Venous Stasis
Management and
Ulcer Healing
Evidence base and expert opinion put into practice
• Christine Herb, MS, FNP-C, CWON
• Syracuse VA Medical Center
• June 13, 2014
1st it is critical to correctly determine the etiology!
Venous vs. Arterial vs. Neuropathic
Lymphedema w/ Venous Stasis
Diseases Process
Bicuspid valve damage due to DVT or heredity results in
venous HTN and regurgitation.
White cell trapping theory: venous HTN & increased cap pressure
trap leukocytes in cap & become activated, thus damaging cap beds.
Increased permeability leads to fibrin cuff formation & hypoxemia,
which leads to inflammation & tissue loss.
Venous stasis / insufficiency disease
We should all be more like giraffes!
Location
VS ulcer Characteristics
Irregularly shaped
Granular base
Edema & lymphedema
Hemosiderin staining
Varicosities
Exudate
Stasis Dermatitis
Cellulitis
Sharp or aching pain
Itching
sc fibrosis
Scope of the problem
• VIU 1-3% population
• Peak at 60-80 yo
(Kerstein 2003)
(Pauqette & Falanga, 2002)
• 6-7 million Americans have LEVD &
1 million of those develop ulcerations
(WOCN Society 2005)
$ Costs of Venous Ulcers $
• Costs:
• Lifetime costs of LEVD care est at $40,000/individual
• Total cost of care of LEVD in US est at $1 billion/year
(Simka & Majewski 2003)
• Ulcer Recurrence:
• 57-97%, which reflects the chronicity of the problem & also failure
to effectively address the underlying etiology
(Paquette & Falanga 2002)
• Repeat hospitalizations, repeat abx
• Lost productivity (work, hobbies, family care, volunteering)
• Loss of independence (application of compression garments)
• Pain, itching, anxiety, social isolation & reduced ability to
carry out usual activities reported to be areas of greatest concern by
individuals w/ venous disease (deAraujo et al, 2003)
WHAT TO DO?
Let’s start with the evidence…
AHRQ: Treatment approaches for chronic
venous ulcers reviewed
(Johns Hopkins University Evidence-based Practice Center :Dec 2013)
There is a general lack of conclusive evidence on the
benefits and harms of advanced wound dressings,
systemic antibiotics, and surgical interventions in the
treatment of venous leg ulcers lasting six or more weeks
in patients with preexisting venous disease
Some evidence supports:
Antimicrobial dressings
Collagen dressings
(mod str evidence)
(low str evidence)
Bilayered human skin equivalents
(mod str evidence)
Surgical procedures do not improve healing or
recurrence (high str of evidence)
 SEPS: subfascial endoscopic perforator vein surgery
Evidence Based Treatment
 Compression for venous ulcers
(Cochrane review) 2009 by O’Meara, Cullum & Nelson.
• 39 RCTs reporting 47 comparisons
• Author’s conclusions:
• Compression increases ulcer
healing rates compared to no
compression.
• Multi-component systems are
more effective than singlecomponent systems
Evidence Based Treatment
 Inflammatory cytokine levels in chronic
venous insuf ulcer tissue before and after
compression
(2009) J of Vasc Surgery. Beidler et al.
• 30 limbs untreated CVI ulcers received high
compression therapy for 4 weeks.
• Biopsy of healthy & ulcerated tissue before & after
therapy & using a multiplexed protein assay to measure
multiple cytokines
• CONCLUSIONS: CVI ulcer healing is asso with proinflammatory environment prior to treatment. Treatment
with compression therapy results in healing that is
coupled w/ reduced pro-inflammatory cytokine
levels & higher levels of the anti-inflam cytokine IlRa.
Evidence Based Treatment
 Skin grafting for venous leg ulcers
(Cochrane review) 2007 by Jones & Nelson.
• 15 trials generally of poor methodology.
• Author’s conclusions:
• Bilayer artificial skin, used in conjunction with compression bandaging,
increases the chance of healing a venous ulcer compared with compression and
a simple dressing.
• Further research is needed to assess whether other forms of skin grafts increase
ulcer healing.
Evidence Based Prevention
 Compression for preventing recurrence of
venous ulcers
(Cochran review) 2000 by Nelson, Bell-Syer & Cullum.
• Author’s conclusions:
• No trials compared compression with vs no
compression for prevention of ulcer recurrence.
• Not wearing compression (non-compliance in trial) was
associated with recurrence in both studies indentified in
this review.
• Recurrence rates may be lower in high compression
hosiery than medium compression hosiery and
therefore patients should be offered the strongest
compression with which they can comply.
• People are more likely to wear hosiery with moderate
rather than high compression.
Evidence Based Practice
“the integration of
•best research evidence with
•clinical expertise and
•patient values”
Sackett, et al. (2000)
“...in the context of
available resources”
DiCenso, et al. (1998)
Safe to Compress?
 Ankle/Brachial Index
• (> 1 calcified vessels)
• ABI of 0.8-1.0 safe
• ABI of 0.5-0.7 modified
compression may be safe
 Clinical presentation
of adequate perfusion:
 Palp DP, PT pulses
 Strong doppler
signals
 Warm
 Pink color
 Hair on feet or toes
Compression wraps for healing
Dyna-Flex
vs
3M coban
What are the essentials of effective ulcer tx?
• Effective COMPRESSION is essential !!!!
• Debridement of slough and fibrin
• Removing scales & moisturizing
• Reduce the bioburden: antimicrobial topicals
• Medical grade HONEY
• Cadexomer iodine paste
• Mupirocin, bacitracin oint
• Dakins sol
• Bioelectric dressings
• Manage the drainage
• Start simple and change one thing at a time
• Progress to the advanced products if failure
• Collagen, bilayered skin substitutes, skin grafts
Fibrin can fool ya
Compression stockings
are NOT all created equal!
Compression Stockings
• Anti-embolism: 16-18mmHg, TED hose are not
appropriate to tx venous stasis.
• Light compression: 10-20mmHg
• Class I: light support, 20-30mmHg at the ankle, usually
not adequate to prevent venous ulcer recurrence.
Class II: medium support, 30-40mmHg, level of
compression needed to prevent recurrence & manage
lymphedema.
Class III: strong support, 40-50mmHg, indicated for
venous ulcer recurrence & manage lymphedema.
Heal the ulcers…then get them into stockings!
Important points about compression stockings:
• Change daily into clean pair
• Do not pinch & pull fabric. Must use tacky rubber gloves
•
•
•
•
to stroke fabric in place.
Evenly distribute fabric.
Remove all wrinkles. Bunching fabric causes wounds!
Wash w/o bleach or fabric softener. Air dry.
Replace every 6 months!
COMPRESSION STOCKING REMINDERS
REMEMBER TO…………
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Apply first thing in the morning and remove at night before bed
Remove wrinkles in stocking after applying them to prevent pressure wounds
Do not pull stockings up leg but to stroke them up using your rubber gloves to
avoid overstretching of your stockings
Rotate all 6 pairs of your stockings to prevent stockings from wearing out and
overstretching
Wear stockings only ONE day at a time then change to a clean pair
Moisturize your legs at night after removing stockings before bedtime
Wash stockings in laundry detergent by hand or washing machine and air dry or
on low setting in the dryer (no fabric softener or bleach)
If you have problems with applying them after training call the Wound Dept at
425-4400 ext 52827. We will help you work out the kinks!
 REMEMBER to call Prosthetics Dept (425-4400 ext 54659)
to reorder 6 new pairs of stockings EVERY 6 MONTHS

Throw away the 6 pairs you already have when the new ones arrive
(no stock piling of old stockings!)
Enjoy these stockings!
You've made a great decision to wear compression everyday to control swelling and
prevent wounds & infection.
Good job! Your legs will be very happy!
DS/Aug2011/RevMar2014
Contract
Venous Stasis Compression
VENOUS STASIS DISEASE IS CHARACTERIZED BY:



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
Spider and Varicose Veins on lower legs and feet
Swelling in Feet and legs
Infection
Wounds
Weeping Skin
You may have experienced some or all of these symptoms. Once these symptoms are brought under
control you will be required to wear compression garments. These garments will; reduce swelling and
prevent wounds, infection, and weeping skin from returning. This is a chronic condition and there is no
"cure", but it can be managed with compression garments that will effectively prevent skin problems
from returning if worn every day.
I UNDERSTAND THAT:




Compression therapy is lifelong therapy.
Garments must be worn everyday (on first thing in the morning, off at night) to be effective in
preventing problems from returning.
Failure to wear these garments every single day will likely result in swelling, infection, ulcers, and
possible need for hospitalization if symptoms are severe.
I must contact the Prosthetics Dept (x-54659) to replace my compression garments
every _________________________.
 Signing this contract I confirm understanding of venous disease and my responsibility in
managing this lifelong condition.
 I am committed to wearing my compression stockings everyday for the rest of my life.
Sign: _________________________________(print name/last 4:____________________________)
Date: ___________
Wound Clinic: Christine Herb, FNP-C, CWON (x-54425), Diane Simcox, RN, BSN (x-52827)
DS/ 3-2011
Compression Stocking Application
NOT!
Device transformed compliance
Other compression stockings
CircAid Classic-flex
CircAid Juxta-fit
Compliance is crucial
• 2003 W.H.O. reported:
50% people don’t comply w/ chronic disease
management.
• “Few providers take the time to address the obstacles to
non-compliance…
• Often there is a will, but the way is not shown”.
Christine Herb
Keys to compliance:
• Patient buy-in
• ID the obstacles:
• Huge belly
• Back or hip pain
• Arthritis in hands
• Determine which form of compression is most do-able.
• Compression is NOT for every patient; consider advanced age,
further complicating life vs benefits.
• Call in all forces (spouse, friend/neighbor, adult child) to assist.
• One-to-one training, demonstration & return demonstration,
encouragement, getting the kinks out & not quitting until they
are successful.
• Homecare for more training in home environment & assess
compliance.
Your role as PCP:
• Identify venous stasis and refer to the specialists for
healing ulcers and fitting of compression garments,
training, etc. Don’t wait for an ulcer or cellulitis.
• On each f/u clinic appt:
PCP should assess compliance with compression
garments and reinforce vital importance of wearing
compression garments EVERY day for lifetime. Replace
stockings every 6 months.
Managing
Chronic Venous Insufficiency
• Requires compression!
to start with…
• and for a lifetime!
Thank you!
References:
• Treatment approaches for chronic venous ulcers
reviewed:
http://www.ahrq.gov/news/newsletters/researchactivities/14feb/0214ra30.html
• Cochrane Reviews: venous ulcers
http://www.thecochranelibrary.com/details/browseReviews/
576613/Ulcers-venous.html
• Resources:
• http://ezyasabc.com/
• WOCN.org