Friday, 25 February 2011

Wednesday, 15 December 2010

Pressure Ulcers

EPUAP grading system
Glos Trust Policy
RCN Guidelines
NICE Guidelines for management of pressure ulcers in primary and secondary care.
Powerpoint presentation
Wound care websites
2004 Nursing Times Article
Glos Policy on Fungating Wounds
Glos Patient Leaflet on Pressure Ulcers
Judy Waterlow Site
Whittington Hospital Guidelines
30% Tilt
Critical review of Waterlow
Systematic review of Positioning as a means to improve pressure area care.

EPUAP2 (European Pressure Ulcer Advisory Panel) grading system

stages PU development

Grade FourFull thickness skin loss involving muscle, bone or supporting structures



Grade ThreeFull thickness skin loss involving damage to sub-cutaneous tissue that may extend to but not through the underlying fascia



Grade TwoPartial thickness skin loss involving epidermis, dermis or both



Grade OneNon blanching erythema


Figure 1: This illustrates the stages of pressure ulcer
development according to the EPUAP grading system.

PU Grade 4

Figure 2: A grade 4 pressure ulcer.

The principles of best practice with regard to wound management should be adopted in order to resolve symptoms and tissue types at the wound bed and ensure the dressing regime selected maximises patient comfort and supports a moist wound healing interface. Pressure Ulcers are recognised to be chronic wounds which can take time to heal.

Pressure Ulcers are prone to infection and odour and Clinisorb activated charcoal dressing is a useful dressing to use in the management of these symptoms. LBF may also prove valuable in protecting the delicate peri-wound area from exudate and excoriation.

Other sections available:-

Monday, 13 December 2010

Free Accreditation and NHS Choices

Cancer Nursing
NHS Choices

Harvard Referencing System

Access to Cinahl

Glos Uni

http://ist.glos.ac.uk/referencing/harvard/


References

Bosworth, D.P. (1992) Citing your references: a guide for authors of journal articles and students writing theses or dissertations. Thirsk, N Yorks: Underhill Press.

Craig, P. (2003) 'How to cite', Documentation Studies, 10(1), pp. 114-122.

Li, X. and Crane, N. B. (1996) Electronic styles: a handbook for citing electronic information. 2nd ed. Medford, New Jersey: Information Today.

Walliman, N. (2001) Your research project: a step-by-step guide for the first-time researcher. London: SAGE.

Wednesday, 1 December 2010

Patient Compliance with Compression Bandaging

http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2702.2007.01996.x/abstract

Aim.  To describe and explore reasons for use or non-use by district nurses of compression bandaging, a best practice component of venous leg ulcer management.

Background.  Leg ulcers are costly to both individuals and communities. The most prevalent of leg ulcers are venous leg ulcers, which are common wounds treated by district nurses. Compression bandaging is the best practice for the treatment of venous leg ulcers with considerable evidence that this aids healing in an effective and timely manner. It is anecdotally known that compression bandaging is not always used by district nurses when treating venous leg ulcers, yet little is known as to why this is so.

Method.  A qualitative descriptive/exploratory study was used; interview data were collected with constant comparative data analysis applied until data saturation was obtained.

Findings.  As could be anticipated, several basic elements need to be present for a district nurse to use compression bandaging, like knowing that compression bandaging is best practice, knowing how to use compression bandaging and being able to determine that the ulcer is venous in nature. However, the major finding is the essentialness of having a patient willing for compression bandaging to be applied and sustained; the study explored what determines willingness or non-willingness and strategies that can be used to encourage willingness.

Conclusion.  A prime enabler of the use of compression bandaging is having a patient willing to agree to the commencement of this treatment and for this to be sustained. Consequent recommendations are offered. Evidence-based nursing requires not only knowledge of cause and effect evidence but also evidence that provides understanding about human responses and choices when there is a health challenge.

Relevance to clinical practice.  The relevance of the findings for clinical practice is that knowledge is provided about what factors may constrain a patient's willingness for compression bandaging to be applied and sustained as treatment for a venous leg ulcer and about what actions can be tried to facilitate willingness.

Ankle Brachial Pressure Index

Doppler assessment: calculating an ankle brachial pressure index

21 October, 2003

VOL: 99, ISSUE: 42, PAGE NO: 62

Deborah Ruff, RGN, is vascular nurse specialist, The Royal Oldham Hospital, Oldham
An ankle brachial pressure index (ABPI) is a simple non-invasive method of identifying arterial insufficiency within a limb. It compares the ankle and brachial systolic blood pressures. An important factor determining the rate of healing of any wound is adequate arterial blood supply. In the management of leg ulcers, the ABPI forms a fundamental part of the assessment.

An ankle brachial pressure index (ABPI) is a simple non-invasive method of identifying arterial insufficiency within a limb. It compares the ankle and brachial systolic blood pressures. An important factor determining the rate of healing of any wound is adequate arterial blood supply. In the management of leg ulcers, the ABPI forms a fundamental part of the assessment.

It should be noted that the ABPI should not be undertaken in isolation, but should be used in conjunction with a holistic assessment, and a medical and clinical examination of the limb.

In the past, a clinical examination would have involved palpating the pulses to detect any arterial impairment. However, the evidence is that palpation of pulses is subjective and prone to considerable error (Moffatt and O'Hare, 1995).

KEY POINT - Accurate assessment is necessary to determine the correct aetiology of the ulcer and exclude those patients with arterial disease for whom compression is dangerous (Stacey et al, 2002).

How is the ABPI calculated?
Equipment The procedure requires the following equipment:

- Bed or couch;

- Hand-held Doppler ultrasound machine;

- 8mHz probe (5mHz probe if required for large or oedematous limbs);

- Ultrasound transducer gel;

- Sphygmomanometer and cuff;

- Cling film/vapour-permeable film dressing or equivalent;

- Calculator.

KEY POINT - In order to prevent cross-infection the Doppler probe should be cleaned twice with an alcohol impregnated wipe prior to its use (Kibria et al, 2002).

Preparation of the patient:

- Provide the patient with an information leaflet about the procedure prior to the appointment;

- Explain the procedure to the patient to relieve any anxieties he or she may have;

- Ensure the room temperature is comfortable;

- Ask the patient to remove any tight articles of clothing, which may cause pressure on the blood vessels proximal to the site where the blood pressure is being measured;

- Remove any dressings from the ulcers and cover with clear film to reduce risk of cross-infection (Kenny, 1997);

- Ask the patient to lie flat and rest for a minimum of 10 minutes to obtain a resting pressure (Yao, 1993).

PRACTICAL TIP - If the patient is unable to lie flat, elevate the legs to the level of the heart. By elevating the legs, the hydrostatic pressure to the legs is reduced.

Measure the brachial systolic blood pressure:

- Select a sphygmomanometer cuff of an appropriate size and wrap it around the patient's upper arm just above the elbow;

- Palpate the brachial pulse and apply ultrasound gel;

- Angle the Doppler probe at 45 degrees to the direction of the blood flow (towards the heart) and adjust the position to locate the best signal;

- The Doppler emits an audible signal. Some Doppler ultrasound machines also provide a visual wave form;

- Inflate the sphygmomanometer cuff until the signal disappears, then deflate the cuff slowly and record the pressure at which the signal returns;

- Repeat this procedure using the patient's other arm (Stubbing et al, 1996);

- Use the highest of these two readings to calculate the ABPI.

PRACTICAL TIP - Place the cuff upside down, to prevent the tubing being soiled by the gel.

Measuring the ankle systolic pressure:

- Select an appropriately sized sphygmomanometer cuff and place around the leg just above the ankle;

- Palpate the posterior tibial artery, apply ultrasound gel and locate the best signal (Fig 1);

- Inflate the sphygmomanometer cuff until the signal disappears, then deflate the cuff slowly and record the pressure at which the signal returns;

- Repeat this procedure with either the anterior tibial or peroneal artery (Fig 1);

- Use the highest of these two readings to calculate the ABPI (Vowden and Vowden, 1997).

Calculating the ankle brachial pressure index and interpreting the findings The ABPI is calculated using the following equation:

ABPI = highest ankle systolic pressure/highest brachial systolic pressure

An ABPI <0.8>0.8 does not necessarily mean that high-compression bandaging can be undertaken safely. Other factors such as diabetes, rheumatoid arthritis, peripheral neuropathy and cardiac failure need to be considered before applying compression. In these circumstances, reduced compression would be a more suitable option.

If the ulcer is classified as having a mixed aetiology, and the ABPI is 0.5-0.8, it is important to refer the patient to a specialist team with immediate access to vascular services. Following a holistic assessment, the patient may be treated with reduced compression at 15-25mmHg.

For patients with an ABPI <0.5, compression therapy is contraindicated and urgent referral to a vascular specialist is recommended.

Factors creating an erroneous ankle brachial pressure index:

- Inadequate preparation, for example uncomfortable room temperature. Extremes of temperature can make the patient restless and extreme cold can make the signal difficult to hear due to vasoconstriction;

- Patient anxiety;

- Incorrect positioning of the patient;

- Inappropriate gel;

- Incorrect size of sphygmomanometer cuff;

- Incorrect size of Doppler probe;

- Excessive pressure on the blood vessel during the procedure;

- Releasing the sphygmomanometer cuff from the patient too quickly;

- Prolonged inflation of the sphygmomanometer cuff or repeated inflation;

- Moving Doppler probe during the procedure;

- An inexperienced practitioner.

[H2] Contraindications
There is controversy about the circumstances in which an ABPI should not be performed, so more research is required. It has been suggested that an ABPI should not be performed under the following circumstances:

- If the patient has a suspected deep vein thrombosis, because there is a risk of emboli;

- If the patient has cellulitis, because the procedure would be too painful;

- If the patient has severe ischaemia, because there is a risk of further tissue damage.

How often should the ABPI be performed?
It is recommended that the APBI should be repeated every 12 weeks (Simon et al, 1994). However, if the patient's condition changes during that time, for example if he or she experiences an increase in pain or deterioration in the condition of the ulcer, the procedure should be repeated. If the ulcer reoccurs, repeat the leg ulcer assessment. Never presume the ulcer is of the same origin.

How reliable is the ABPI?
For most patients, the ABPI is a reliable method of detecting arterial insufficiency. However, in some cases:

- The result may be falsely elevated in patients with diabetes due to calcification of the medial layer of the artery, preventing the arteries from being compressed (Williams et al, 1993);

- An exercise test may be more accurate for patients with suspected arterial disease who have a normal resting ABPI, but where there is doubt about the diagnosis. Following exercise, a fall in the ABPI is indicative of arterial disease (Laing et al, 1983).

For these patients, Doppler waveforms and toe pressures are a more reliable method of assessment (European Leg Ulcer Advisory Board, 2002).

Waveform analysis
As the practitioner becomes more experienced with the procedure, he or she may also be able to detect a difference in the quality of the audible signal transmitted from the Doppler machine.

Triphasic waveform - In the lower limb, the Doppler signal detected from the arterial flow has three phases and is therefore described as 'triphasic' (Fig 2).

Phase one - During systole (as the heart contracts), blood flow accelerates in a forward direction within the blood vessel.

Phase two - A drop in peak systolic pressure leads to a reverse flow of blood within the blood vessel.

Phase Three - Elastic recoil of the vessel at the end of diastole (when the heart muscle relaxes) leads to a further forward flow of blood in the vessel.

Biphasic waveform - Vessels naturally lose their elasticity as part of the ageing process, making the signal biphasic. Fig 3 illustrates the loss of the reverse blood flow component (phase three).

Monophasic waveform - A monophasic signal produces only one sound and usually denotes vessel disease. The sound heard is usually lower in pitch. Fig 4 illustrates the loss of phases two and three and reduced blood flow during systole (phase one).

Conclusion
Provided that the ABPI is performed correctly and the factors affecting the results are considered, the literature suggests it is a simple, reliable method of assessing arterial insufficiency within a limb (Vowden and Vowden, 1996). Calculating the ABPI is a vital part of the assessment process when examining a patient with leg ulceration, but the results should always be used in conjunction with a holistic assessment and never in isolation. This reduces the risk that compression bandaging will be applied inappropriately.

FURTHER INFORMATION
European Wound Management Association (2003) Understanding Compression Therapy. London: Medical Education Partnership.

This useful document is divided into four sections:

- Understanding the pathophysiological effects of compression;

- Compression bandages: principles and definitions;

- Cost effectiveness of compression therapy;

- Compression therapy: a guide to safe practice.

It contains a treatment pathway developed by the Leg Ulcer Advisory Board for the use of compression therapy in venous leg ulcers. It is sponsored by a educational grant from Smith and Nephew and can be downloaded at: www.proguide.net
Have your say

Managing compression therapy in a care home setting

Leg ulcer assessment and management is complex and requires the input of nurses with specialist training. Irene Anderson provides guidance on the management of residents with leg ulceration.

Leg ulceration affects between 1 and 2% of the population in the UK and many people who suffer with the condition are elderly (Briggs and Closs, 2003). If a person with leg ulcers is admitted to a care-home setting (or develops leg ulcers as a resident) it is very important that she or he has access to skilled and competent clinical practitioners otherwise her or his condition may deteriorate leaving them at risk of further damage to the leg, due to inappropriate management (Anderson, 2003).

Causes of leg ulceration
Most leg ulcers are caused by venous disease (70%) although a significant proportion (10–15%) may be due to arterial disease, particularly in an older population (Moffatt, 2001). Approximately 15–20% may be due to a combination of either factors or other co-existing conditions such as rheumatoid arthritis (Morison and Moffatt, 2004).
Veins carry blood back to the heart and contain valves that prevent backflow of the blood. As we walk and flex our ankle joint, the calf muscle pump pushes the venous blood up the leg. If the valves are damaged by, for example, surgery, trauma or deep vein thrombosis, backflow can occur. If the resident is non-mobile or has a fixed ankle joint, the calf muscle is not activated and venous congestion results. This congestion causes the vein pressure to rise and so the capillaries swell to deal with the extra volume of blood. This makes the capillaries leak fluid and other cells into the tissues, which results in oedema and skin changes (Anderson, 2006).

Managing venous leg ulcers
The management of venous ulcers focuses on elevating the leg when sitting to reduce oedema, mobilising as much as possible, moving the ankle to activate the calf muscle, and compression therapy. Compression may be in the form of bandages or hosiery. To ensure effective treatment and patient safety a full clinical assessment, including the use of a hand-held Doppler to help exclude the presence of arterial disease, needs to be carried out before compression therapy is begun and at intervals thereafter.
The resident may be at risk if compression therapy is not applied by a skilled and trained practitioner (RCN, 2006) and a referral should be made to a specialist as soon as possible. The appropriate person to refer to may be a district nurse or a tissue viability/leg ulcer specialist nurse.
Maintaining competencies
There may be scope in a care home to have personnel with the required competencies in assessment and compression therapy but such competencies need to be practised to remain current. If residents requiring compression therapy are small in number then it is unlikely that the designated nurse will maintain the required level of skill (Anderson, 2003). It may be worth exploring methods of updating in collaboration with other settings (for instance, a local leg ulcer clinic).
If there are a significant number of residents requiring leg-ulcer care then managers need to consider accessing appropriately validated courses for their staff, ensuring that such courses include assessment of competencies and sufficient theoretical components to ensure competent and evidence-based care (Fletcher, 2006).
An algorithm has been published (Aldeen, 2007) that is designed for use in the acute sector where practitioners may not have or be able to maintain appropriate competencies. This is also useful in care homes.

Ensuring safe care
It is vital that the resident receives skilled input as soon as possible and that her or his admission to the care home prompts a further assessment of her or his lower-limb condition. By protecting the resident’s legs, managing the underlying venous disease by promoting venous return, and monitoring for progression of arterial disease, the resident is less likely to experience deterioration and/or recurrence of her or his ulcer.
Author Irene Anderson, MSc, PGCE, BSc, LPE, DPSN, RGN, is senior lecturer, tissue viability, University of Hertfordshire and chairperson of the Leg Ulcer Forum.

References
Aldeen, L. (2007) Recommendations for leg ulcer care in acute trusts. Nursing Times; 103: 43, 40-42.
Anderson, I. (2006) Aetiology, assessment and management of leg ulcers. Wound Essentials; 1: 20-37.
Anderson, I. (2003) Developing a framework to assess competence in leg ulcer care. Professional Nurse; 18: 9, 518-522.
Briggs, M., Closs, S.J. (2003) The prevalence of leg ulceration: a review of the literature. EWMA Journal; 3: 2, 14–20.
Fletcher, J. (2006) So you want to do a leg ulcer course? Leg Ulcer Forum Journal; 20: 44–46.
Moffatt, C. (2001) Leg ulcers. In: Murray, S. (ed) Vascular Disease: Nursing and Management. London: Whurr.
Morison, M.J., Moffatt, C. (2004) Leg ulcers. In: Morison, M.J. et al (eds) Chronic Wound Care: A Problem-based Learning Approach. Edinburgh: Mosby.
RCN (2006) The Nursing Management of Patients with Venous Leg Ulcers.
www.rcn.org.uk.


For a guide on managing leg ulceration click on Tissue Viability

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Costs can be cut by providing high quality training in leg ulcer care

3 September, 2010

Leg ulcer care is complex, and a lack of understanding by managers and funders about its management can cause unnecessary costs and harm care, says Irene Anderson

Wound care is a complex specialty, and requires a vast range of skills and knowledge on how to assess and manage patients. It comes with the potential to do harm and incur costs.

Managers may not be aware of issues around specific wound types and their treatment. Patients may be at risk if the person delivering treatment does not have the skills to do this, or know how to conduct continuous assessment.

Redistribution of resources and staffing may lead to staff carrying out care for which they are not competent. In these circumstances, educational processes, competence frameworks and support should be put in place, and there should be expert leadership from people with relevant knowledge and skills.

There are no national competencies or standards for leg ulcer management, although the RCN Leg Ulcer Guidelines (RCN, 2006) serve as a framework for the components of leg ulcer care.

Leg ulcer training can be provided in house, by commercial companies or by higher education institutions. Questions we need to ask about education centre on course content and the qualifications, experience and teaching ability of those delivering such courses.

Many decisions are made on the basis of clinical presentation, so experience should be gained in real life situations; using models and simulations may not develop skills and test competencies on the intricacies of the type of skin and leg shapes many patients have. The person responsible for signing off these competencies needs to be prepared and qualified for this.

At the Leg Ulcer Forum conference in April 2010, interim results were presented from an RCN survey of community nurses. Early findings show that about a quarter of nurses have not had leg ulcer training in the past three years, some for much longer. Considering leg ulcer care takes up over half of a community nurse’s caseload, this is a concern.

More practice nurses are becoming involved in leg ulcer care. This is fine if the nurse has the skills and time and space is allowed for this. However, we often hear this is not the case and that patients are being treated for months without any progress being made.

It is pointless to blame practice nurses: the problem is a lack of recognition by managers and funders about leg ulcer management and the benefits of training and support.

Prevention is better than cure, but funding for leg ulcer prevention is not seen as a priority. People with signs of vascular disease, venous or arterial, and those with chronic oedema would benefit from a proactive service offering assessment and prevention strategies.

More leg ulcer clinics are needed to concentrate expertise, costs and logistics in one place. This would drive up care standards, develop more centres of excellence and reduce the isolation many patients feel.

Quality frameworks allow us to work more closely with patients and demonstrate that our work is effective, professional and makes a difference.

The financial climate means we have rethink how we approach the management of people with leg ulceration and related conditions. Improvements in care will be driven by skilled and knowledgeable practitioners. This relies on quality education that is focused on quality care, and patient outcomes must be inherent in the quality measurements.

IRENE ANDERSON is a reader in learning and teaching in healthcare practice and module leader for leg ulcer theory and practice and complexities in leg ulcer management courses at the University of Hertfordshire, and chair of the Leg Ulcer Forum

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BMJ 2004; 328 : 1358 doi: 10.1136/bmj.328.7452.1358 (Published 3 June 2004)

Management of venous leg ulcers

  1. Deborah A Simon, research nurse specialist1,
  2. Francis P Dix, research fellow1,
  3. Charles N McCollum, professor of surgery (cnmcc@man.ac.uk)1

+ Author Affiliations

  1. 1Academic Department of Surgery, Wythenshawe Hospital, Manchester M23 9LT
  1. Correspondence to: C N McCollum

Introduction

Leg ulcers are a big problem for both patients and health service resources.13 Most ulcers are associated with venous disease, but other causes or contributing factors include immobility, obesity, trauma, arterial disease, vasculitis, diabetes, and neoplasia (box 1). In the United Kingdom, venous leg ulceration alone has been estimated to cost the NHS £400m ($720m; €600m) a year.13 Much of this cost is accounted for by community nursing services; district nurses spend up to half of their time caring for patients with ulcers.1 4

Most venous leg ulcers could be healed if patients were admitted to hospital for continuous leg elevation. Shortage of hospital beds, the high cost of inpatient care, and the need to maintain independence in this elderly population of patients mean that this once popular approach is now rarely practical.2 Furthermore, ulcers often recur when the patient returns home and resumes a lifestyle in which most of the day is spent with the legs in dependency.w1 Outpatient systems of care that maintain mobility and avoid the complications of bed rest are more cost effective and appropriate. Outpatient and community based care also maintain independence and quality of life.

Care for patients with leg ulcers has improved in the past two decades as research based approaches have been adopted. Community leg ulcer clinics using compression bandaging have dramatically improved healing rates and reduced costs, but close supervision by leg ulcer nurse specialists is essential if standards are to be maintained.1 2 5 We have reviewed the evidence for this approach and on new treatments that may improve care of leg ulcers in the future.

Sources and search criteria

We compiled material for this review from published literature located by online searches of Medline, PubMed, and Embase using the terms “leg ulcer management,” “treatment of leg ulcer,” and “leg ulcer.” We also sourced references quoted in these original papers and examined Cochrane reviews on leg ulcers.

Causes of venous ulceration

The pathophysiology of venous ulceration is contentious, and detailed consideration of the microcirculatory changes leading to tissue necrosis is beyond the scope of this review. However, management must be based on an understanding of the causes of the venous hypertension that is ultimately responsible for both the symptoms of chronic venous insufficiency and venous ulceration. Chronic venous insufficiency has been widely assumed to be due to deep venous obstruction or incompetence, and the term “post-phlebitic limb” has been used, even though most people with venous ulcers have no history of deep vein thrombosis. Venous ulceration is clearly associated with age, and younger patients with severe chronic venous insufficiency may avoid ulceration by virtue of their mobility, which maintains function of the calf muscle pump. Whether the final mechanism in ulceration is a fibrin cuff, leucocyte trapping, or chronic inflammation due to a repetitive ischaemia reperfusion injury, the treatment for venous ulceration is based almost entirely on avoiding sustained venous hypertension.6 Venous hypertension is usually caused by a combination of the factors given in box 2, of which venous disease, obesity, and immobility are perhaps the most important; many factors develop with increasing age.

Summary points

Care of patients with venous leg ulcers has been improved by a research based approach

Most venous ulcers can be managed by compressionbandaging in the community

Supervision by leg ulcer nurses is essential if standards are to be maintained in community leg services

Future research should focus on preventing by identifying at risk populations

Sustained venous hypertension results in oedema within the dependent lower limb, which increases the distance over which metabolites must diffuse from the microcirculation to tissue cells. The tissues around the ankle become ischaemic during dependency, with reperfusion on walking or elevation.7 This chronic reperfusion injury results in an inflammatory process with further oedema, tissue fibrosis, and formation of a cuff of extracellular matrix proteins around capillaries. These changes result in the features of chronic venous insufficiency, which include aching, heaviness of the legs, itching, lipodermatosclerosis, pigmentation, swelling, eczema, and ultimately ulceration (fig 1). Treatment is based on preventing sustained venous hypertension and reducing its effects by compression bandaging to reduce venous stasis and tissue oedema.

Fig 1

Fig 1

This superficial leg ulcer, in the classic position above the medial malleolus, has healthy granulation tissue after two weeks of compression treatment. The features of lipodermatosclerosis with pigmentation can be seen at the upper margin

Box 1: Causes of leg ulcers

Vascular

  • Venous—80-85% of all leg ulcers

  • Arterial—atherosclerosis, arteriovenous malformation

  • Vasculitis—systemic lupus erythematosis, rheumatoid arthritis, scleroderma, polyarteritis nodosa, Wegener's granulomatosis

  • Lymphatic

Neuropathic

Diabetes, peripheral neuropathy—usually feet

Haematological

Polycythaemia rubra vera, sickle cell anaemia

Traumatic

Burns, cold injury, pressure sore, radiation, factitious

Neoplastic

Basal or squamous cell carcinoma, melanoma, Marjolin's ulcer, Bowen's disease

Others

Sarcoidosis, tropical ulcer, pyoderma gangrenosum

Diagnosis and investigation

Management must start with a full history and examination to identify risk factors such as age, sex, cardiovascular disease, body mass index, mobility, arthritis, diabetes, and a history of leg injury or deep vein thrombosis. Leg ulceration can be defined as any chronic ulcer on the lower leg but excluding those on the forefoot or toes.w2

The patient should be examined both lying and standing to detect varicose veins. Hand held Doppler is essential to measure the ankle brachial pressure index to exclude arterial disease (ankle brachial pressure index > 0.9) and assess superficial venous reflux.w3 Venography gave little functional information and has been superseded by duplex imaging, which is indicated for patients with recurrent or complicated varicose veins, short saphenous incompetence, or suspected deep venous disease.8 Superficial venous incompetence is almost universal and is the predominant cause of venous hypertension in approximately half of limbs with venous ulcers, particularly in younger patients with good mobility.9 Venous function in patients with mixed deep and superficial disease should be investigated by ambulatory venous pressure measurements.10 This involves cannulation of a foot vein and the use of tourniquets to occlude incompetent superficial veins to select those patients who may benefit from superficial venous surgery.

Box 2: Causes of sustained venous hypertension

• Venous disease:

Superficial venous incompetence—varicose veins

Deep venous incompetence

Primary Deep venous obstruction (rare)

Previous deep vein thrombosis

External compression

• Impaired calf muscle pump function:

Immobility

Joint disease

Paralysis

Obesity—immobility, femoral vein compression, high abdominal pressures

• Congestive cardiac failure

Box 3: Effective treatment for venous leg ulcers

  • Four layer compression bandaging

  • Leg elevation

  • Improve mobility

  • Reduce obesity

  • Improve nutrition

  • Skin grafting in selected patients

  • Venous surgery in selected patients

Management of the ulcer

Despite considerable research, little evidence of major benefits from modern interactive dressings has been published. An emphasis on education, training, and further development of compression systems is needed to improve patient care and ulcer healing. The basis for effective treatment of venous leg ulcers is outlined in box 3.

Where should care be carried out?

Patients with venous leg ulcers are best managed in the community for two reasons:

  • Maintenance of independence and mobility is important in this elderly population

  • The number of patients would overwhelm hospital services.1 2

However, direct access to appropriate specialised hospital services is essential forthe investigation of underlying vascular disease and for microbiology, histopathology, and dermatology. Having said that, leg ulcer services provided in hospitals often fail to appreciate how many patients with leg ulcers simply refuse to come to hospital, let alone consent to venous investigation or surgery.1 2 Few community patients are prepared to be referred for assessment of their underlying venous disease.12 5

Rates of healing have been shown to be improved and costs to be reduced when a coordinated service using research based protocols was introduced.1 2 5 11 Responsibility for patient care should not be removed from community nurses; they should be provided with resources and training aimed at delivering an appropriate, high quality service in specialist leg ulcer clinics. Evidence from our own research in two large health authorities in the United Kingdom showed that standards could be maintained only with close supervision; when a leg ulcer service was continued without the direct involvement of a leg ulcer nurse specialist, healing rates declined and costs increased.5

Treating the ulcer

The underlying causes need to be identified (box 2). Multiple pathologies are common, but patients with diabetes may have simple venous ulcers that are no more difficult to heal than in people without diabetes. As 80-85% of ulcers are associated with venous hypertension, compression remains the mainstay of treatment.12 w4

Dressing materials Patients with leg ulcers are prone to contact sensitivity, particularly from wool alcohols, topical antibiotics, cetylstearyl alcohols, parabens, and rubber mixes, which are present in many dressings, ointments, and creams.w5 Many entirely inadequate studies have examined the role of different dressing materials; most have shown that modern “designer” dressing materials have no additional effect on wound healing over that achieved by simple low adherence dressings under multilayer compression bandaging.w6

Compression treatment Sustained graduated compression overcomes the effects of venous hypertension by reducing venous stasis and preventing (or treating) tissue oedema. The pressure within the veins on standing is largely hydrostatic, and the level of external pressure needed to counteract this decreases progressively up the leg.

Compression treatment has been covered in a Cochrane review on the cost effectiveness of both bandaging and stockings in the treatment of venous ulceration.13 Twenty two trials were identified and consistently showed that compression encouraged healing of ulcers.13 More ulcers were healed at 12-15 weeks with high compression systems than with low compression systems.13 No significant difference was found between the effectiveness of different high compression systems, but more ulcers healed at 24 weeks with four layer bandages than with a single layer.w7

The most effective level of compression to overcome venous hypertension has been determined to be around 40 mm Hg at the ankle.w8 Correct application of bandages is essential to avoid pressure ulceration over bony high points and along the anterior border of the tibia. To achieve this pressure in a range of limb diameters, bandaging regimens must be adjusted according to ankle circumference (fig 2). Despite training, community nurses have been found to abandon ankle circumference measurements when not closely supervised by a venous nurse specialist.5

Fig 2

The combination of compression bandages used to achieve compression of 40 mm Hg at the ankle will depend on ankle circumference according to Laplace's law. A combination of bandages achieving ideal pressures in the average ankle will produce ineffective pressures in a large oedematous limb and dangerously high pressures risking skin necrosis over bony high points in small or narrow ankles

As venous ulcer services improve, more patients have their ulcers healed and are then at risk of recurrence; recurrence rates of 26% at one year and 31% at 18 months have been quoted.14 A Cochrane review on the role of compression in the prevention of recurrence identified few adequate trials, but concluded that recurrence may be lower with higher compressions.15

Limb elevation Limb dependency, immobility, and oedema all contribute to venous hypertension. Limb elevation reduces oedema and enhances flow in the microcirculation, reducing trapping, sequestration, and activation of white cells—a necessary first step in the pathophysiology of ulceration.w9 Leg elevation in hospital enhances healing.w1

Skin grafting Split skin grafting is technically demanding and requires hospital admission. The discharge from the surface of venous ulcers tends to dislodge continuous sheets of split skin, leaving a choice between mesh and pinch skin grafting.w10

Box 4: Indications for superficial venous surgery

  • Patient fit for surgery (local anaesthesia if necessary)

  • Sufficient mobility to activate calf muscle pump

  • Prepared to attend hospital for investigation and surgery

  • Obesity controlled (body mass index <>

  • Superficial venous incompetence: no deep venous incompetence on duplex imaging, or predominantly superficial venous incompetence on ambulatory venous pressures with tourniquet occlusion of the superficial veins

Information resources for patients and professionals

Tissue Viability Society (www.tvs.org.uk/Booklets/legulcers.html)—Aims to raise standards in the prevention and treatment of chronic wounds Vascular Surgical Society (www.vssgbi.org/patientinfo/legulcer.html)—Information resource for doctors and patients

British Vascular Foundation (www.bvf.org.uk/cond_explained.htm)—Information resource for healthcare professionals and patients

Patient UK (www.patient.co.uk/showdoc.asp?doc=23068777)—Usefulresource for patients

Pinch skin grafts provide epithelial islands, from which epithelial growth may spread outwards as well as inwards from the ulcer margin. Pinch skin grafting has been done by district nurses in the community and has been found to be cost effective, accelerating healing when used with multilayer compression bandaging (fig 3).w11 w12

Fig 3

Pinch skin grafts applied two weeks previously are growing halos of new epithelium that are beginning to merge (top). Only one week later, perhaps as a result of growth factors from healing epithelium, almost complete healing has been achieved (bottom)

Bioengineered skin products, including bilayered skin constructs and frozen human allogeneic epidermal cultures, are being developed and may stimulate wound healing through the release of growth factors and cytokines. The numbers of patients recruited to such studies have been small, and most products are not yet available for clinical use.w13 w14 These new approaches have yet to be compared with pinch skin grafting, which is simple and inexpensive.w12

Growth factors Wound fluid from non-healing ulcers contained higher concentrations of pro-inflammatory cytokines, interleukin-1, interleukin-6, and tumour necrosis factor-╬▒ and had reduced proliferative responses compared with fluid from healing ulcers.16 Research on platelet derived growth factor, hepatocyte growth factor, and human keratinocyte growth factor-2 has been published, but these studies were small and often poorly designed.17 w15 w16

Drug treatment Antibiotics have little effect on ulcer healing but are needed for clinical infections with surrounding cellulitus.w17 Pentoxifylline has been evaluated in clinical trials, but the largest placebo controlled, double blind, randomised study included only 80 patients; 88% were healed by 12 months on pentoxifylline compared with 44% on placebo.18 Oxerutins failed to improve ulcer healing or influence recurrence.19 w18 Fibrinolytic agents such as stanozolol have also been disappointing.w18 Studies on prostaglandin E1 and micronised purified flavonoids were simply too small to influence clinical practice.w19 w20 Sulodexide is a profibrinolytic and antithrombotic drug that was evaluated in a clinical trial that recruited 94 patients and achieved healing rates at two months of 58%, compared with 36% in controls (P = 0.03).20 Aspirin has also been studied in a randomised trial and significantly improved healing, but only 20 patients were randomised.21 In both the above studies, the healing rate achieved with drugs was no better than that achieved without drug treatment in community leg ulcer clinics.1 2

Venous surgery Superficial venous surgery has been shown to improve ulcer healing in patients with only superficial venous incompetence.22 In patients with no deep reflux on duplex imaging, superficial venous surgery also reduced ulcer recurrence at three years from 44% to 26% in a non-randomised study.23 When superficial venous surgery was compared with compression alone in 87 patients with venous ulcers, surgery achieved complete healing at a mean of 31 days compared with 63 days with compression; recurrence rates at three years were 9% and 38%.24 Box 4 shows indications for superficial venous surgery.

A patient's perspective

I developed an ulcer on my right leg in 1992. It started when I kicked my right ankle with the heel of left shoe. This broke the skin, and very soon the wound became infected. I went to my general practitioner and had the wound dressed by a nurse at the surgery. This went on for several weeks, but the wound would not heal. doctor then decided to send me to hospital, where a treatment was being used with great success. This compression bandaging. I attended the hospital clinic for a time until a local clinic was opened in area near to where I live. I attended the clinic once week to have my leg bandaged. This was not always done the same nurse, and the tension in the bandaging varied.After some time they told me that the bandaging did suit my condition. I was then put into compression stockings, but the ulcer got bigger. I must mention that at this time I had rheumatoid arthritis and was on a lot of medication for it. I was told that this affected the healing process. The ulcer on my leg became very badly infected, and I was in a lot of pain. It was then discovered that I had MRSA, and the district nurse had to attend to my bandaging at home. As the ulcer was getting worse, I was then referred to the ulcer clinic at Withington Hospital. After many setbacks, with infection and many different antibiotics, it was suggested that because ofmy ankle size I needed a different combination of bandages to get the pressure I needed for the ulcer to heal. With this, coupled with leg elevation when sitting and in bed, my leg started to improve. It did take time, but I am pleased to say that my leg has completely healed. Four layer bandaging did work in the end, but the same nurse did it all the time and used consistenttension of bandaging.

The role of surgery in mixed superficial and deep venous incompetence is less clear. In unselected patients with combined superficial and deep incompetence, superficial surgery without postoperative compression failed to improve venous hypertension or achieve ulcer healing.25 However, where the deep incompetence was limited or “segmental” improvements in healing were achieved.26 Ambulatory venous pressures may help to identify patients who would benefit from surgery. Virtually no research has been done on prophylactic surgery to prevent ulceration in at risk patients with superficial venous incompetence.

Future research

Research is currently focused on the role of superficial venous surgery and the use of cultured skin allografts. The level of compression needed to optimise healing should be explored. On a microvascular level, the wound healing process is thought to be directed by a variety of cell derived soluble factors, including cytokines (growth, regulatory, and chemotactic factors) and proteolytic enzymes (proteases); these will inevitably become future targets for specific treatments.16 Ultimately, our focus should move from treating active ulcers to the prevention of ulceration by identifying at risk populations. Prevention would undoubtedly be cheaper than cure and would also improve quality of life for patients with chronic venous hypertension at risk of ulceration.

GraphicExtra references are on bmj.com

Footnotes

  • Contributors DAS and FDP did the literature review. All authors contributed to writing the paper

  • Competing interests None declared

References

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