Venous Leg UlcersVenous Leg UlcersAn Evidence-Based Approach

Researched and Compiled byResearched and Compiled by

Valarie, Sandy, Leann, Ruth

Venous Leg UlcersVenous Leg Ulcers

What interventions work best?

An Introduction:An Introduction:

Venous Leg UlcersVenous Leg Ulcers

• A non-healing open wound

• Often near the ankle

• With or without visible varicose veins

Signs and SymptomsSigns and Symptoms

• red, open, draining

• non-healing

• painful

• swollen leg

What Lies What Lies Beneath:Beneath:IncompetentIncompetentPerforatorsPerforators• Perforators should

only allow inward flow from super-

ficial to deep

• Valve competencein perforators is critical to protectingsuperficial tissues from elevated deep venous pressure

• 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

Risk FactorsRisk Factors

Venous Insufficiency:Venous Insufficiency:

it’s in the it’s in the circulationcirculation

edema varicoseveins

changes in color, skin

ulceration

• >80% of ulcers treated are venous

• 1-2% of the population affected

Venous Leg Ulcer FactsVenous Leg Ulcer Facts

• Rarely occurs < 45years of age

• Average time to heal 12-30 weeks

• Annual burden: >$1B

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

Blood Flow:Blood Flow:The key to The key to Wound Wound HealingHealing

InterventionsInterventions

• Modify activity to promoteblood flow

• Apply compression therapy

• Provide local wound andskin care

• Treat and control infection, inflammation

• Improve nutrition

First Step: Assess for PADFirst Step: Assess for PAD(Peripheral Arterial Disease)(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: Keep the pressure on: Unna Boot Unna Boot

• A paste bandage withzinc oxide, glycerin, etc.

• Applied without tensiondistal 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 Pneumatic Compression Pump Pump

• Inflatable boot and pump

rhythmically fills with air

• Long-term use for ptsnoncompliant with

othermethods

• For pts who have failedtreatment with other compression devices

Lifelong: Lifelong: Compression Compression TherapyTherapy

• 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:Advanced Cases:Surgical TreatmentSurgical Treatment

• Subfascial endoscopic perforator surgery (SEPS)

• Improves healing rates, and reoccurence

Advanced Cases:Advanced Cases:Maggot TherapyMaggot Therapy

• Maggots are currently one of the mosteffective 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 thistherapy in Jan, 2004.

Venous Leg UlcersVenous Leg UlcersRandom Control TrialsRandom 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 UlcersVenous Leg UlcersRandom Control TrialsRandom 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 UlcersVenous Leg UlcersRandom Control TrialsRandom Control Trials

Best Nursing PracticeBest Nursing PracticeIdentify and treat the causeIdentify and treat the cause

• Obtain history

• Perform physical assessment

• Determine cause

• Implement appropriate therapy

Best Nursing PracticeBest Nursing PracticeAddress Patient ConcernsAddress Patient Concerns

• Communicate

• Establish realistic goals

• Provide information

• Assess support system

Best Nursing PracticeBest Nursing PracticeProvide Wound Care & Provide Wound Care &

SupportSupport

• 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