Venous Leg Ulcers

An Evidence-Based Approach

Researched and Compiled by

Valarie, Sandy, Leann, Ruth

Venous Leg Ulcers

What interventions work best?

An Introduction:

Venous Leg Ulcers

 A non-healing open wound Often near the ankle With or without visible varicose veins

Signs and Symptoms

red, open, draining non-healing painful swollen leg

What Lies Beneath: Incompetent Perforators

Perforators should only allow inward flow from superficial to deep Valve competence in perforators is critical to protecting superficial tissues from elevated deep venous pressure

Risk Factors
Maternal history of venous insufficiency History of DVT, DM, chronic heart failure or recent edema Obesity Severe trauma to the leg Vigorous exercise Number of pregnancies

Venous Insufficiency: its in the circulation

edema

varicose veins

changes in color, skin

ulceration

Venous Leg Ulcer Facts

>80% of ulcers treated are venous

1-2% of the population affected

Rarely occurs < 45 years of age Average time to heal 12-30 weeks Annual burden: >$1B

Blood Flow: The key to Wound Healing

Poor circulation decreases delivery of oxygen and nutrients, prevents removal of metabolic waste products such as carbon dioxide, and ultimately delays healing.

Interventions
Modify activity to promote blood flow Apply compression therapy Provide local wound and skin care Treat and control infection, inflammation Improve nutrition

First Step: Assess for PAD

(Peripheral Arterial Disease)

Check pedal pulses before compression Use Doppler to check ABPI >0.8
(ankle/brachial press. index)

If ABI is <0.5 NO compression needs referral to vascular surgeon

Keep the pressure on: Unna Boot

A paste bandage with zinc oxide, glycerin, etc. Applied without tension distal to proximal to below knee Primary dressing applied first Boot dries to a semirigid cast Changed 1-2x q week, depends on drainage

Pneumatic Compression Pump

Inflatable boot and pump rhythmically fills with air Long-term use for pts noncompliant with other methods For pts who have failed treatment with other compression devices

Lifelong: Compression Therapy

After healing of ulcer, fit for custom stockings Remove and bathe each evening, apply moisturizer Each morning put on to prevent edema Metal frame used to assist Pt should purchase in pairs of two, replace every 6 months

Advanced Cases: Surgical Treatment

Subfascial endoscopic perforator surgery (SEPS) Improves healing rates, and reoccurence

Advanced Cases: Maggot Therapy

Maggots are currently one of the most effective means of treating ulcers with MRSA Specially bred fly larvae secrete enzymes to break down dead tissue into a liquid they will ingest The FDA approved this therapy in Jan, 2004.

Venous Leg Ulcers Random Control Trials

Study 1-Review Question: What are the effects of systemic antibiotics and topical antibiotics and antiseptic on healing?
22 RCTs included

High bacterial colonization

Currently no strong evidence

Venous Leg Ulcers Random Control Trials

Study 2 Efficacy and safety of CHRONOSEAL cream Evaluates if CHRONOSEAL
Is safe Is tolerated Reduces size

The study is currently recruiting participants

Sponsors and collaborators: Tripep AB, Kringle Pharma, Inc.

Venous Leg Ulcers Random Control Trials

Best Nursing Practice Identify and treat the cause

Obtain history Perform physical assessment Determine cause Implement appropriate therapy

Best Nursing Practice Address Patient Concerns

Communicate Establish realistic goals Provide information Assess support system

Best Nursing Practice Provide Wound Care & Support

Assess Optimize healing environment Consider additional therapies Refer as needed Consider all factors that affect healing Teach patient measures of prevention

REFERENCES
http://www.medscape.com http://www.mayoclinic.org/vascularcenter http://www.ncbi.nlm.nih.gov http://veinforum.org http://www.cawc.net/ http://www.VeinClinics.com http://www.icvein.com/

http://clinicaltrials.gov/identifier:nct00797706
Journal of Advanced Nursing, prepared by Joana Briggs Institute, Cochrane Library; 2008