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Venous Leg Ulcer Update
Tissue Viability Team
Feb 2018
What is a Venous Leg
Ulcer?
A Venous Leg Ulcer is defined as an open lesion between the knee and ankle joint that occurs in the presence of venous disease and takes more than 2 weeks to heal
NICE, 2013
Prevalence of Venous
Leg Ulceration 1.5 %of the Adult population have a Venous Leg Ulcer
At least 730,000 patients with Venous Leg Ulceration in the UK
1 in 170 Adults has a Venous Leg Ulcer
Guest et al, 2015
Those at risk of Venous
Leg Ulceration
Obesity or being over weight
This increases pressures known as hydrostatic pressures in the lower limbs
and abdomen
Reduced Mobility
This compromises venous return due to reduction in calf muscle pump usage
Previous history of DVT
Valves in the veins maybe damaged affecting venous return
Varicose veins
Malfunctioning valves cause swollen and enlarged veins
Previous limb injury or surgery
Such as bone fractures or flap surgery which may cause damage to the veins,
lymphatic's, mobility and gait
History of Intra venous drug
use
This increases the risk of DVT and vein damage
NHS, 2016
Increasing Age
This increases the risk of reduce mobility and conditions such as
arthritis which may restrict mobility
Chronic Oedema
Compromises skin and tissue condition
Family History
Maybe predisposed to varicose
veins increasing the risk malfunctioning valves
Why Venous Leg Ulcers
happen
Failure of the calf pump and the valves in the superficial veins which affect the
one way return uphill.
Reflux occurs downhill obstructing the veins
Results in pooling of blood in the lower part of the leg
Increased pressure causes fibrin deposits around the capillaries which inhibits
O2 and nutrients to the tissue
Signs of Venous Disease
Atrophie Blanche Oedema
Hemosiderin Staining
Ankle Flare Varicose Eczema
Varicose Veins
Hyperkeratosis
Cellulitis
Appearance of Venous Leg
Ulcer
Usually appear around the malleolus & gaiter region
Irregular in Shape
In the presence of the signs of Venous disease we have discussed
Shallow in appearance
Myths
A wound must be present on the
limb for at least 6 weeks to be
classed as a VLU and therefore treated with compression
A wound after 2 weeks should be
considered for compression
therapy
ABPI assessment confirms the presence of a
VLU
ABPI is not diagnostic
although it is a fundamental
component of assessment
If a wound is healing the
surrounding skin does not require
management
Surrounding skin should be protected
appropriately, with the safe removal of
hyperkeratosis and application of
emollient
Superabsorbent dressings should not be used under compression and should be applied
over if required
Superabsorbent dressings can be used as long as they manage the
exudate effectively, are not bulky and
protect the surrounding skin
Wounds UK, 2017
Quick refresher
Where are Venous Leg Ulcers usually located ?
What is the prevalence of Venous Leg Ulcers ?
What are the risk factors resulting in Venous Leg Ulceration?
Name some other causes of Leg Ulceration
What happens within the veins ?
What are the signs of Venous Disease?
Is completing ABPI a diagnostic tool ?
Cellulitis Venous Disease
May have pyrexia No pyrexia
Location - Anywhere Location – often lower third of limbs
Painful May be painful but pain often not acute
Inflamed erythema to specific location Discoloration around gaiter region
Bright red in colour Red/Brown, hyperpigmentation which may appear
inflamed when acute
Clearly defined edges No sharp defined edges
Tender to the touch Minimal tenderness
Warmth to skin Minimal/no warmth to skin
Cellulitis V’s Venous disease
Cellulitis Venous Disease
Skin can resemble orange peel Skin may have wooden appearance
No crusting Crusting can be evident
Oedema present to the surrounding
skin
General lower limb oedema
CRP, WCC may be raised No change to CRP or WCC
Unilateral Can be Unilateral but commonly
bilateral
Rapid onset Develops over weeks/ months
Primary Dressing Choice
Simple non-adherent dressings are recommended with the use of non-bulky absorbent layer if required for
exudate management
Silver dressings are not recommended in the routine treatment of patients with
venous leg ulcers when required to reduce local antimicrobial load apply
and reassess on a two weekly basis. If at re assessment there is no improvement or deterioration consider a different anti
microbial dressing
Myths
Hosiery kits are only for self caring patients
Hosiery kits can be applied by the patient, carer and health care
professionals
The compression system used determines the frequency of
changes required
This should depend on patient and presentation and not what
system is use
Compression should not be applied to the foot
Moderate to high compression must be applied at the foot to
prevent foot oedema
Venous leg ulcer are not painful
64% of patients with VLU’s report suffering with severe pain
Sterile water is required to wash VLU’s
VLU’s should be washed in a lined bucket or shower and are
not a sterile wound
Wounds UK, 2017
Doppler studies Explain the procedure to the patient
Lay the patient in the supine position for 15 minutes
Measure the Brachial systolic pressure, placing a cuff around the arm and applying gel to the brachial pulse. Gently
inflate the cuff whilst holding the Doppler probe over the pulse, once the signal is no longer heard deflate the cuff
slowly taking note of the pressure at which the pulse sound returns.
Repeat in for both arms
Do not be alarmed that arms may vary and use the highest value to calculate your ABPI
Next measure the ankle systolic pressure
Protect ulceration using appropriate covering (i.e. sterile bag from dressing pack)
Place appropriate sized cuff with the cables facing up the limb to avoid contact with the wounds and interruption
with the procedure above the malleoli
Locate Pulses using gel and probe, describing the sound, rhythm and strength
Monophasic (one sound)
Biphasic (Two sounds)
Triphasic (Three sounds)
Inflate the cuff as per brachial pressure listening for the signal returning. Complete this for 3 different pulses again
using the highest value to calculate your ABPI
Repeat on both limbs (limbs can vary)
Identifying Sounds
Mono-Phasic
(Compromised)
D-D-D-D DD-DD-DD DDD-DDD-DDD
Tri-Phasic
(Healthy)
Bi-Phasic
(Aging)
Interpreting Doppler
Studies
Calculate the ABPI
Highest Ankle Pressure (per Limb) ÷ Highest Brachial Pressure (Both Limbs) = ABPI
ABPI 0.5 and below – Potential critical ischemia, refer to vascular surgeons DO NOT COMPRESS.
ABPI 0.5 - 0.8 - Significant arterial disease, Refer to TVN.
ABPI 0.8 - 1.0 - Minor arterial disease, consider 20-40mmHg compression with holistic assessment.
ABPI 1.0 - 1.3 – Normal arterial flow, consider 40mmHg compression with holistic assessment.
Above 1.3 – Calcification may mean vessel cannot be compressed, Refer to TVN.
Evidence from Guest et al (2015)
• It appears that only 16% of patients with a leg or foot ulcer had a Doppler. However, national guidance in the UK for both leg ulcer management and the management of diabetic foot ulceration requires arterial assessment by Doppler ultrasound measurement of the ankle-brachial pressure index.
Choosing Compression
Therapy 40mmHg High compression multicomponent compression should be routinely used for the treatment of venous leg
ulcers.
Consider patient concordance when choosing the right compression
Check all patients 24-48 hours following the commencement of any compression
Compression should only be applied by staff with appropriate training in the specific component they are applying
LEG ULCER ALGORITHM – Adapted from the Best Practice Statement 2016.
[Type
Holistic Patient Assessment
including:
Past Medical History
Limb Assessment
Ulcer history
Consider other causes and refer
to appropriate specialist:
Dermatology
Malignancy
Pressure
Autoimmune
Arterial
Diabetes
ABPI less than 0.5
Urgent Referral to
vascular centre, NO
compression.
ABPI 0.5-0.8
Mixed disease, refer to
vascular/ Tissue
Viability team, reduced
compression
(20mmHg) following
specialist advice
PERFORM
ABPI
ABPI 0.8-1.3 No
evidence of significant
arterial disease, safe to
compress
ABPI over 1.3
Consider calcification. Assess
foot pulses, Doppler waveflow.
Consider referral to vascular.
Consider 20mmHG
compression.
Is the exudate
controlled within
topical dressing?
Consider why exudate is not
controlled with topical
dressings, is there any
evidence of infection or
increased bacterial load, is the
dressing size / choice
appropriate for exudate
amount?
If oedema present
apply:
ACTICO
Compression as
per instructions.
If no oedema
present apply:
ACTICO 2C
Or K-TWO
bandage systems
as per instructions
Once VLU is healed, refer to
Recommendations in Best Practice
Statement: Compression Hosiery (2nd
edition) Wounds UK.2015). Consider
referral to vascular services to assess
need for venous intervention to reduce
the risk of recurrence as per NICE
guidelines CG168 (2013)
Is there a large amount
of reducible oedema /
limb distortion?
Apply ACTICO
Compression
system
When oedema and
limb distortion
controlled, change to
European
classification hosiery
40mmHG kit
Compression
Hosiery kit
40mmHG
After 4 weeks of
treatment, if there is no
reduction in ulcer size
refer to vascular/ Tissue
Viability service for
review
Yes
No
Yes
No
Or
Reassess
Weekly
Any Questions?