1 Dr Peter Chapman-Smith Phlebologist NZ Stem Cell Treatment Centre, Whangarei 12:00-12:30 Healing Those Heartsink Leg Ulcers
2 Healing Those Heartsink Leg Ulcers Practice Nurses Presentation GPCME Christchurch August 2016 Dr Peter Chapman-Smith Foundation Fellow of the Australasian College of Phlebology
3 Not Just Heartsink Patients
4 A leg ulcer is an open skin lesion of the lower leg that has not healed for 14 days.
5 Impact of Varicose Ulcers France & Germany 4-6% health expenditure NZ 1-2% Vote Health USA ½ million people with VU S pa Cost $5-6K in NZ every year Personal : poor QOL, offensive smell, ooze, inability to participate in activities
6 Who Gets Leg Ulcers? 80% venous 20% arterial, diabetic, decubitus, malignant C4-C6 disease factors: (N Labropolous) Older Age Post DVT, PTS Chronic CVI Obesity (BMI > 40) Post surgery 3% have DVI alone >90% superficial venous disease +- IPVs
7 Varicose Ulcer Defined An open skin lesion of the leg or foot occurring in an area affected by venous hypertension
8 Pathophysiology VU Valvular insufficiency 2o to:- valvular damage ( as prior DVT) valvular obstruction Site: Lower leg/ankle - usual medial malleolus Recurrences - usual same site Gravitational eczema (weeping, oozing, crusting) Size cm diameter
9 Varicose Ulcers If unhealing, biopsy ABI modify compression ABI <0.5 no compression Treat all nearby perforators ( improves healing, less recurrence) EVLA heal faster ( v. surgery no effect) Ref: AVF-SVS Guidelines, Fedor Lurie, USAv
10 Leg Ulcer Treatment 1. Treat the cause 2. Adequate compression 3. Debride necrotic tissue 4. Good nursing COD 5. Rarely ABs for infection 6. Treat comorbidity as obesity 7. Educate patient, family, carers
11 Beware what lies beneath..
12 Varicose Veins May Look Like this?
13 Or this?
14 Or this?
15 And They May Even Look Like This Presents with painful aching legs
16 Ultrasound - significant varicose veins
17 VV Symptoms. Aching Swelling Heaviness Tired Restless legs Cramps Itchy Ulcers Bleeding Worse - end of day/heat/period
18 Varicose Veins Low pressure capacitance leg vessels Damaged valves Affect blood flow towards the heart Weakened vein wall may bulge % population affected
19 CAUSE:- eczema Ulcers bleeding
20 L- term Complications of VVS Varicose eczema Thrombophlebitis Pigmentation Haemorhage Ulceration Higher risk VTE Reduced QOL Lipodermatosclerosis
21 Varicose Ulcers can be treated! Ulcer before treatment 3 months after treatment
22 Step 1 - Assessment Full clinical assessment Ultrasound scan: Diagnose Determine anatomy Plan treatment
24 Venous Ultrasound Mapping Report Normal scan. Blood flows upwards, back towards the heart. Severe varicose veins. Blood flowing down the leg
25 Step 2 Treat The Underlying Cause = Chronic Venous Hypertension
26 Non-surgical VV Treatments 1st line Rx in Western World > 10 yrs ENDOVENOUS LASER ABLATION (EVLA) ULTRASOUND GUIDED SCLEROTHERAPY (UGS) REF: NICE GUIDELINES JULY 2013
27 Endovenous Laser Ablation (EVLA) walk in walk out treatment Recognized best Rx for VVs 7/2013. No GAs No down-time No scars Drive yourself home Normal activity stat
28 Endovenous Laser Ablation (EVLA) 1. Laser fibre inserted into the vein 2. Local anaesthetic placed around the vein 3. Vein thermally sealed by laser energy
29 Endovenous Laser Ablation (EVLA) Before 1 Year after EVLA
30 EVLA there s no bed rest... Treatment in the morning Afternoon exercise..!
31 Ultrasound Guided Sclerotherapy (UGS) Injection of a sclerosant foam into veins under ultrasound guidance (UGS) Vein closes by a natural healing process Left GSV Left GSV Before 2 Yrs after UGS
32 Before UGS treatment Scars from previous Surgery (not UGS) 6 months after UGS and microsclerotherapy
33 Varicose Veins Before 1 year after UGS 2 years after UGS
34 Aim of Rx To improve venous haemodynamics To improve patients QOL Reduce weight Increased exercise Patient compliance is the key
35 Improved Patient Compliance Compliant patients do better ( Erickson CA et al J Vasc Surg 1995/22. A NZ study) Noncompliant Patients believed: compression hose were not worthwhile compression hose would be uncomfortable Education is important for 12 months Compression is the basis of care Compliance is essential for success
36 QOL Men with VVs : present later more severe disease worry about ability to work Women - higher perception of QOL disability from VVs SSV- higher QOL impairment, more vulnerable to rationing, consider separately from the GSV Dr Daniel Carradice, Hull and East Yorkshire Hospitals, UK. FRCS. Report to ACP 2010.
37 Varicose Ulcers Rx 1. Dressings- good nursing, clean, debride necrotic tissue, all dressings work 2. Treat underlying CVH/ VVs 3. Compression if tolerated class 2 GCS (During healing inelastic; post healing elastic hose) 4. Antibiotics- rarely required, often prescribed 5. Cleanliness, reduce obesity
38 Treatment of Venous Ulcers Nursing debridement, dressings, sepsis. Compression class 2 hose, elastic/inelastic, layered bandaging. Rx of underlying cause (= varicose veins) CVI, chronic venous hypertension, interstitial oedema, local ischaemia and hypoxia Rx exacerbating factors- HT, DM, obesity, sepsis, hygeine
39 The Nurses Role Topical dressings: Duoderm, Comfeel, Allevyn, Honey, Silver, seaweed (arginates), Ichthyopaste, and more THEY ALL WORK COD 1-2 x weekly NOT saline, guaze & tubigrip! Ongoing patient education and support Maintenance of adequate compression Patient rapport/confidence/observation re progress
40 Compression Classes Prescribe it Compression power, height on leg Level of compression at the ankle European Standard mmhg mmhg mmhg mmhg Travel 8-15mmHg
41 TED stockings are Useless 18 mmhg = Class 0.5 Used supine to prevent DVT peri-operatively Manufacturers recommendation: For use in the non-ambulant convalescing patient
42 Compliance Need stakeholder buy in Education for patients and nursing staff Written handouts- English, Maori. Review weekly first 4 weeks with COD DN service needs conformity dressings, compression, attitudes to GCS
43 End Point Assess costs and benefits public and private End goals: to reduce ulcers to reduce CVI to reduce obesity ( with other benefits) improved QOL to reduce the public cost L term
44 Prior ulcer scar Ulcer pre EVLA 3 months Farmer,CEAP6x 2yrs. 1 o VVs. 12 months
45 EVLA/ UGS Rx for VU Reduce ulcer healing time Reduce ulcer recurrence rate
46 18cm diam. for 10yrs. Rx guaze dressings only...