Transcript Dialysis Induced Cerebral Emboli Study (DICE): evaluating

Wound care management of vascular ulcers
M J Sultan
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
Leg ulcer aetiology
Venous insufficiency 80 - 85%
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: 347-50
Assessment of the patient history
History suggesting venous
disease
History suggesting arterial
disease (c.10-20% patients)
Varicose veins, immobility, obesity
Ankle Brachial Pressure Index less
than 0.8
Proven deep vein thrombosis in the Ischaemic heart disease, stroke or
affected leg
transient ischaemic attack
Phlebitis in the affected leg
Rheumatoid arthritis
Previous fracture, trauma, or
surgery
Diabetes mellitus
Family history of venous disease
Peripheral 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
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
Assessment of the ulcer
RECORD
RATIONALE
Size, depth, edges and site of ulcer
Serial 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
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
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
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
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
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
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
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: 347-50
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: 347-50 Nelson EA et al. Dressings
and topical agents for arterial leg ulcers. Cochrane Database of Systematic Reviews
2007, Issue 1.
Diabetic ulcers
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
Treatment of DU:
What Works
Surgically debride ulcer to allow healing
Must keep pressure off the ulcers to allow healing
Orthopedic shoes: drop recurrence rate from 83% to 17%
Sandals
Splints
Crutches/wheelchairs
Total contact casting
Podiatric physician
Other Possibly
Helpful Treatments
Hyperbaric O2
Dermagraft (cultured skin—human)
Pinch skin graft
Platelet-derived growth factor
U/S
Electrical stimulation
Management of infection in ulcers
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
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
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)
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
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
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
Wound dressings
Dressings
Consider using potassium permanganate 0.01% soak if
the ulcer is malodorous
For uncomplicated, non-infected ulcers apply a lowadherent dressing & replace weekly. (If heavy
exudate - more frequent change)
Other dressings may be used if needed - pain
(hydrocolloid), heavy exudate (alginate) or slough
(hydrogel)
Compression
Simple
dressings
Skin care
Management
of ulcer
Removal of
slough
Pain
management
Elevation and
exercises
Choice of dressing
Do not use antimicrobial dressings
local costs
preference of practitioner/patient
debridement
Prevention is better than cure