Transcript Doppler Assessment Management - The Lindsay Leg Club Foundation

Leg Assessment and IPC
Elaine Gibson BSc(Hons) DipN, RGN
Aspen Medical Europe
Tissue Viability Nurse Specialist
East Kent University Hospitals Foundation Trust
Dr Jon Evans BSc PhD MIET CEng
Vascular Business Unit Manager
Theresa Hanlon RN DIP HE
Product Specialist
Huntleigh Healthcare
Jane Wigg RGN MSc
Clinical Innovations Manager
Haddenham Healthcare
Trudie Young RGN MSc
Facilitator
Conference workshops in association with the Leg Club Industry Partners
“Empowering patients through a unique collaboration with
industry dedicated to lower limb conditions”
Examination of the arterial patient
Past Medical History
 Cardiac: angina; arrhythmias; MI
 Diabetes
 Hypertension
 Renal
 Neurological: cerebrovascular; peripheral
 Injuries
 Arthritis / collagen disease
 Clotting abnormalities
Clinical features of the ischaemic foot
• Cold
• Pale colour
• Glass like skin
• Little callous
• Pulse less
• Dependent rubor
• Claudication
• Rest pain
• Ulcers on edges
© copyright Cardiff and Vale Trust
Doppler Assessment
• Doppler probes come in several Frequencies 2-10 MHz
• It is important to use contact gel, use at 45 degree angle
• 8MHz probe is ideal for measuring ABPI
Doppler ABPI Measurements
• Position patient supine and rest for 15-20
minutes
• Measure both Brachial pressures
• Measure two pedal pressures per foot
• Calculate ABPI using highest ankle/highest
brachial pressure
ABPI > 1.0 - 1.3
Unlikely to be arterial
in origin
Apply compression
therapy
ABPI = 0.8 - 1.0
Mild peripheral
Apply compression
therapy with caution
ABPI = 0.5 - 0.8
Moderate arterial
disease
disease
ABPI < 0.5
Severe arterial
disease
ABPI > 1.3
Measure toe
pressures or refer to
specialist
Do not compress
refer to specialist
Do not compress - refer
urgently to vascular
specialist.
Other useful tests
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Waveform assessment (TASC2)
Exercise Doppler
Segmental pressures
Buergers test
Slow capillary return after blanching
Pole test
Toe pressures (TASC2)
Pulse Volume Recording (TASC2)
Pole Test
 Pole test for measurement of
ankle pressures in patients with
calcified vessels: the Doppler
probe is placed over a patent
pedal artery and the foot raised
against a pole that is calibrated
in mm Hg. The point at which
the pedal signal disappears is
taken as the ankle pressure
Doppler Waveforms and Sounds
Waveforms provide extra information to confirm
clinical findings and ABPI’s
Triphasic Waveform - Normal
Biphasic Waveform – Normal with age
Doppler Waveforms and Sounds
Monophasic Waveform 1 - Abnormal
Toe Pressures
Doppler or Photoplethysmography (PPG)
 Toe/brachial pressure > 0.7 = normal
 Rest pain usually present in patients with index < 0.15
 Absolute pressure in the toes of 20-30mmHg is usually
associated with rest pain
Problems with measuring ABPI using Doppler
• Difficult to maintain vessel contact during inflation and
deflation
• A reasonable knowledge of anatomy is required
• Difficult to locate vessels
• Typical average time for ABPI is 11mins + 15-20 mins
rest (Ipsilon and Get ABI Study 2006)
• Clinicians must be trained and monitored
(RCN Guidelines 2006)
• Doppler ABPIs taken by junior doctors disagreed with
vascular technicians by 30%. This improved to 15%
after formal training (Ray et al 1994)
Two Chamber Cuffs
Specially designed two chamber cuffs are used to detect systolic
pressures
An Auto ABI Device
Systolic Pressures and ABI
PVR Waveforms
Pulse Volume Recordings
Grade A: Normal
Sharp systolic peak with prominent
dicrotic notch
Grade B: Mildly Abnormal
Sharp peak, absent dicrotic notch;
downslope is bowed away from
baseline
Grade C: Moderately Abnormal
Flattened systolic peak, upslope and
downslope time decreased and nearly
equal, absent dicrotic notch.
Grade D: Severely Abnormal
Low amplitude or absent pulse wave
with equal upslope and downslope
time
Advantages of Auto ABI
• Extremely easy to use and fully automatic
• Rapid bi-lateral ABI measurement in < 5mins
(Doppler based ABI typically takes 30mins)
• No need to rest patient for 15mins
• ABI can now be undertaken by less skilled staff
• Only have to apply 4 cuffs
• Physiologically more accurate
• No need to remove socks and tights
• Integral printer for documentation of results and waveforms
• Automatic interpretation
• Clinically validated (Lewis et al, 2010, 2012)
Uses of IPC
 Deep veins (Johns et al 2007)
 Faster muscle recovery (Griffin et al 2007)
 Increases arterial flow (Morris et al 2002, Eze et al 1996)
 Wound healing
(Pflzenmaier 2nd,et al 2005, Coleridge-Smith et al 1990)
 Enhances lymph transport (Baulieu et al 1989)
 Drainage to functional lymphatics aiding removal
(Brennan and Miller 1998)
 Oedema Reduction (Partsch, 2008)
Traditional IPC
Sequential Cycle
 Starts distally and holds pressure in each chamber
 Releases all chambers together
 Useful for venous and dependency oedemas
Traditional IPC
Sequential Cycle
 Starts distally and holds pressure in each chamber
 Releases all chambers together
 Useful for venous and dependency oedemas
Traditional IPC
Wave cycle
 Applies pressure distally and inflates the next progressive chamber
whilst releasing the previous
 It has a ‘wave’ or peristaltic effect and is useful for palliative,
venous and watery oedema
Traditional IPC
Wave cycle
 Applies pressure distally and inflates the next progressive chamber
whilst releasing the previous
 It has a ‘wave’ or peristaltic effect and is useful for palliative,
venous and watery oedema
New machines
‘To date, no mechanical device has
been designed to mimic the
technique of manual lymphatic
drainage, This would essentially
consist of reverse sequential
compression’
(Comerota and Aziz, JOL, 2009)
LymphAssist
(Flowtron Hydroven 12, developed 2006)
A 12 Chamber IPC System
with LymphAssist cycle
 Designed for Lymphoedema only
 The first 12 chamber (overlapping) retrograde
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pump with this unique cycle
Retrograde flow/ commences proximally
5 pulses each chamber
Based on MLD (Leduc)
Maximum pressure 40mmHg
Completes each cycle
Cycle 19.6 mins (2 cycles equivalent to MLD)
Advantages
 Provides supervised self management/Home use
 Increased lymphatic drainage pathways (Furnival-Doran (2012)
 Treat the whole /both limbs (full leg garment)
 Easy to use/ does not required trained therapist
 Cost effective/Time/ resource saving
 Improved healing times
 Problem solving
 Reduced risk
 Assists in longevity of role
 Good patient experience
 EFFECTIVE
Thank You
Any Questions