key slides leg ulcer (2)
TRANSCRIPT
-
8/11/2019 Key Slides Leg Ulcer (2)
1/18
1
Wounds: Leg ulcers
Key slides
-
8/11/2019 Key Slides Leg Ulcer (2)
2/18
2
Wound care: leg ulcersNHS CRD (1997) Effective Healthcare 3 (4), 1-12
SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer
Clinical Knowledge Summaries_Venous Leg Ulcer_Feb 08
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. Its estimated that up to 20 per 1000people 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
-
8/11/2019 Key Slides Leg Ulcer (2)
3/18
3
Leg ulcer aetiologyClinical Knowledge Summary Venous Leg Ulcers_February 2008
Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50
Venous insufficiency 80 - 85%
Other causes:
Arterial disease
Mixed arterial and venous disease Diabetes
Rheumatoid arthritis
Systemic vasculitis
Lymphoedema Trauma
Others including malignancy
-
8/11/2019 Key Slides Leg Ulcer (2)
4/18
4
Assessment of the patient - historyClinical Knowledge Summary Venous Leg Ulcers_February 2008
Royal College of Nursing Clinical Practice Guidelines 2006
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
affected leg
Ischaemic heart disease, stroke or
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
-
8/11/2019 Key Slides Leg Ulcer (2)
5/18
5
Assessment of the leg - examinationClinical Knowledge Summary Venous Leg Ulcers_February 2008
CREST Guidelines for the Assessment and Management of Leg Ulcers 1998
Measurement of Ankle Brachial Pressure Index (ABPI) is the most
reliable way to detect arterial insufficiency
-
8/11/2019 Key Slides Leg Ulcer (2)
6/18
6
Assessment of the ulcerClinical Knowledge Summary Venous Leg Ulcers_February 2008
CREST Guidelines for the Assessment and Management of Leg Ulcers 1998
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
-
8/11/2019 Key Slides Leg Ulcer (2)
7/187
Referral to a specialist clinic before treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008
Uncertain diagnosis
Suspected alternative causes of ulceration:
- Arterial or mixed venous/arterial ulcer. Refer people with
ABPI
-
8/11/2019 Key Slides Leg Ulcer (2)
8/188
Lifestyle adviceClinical Knowledge Summary Venous Leg Ulcers_February 2008
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
-
8/11/2019 Key Slides Leg Ulcer (2)
9/189
Venous leg Ulcer - treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008
Irrigate the wound with warm tap water or saline, then dry. Strictaseptic technique not required
Remove slough or necrotic tissue by gentle washing
If debridement is needed, it should be carried out by a trainedhealthcare professional
Consider using potassium permanganate 0.01% soak if theulcer is malodorous
For uncomplicated, non-infected ulcers apply a low-adherentdressing & replace weekly. (If heavy exudate - more frequentchange)
Other dressings may be used if needed - pain (hydrocolloid),heavy exudate (alginate) or slough (hydrogel)
For uncomplicated, non infected ulcers and where indicated byABPI, apply compression bandaging - 4 or 3 layer if immobile,or 2-layer if mobile
-
8/11/2019 Key Slides Leg Ulcer (2)
10/1810
Uncomplicated venous leg ulcer
Follow up during treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008
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 aboutproblems 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
-
8/11/2019 Key Slides Leg Ulcer (2)
11/1811
Venous leg ulcer - treating infectionClinical Knowledge Summary Venous Leg Ulcers_February 2008
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 i.e. flucloxacillin or erythromycin 500mg qds for seven
days
Change dressing daily or alternate days to assess if infection is
improving Do not use antimicrobial dressings
Do not start compression therapy if ulcer is infected
-
8/11/2019 Key Slides Leg Ulcer (2)
12/1812
Infected venous leg ulcer- follow up
during treatmentClinical Knowledge Summary Venous Leg Ulcers_February 2008
SIGN 26 (1998) The Care of patients with Chronic Leg Ulcer
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
-
8/11/2019 Key Slides Leg Ulcer (2)
13/1813
Venous leg ulcer - dressing choiceSIGN 26 (1998) The Care of patients with Chronic Leg UlcerClinical Knowledge
Summary Venous Leg Ulcers_February 2008
There is good evidence that the type of dressing used has
no effect on ulcer healing
Uncomplicated ulcer-use simple low-adherent dressing
Sloughy ulcer-hydrogel provides moisture that may help liquefyslough
Moderate to heavily exuding ulcer-alginate or foam dressing
may help absorb exudate
Painful ulcer-occlusive hydrocolloid or foam dressing may
reduce pain
Simple non-adherent dressings are recommended in the
treatment of venous ulcers as no specific dressing has
been shown to improve healing rates
-
8/11/2019 Key Slides Leg Ulcer (2)
14/1814
Venous leg ulcer - compression bandagingClinical Knowledge Summary Venous Leg Ulcers
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 theankle 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 layerbandaging
An appropriately trained personshould apply high
compression multi-layer bandaging, to avoid the risk of pressure
ulceration over bony points
-
8/11/2019 Key Slides Leg Ulcer (2)
15/18
15
Venous leg ulcer - preventing recurrenceClinical Knowledge Summary Venous Leg Ulcers_February 2008
CREST Guidelines for the Assessment and Management of Leg Ulcers 1998
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 lessrecurrence than Class II (medium) compression stockings, but
may be less acceptable to the patient
-
8/11/2019 Key Slides Leg Ulcer (2)
16/18
16
Arterial leg ulcersGrey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50
Caused by reduced blood supply to the lower limbs either by a
blockin the artery or narrowing of the arteriesresulting 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
-
8/11/2019 Key Slides Leg Ulcer (2)
17/18
17
Arterial leg ulcersGrey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50Nelson EA et al.
Dressings and topical agents for arterial leg ulcers. Cochrane Database of
Systematic Reviews 2007, Issue 1.
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
-
8/11/2019 Key Slides Leg Ulcer (2)
18/18
18
Summary: leg ulcer therapeutics
For both venous and arterial leg ulcers Systematic assessmentof the wound is essential for baseline dataand to evaluate healing and treatment efficacy
Regular wound reassessmentis good clinical practice
There is insufficient evidence that one type of dressing is superior toanother in leg ulcer wound healing
Treat infection with systemic antibiotics not topical antimicrobials
Management of venous vs. arterial leg ulcers
Compression therapyis the mainstay of venous leg ulcermanagement, but should not be used for arterial ulceration or infected
wounds Increasing peripheral blood flowis the intervention most likely to
affect healing in arterial ulceration