutes, skin grafts

23 Fibrin can fool ya

24 Compression stockings are NOT all created equal!

25 Compression Stockings Anti-embolism: 16-18mmHg, TED hose are not appropriate to tx venous stasis. Light compression: 10-20mmHg Class I: light support, 20-30mmHg at the ankle, usually not adequate to prevent venous ulcer recurrence.  Class II: medium support, 30-40mmHg, level of compression needed to prevent recurrence & manage lymphedema.  Class III: strong support, 40-50mmHg, indicated for venous ulcer recurrence & manage lymphedema.

26 Heal the ulcers…then get them into stockings!

27 Important points about compression stockings: Change daily into clean pair Do not pinch & pull fabric. Must use tacky rubber gloves to stroke fabric in place. Evenly distribute fabric. Remove all wrinkles. Bunching fabric causes wounds! Wash w/o bleach or fabric softener. Air dry. Replace every 6 months!

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30 Compression Stocking Application NOT!

31 Device transformed compliance

32 Other compression stockings

33 CircAid Classic-flex

34 Juxta-fit CircAid Juxta-fit

35 Compliance is crucial 2003 W.H.O. reported: 50% people don’t comply w/ chronic disease management. “Few providers take the time to address the obstacles to non-compliance… Often there is a will, but the way is not shown”. Christine Herb

36 Keys to compliance: Patient buy-in ID the obstacles: Huge belly Back or hip pain Arthritis in hands Determine which form of compression is most do-able. Compression is NOT for every patient; consider advanced age, further complicating life vs benefits. Call in all forces (spouse, friend/neighbor, adult child) to assist. One-to-one training, demonstration & return demonstration, encouragement, getting the kinks out & not quitting until they are successful. Homecare for more training in home environment & assess compliance.

37 Your role as PCP Your role as PCP: Identify venous stasis and refer to the specialists for healing ulcers and fitting of compression garments, training, etc. Don’t wait for an ulcer or cellulitis. On each f/u clinic appt: PCP should assess compliance with compression garments and reinforce vital importance of wearing compression garments EVERY day for lifetime. Replace stockings every 6 months.

38 Managing Chronic Venous Insufficiency Requires compression! Requires compression! to start with… and for a lifetime! and for a lifetime!

39 Thank you!

40 References: Treatment approaches for chronic venous ulcers reviewed: http://www.ahrq.gov/news/newsletters/research- activities/14feb/0214ra30.html http://www.ahrq.gov/news/newsletters/research- activities/14feb/0214ra30.html Cochrane Reviews: venous ulcers http://www.thecochranelibrary.com/details/browseReviews/ 576613/Ulcers-venous.html Resources: http://ezyasabc.com/ WOCN.org


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