PRODIGY Quick Reference Guide

Transcription

1 PRODIGY Quick Venous leg ulcer infected How do I assess a venous leg ulcer? Chronic venous insufficiency and venous hypertension result from damage to the valves in the veins of the leg and inadequate functioning of the calf-muscle pump. This leads to oedema and skin breakdown. Based on PRODIGY guidance last issued in November Review aspects of the past medical history that may suggest venous or arterial disease1. Examine legs for features suggesting venous disease2. Assess features of the ulcer3. Exclude an arterial component by checking the ankle brachial pressure index (ABPI). If ABPI is less than 0.8, assume arterial disease. The presence of pedal pulses is inadequate to rule out arterial insufficiency4. How do I know the wound is infected? Clinical evidence of infection includes pyrexia, increasing pain, enlarging ulcer, or cellulitis. If infection is suspected, take a swab before starting empirical antibiotic therapy. Routine swabs are not recommended. Only swab if there is clinical evidence of infection5. How should infected venous leg ulcer be managed? Treat with antibiotics for 14 days: Oral flucloxacillin 500 mg four times a day (empirical) is recommended first-line. If penicillin-hypersensitive treat with oral erythromycin 500 mg four times a day. Review after 3 days and when swab results are available. If the organism is not sensitive to flucloxacillin, change antibiotic (for 14 days) according to sensitivities. Oral analgesia may be needed: Paracetamol is recommended first-line. Below-knee, four-layer graduated high-compression bandaging is recommended6 unless there is evidence of cellulitis. Consider bed rest and leg elevation to reduce oedema before applying compression. Refer to Prescription details for further information. How should the ulcer be dressed? Dress the wound daily or on alternate days (depending upon exudate seepage). Wash the wound with clean tap water7. Use a suitable contact dressing8 and (if needed) cover with a low-adherent dressing. Apply four-layer compression bandaging. (Measure the ankle 2 cm above the malleolus to obtain the correct size.) What other advice should I give? Elevate the leg when resting. Don t stand for long periods of time, but keep active. When the ulcer has healed, wear support stockings to help prevent ulcer reoccurrence9.

2 Consider stopping smoking. When should I seek further advice or refer? Refer urgently to a specialist clinic where: Acute ischaemic changes occur because of compression bandaging. Ankle brachial pressure index (ABPI) is less than 0.5 (do not use compression bandages). Other indications for referral to a specialist clinic include: ABPI less than 0.8 (assume to have vascular disease, and refer for further assessment). Suspected malignancy. Rapidly deteriorating ulcer. Non-healing ulcer after 12 weeks of adequate treatment. Pain management is inadequate.

3 Venous leg ulcer infected Prescription details Empirical antibiotic for 14 days Drug Age Dose Quantity Flucloxacillin 500 mg capsules 16 years onwards Take one capsule four times a day for 14 days. 56 capsules Erythromycin 250 mg e/c tablets 16 years onwards Take two tablets four times a day for 14 days. 112 tablets Four-layer compression bandaging kits (NOT if there is evidence of cellulitis) These kits also contain a non-adherent wound-contact layer. Four-layer compression kit Sizes (ankle circumference) Quantity Profore1 kit < 18 cm 1 kit cm 1 kit cm 1 kit > 30 cm 1 kit Ultra-four cm 1 kit K-four cm 1 kit System cm 1 kit Hydrogel contact dressing: use on dry, sloughy wounds Dressing Sizes Quantity Aquaform hydrogel 15 g 4 packs Nu-Gel hydrogel 15 g 4 packs Purilon hydrogel 15 g 4 packs 8 g 4 packs GranuGel hydrogel 15 g 4 tubes Intrasite gel 8 g 4 sachets 15 g 4 sachets 25 g 4 sachets

4 Venous leg ulcer infected Prescription details Polyurethane foam contact dressing: use to absorb excessive exudate Dressing Size Quantity Allevyn 5 cm 5 cm 5 dressings Advazorb 5 cm 7.5 cm 5 dressings Curafoam plus 6 cm 6 cm 5 dressings Biatain non-adhesive Tielle plus borderless 11 cm 11 cm 5 dressings Lyofoam C (odour absorbing) Alginate contact dressing: use to absorb excessive exudate Dressing Size Quantity Curasorb 5 cm 5 cm 5 dressings Sorbsan 5 cm 5 cm 1 box of 10 dressings Kaltostat 7.5 cm 12 cm 5 dressings Sorbalgon Algisite M Melgisorb Carboflex (odour absorbing) Analgesia Drug Age Dose Quantity Paracetamol 500 mg tablets 16 years onwards Take two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours. 100 tablets For information on contraindications, cautions, drug interactions, and adverse effects see the British National Formulary ( or the Medicines Compendium (

5 Venous leg ulcer infected Supporting information 1. Past medical history that may suggest venous disease or non-venous disease. History suggesting venous disease History suggesting arterial disease Varicose veins Ischaemic heart disease Proven deep vein thrombosis in the affected leg Stroke Phlebitis in the affected leg Transient ischaemic attack Previous fracture, trauma, or surgery Diabetes mellitus Family history of venous disease Peripheral vascular disease Symptoms of venous insufficiency: leg pain, heavy legs, aching, itching, swelling, skin breakdown, pigmentation, and eczema. Intermittent claudication [Royal College of Nursing, 2000a] 2. The following features are all suggestive of venous leg ulcer: oedema of lower leg, varicose veins, varicose eczema, hyperpigmentation, lipodermatosclerosis, and atrophic blanche [Royal College of Nursing, 2000a]. Other possible causes include arterial ulcer, rheumatoid ulcer, diabetic ulcer, hypertensive ulcer, malignant ulcer, or systemic vasculitis. 3. Assess features of the ulcerated area [SIGN, 1998; Royal College of Nursing, 2000a]: Serial measurement (length and width) is an indicator of the healing process. Tracing of the margins and photography may be helpful. Ulcer site (usually on gaiter area of leg, above the medial or lateral malleoli). Ulcer edge (shallow, punched out, rolling). Ulcer base (granulating, sloughy, necrotic). Condition of surrounding skin, odour, and signs of infection.

6 4. The ankle brachial pressure index (ABPI) is the most reliable way to detect arterial insufficiency [SIGN, 1998]. It provides an index of vessel competency by measuring the ratio of systolic blood pressure at the ankle to that in the arm, with a value of 1 being normal. ABPI less than 0.5: arterial ulcers are likely and compression treatment is contraindicated, requiring urgent referral to a specialist vascular clinic for further assessment and possible revascularisation. ABPI between 0.5 and 0.8: assume that the person has arterial disease, and refer to a vascular clinic for further assessment. Compression bandaging in such instances may further compromise arterial blood supply, and should be generally avoided. However, if the ABPI is between 0.5 and 0.8, reduced compression can be used under strict supervision if the ulcer is clinically venous [SIGN, 1998; Royal College of Nursing, 2000b]. Clinical progress should be checked daily initially, and compression modified according to clinical response. ABPI greater than 0.8: graduated compression bandages may be applied safely. It is important to be aware that ABPI measurements in people with diabetes or atherosclerosis may not be reliable. People with these conditions may have falsely high (and misleading) pressure readings owing to calcification of the vessels [SIGN, 1998]. In addition, microvascular disease associated with rheumatoid arthritis and systemic vasculitis cannot be assessed by ABPI. Therefore, if there is any doubt, such people should be referred for specialist assessment. Arterial disease may develop in people with venous disease, and health professionals should be aware that a drop in ABPI may occur after the initial measurement [Royal College of Nursing, 2000a]. 5. Antibiotics have little effect on wound healing generally [O'Meara et al, 2000], so there is no value in using them to treat organisms that have colonized a wound but are not causing clinical signs or symptoms of infection.

7 Venous leg ulcer infected Supporting information 6. Below-knee graduated compression is the mainstay of treatment to improve venous return and reduce venous stasis and hypertension in uncomplicated venous leg ulcers. Graduated compression delivers the highest pressure at the ankle and gaiter area, and the pressure progressively reduces towards the knee and thigh where less external pressure is needed. High-compression multilayer (four-layer, three-layer) bandaging is recommended as against single-layer compression, resulting in improved ulcer healing rates [NHS CRD, 1997; SIGN, 1998]. A recent study has found similar ulcer healing rates for both four-layer and two-layer short-stretch systems [Moffatt et al, 2003]. Consider twolayer bandage application if patient concordance is an issue. 7. Saline washes are not superior to tap water in cleaning soft-tissue wounds [SIGN, 1998]. There is no evidence that using antiseptics provides additional protection against infection [Royal College of Nursing, 2000a]. Research is conflicted regarding the use of antimicrobial silverbased products to promote ulcer healing [O'Meara et al, 2000]. 8 Suitable contact dressings: Uncomplicated wounds use a low-adherent dressing. Dry, sloughy wounds consider a hydrogel dressing covered by a low-adherent dressing. Heavily exuding wounds consider an alginate or foam dressing covered by a low-adherent dressing. Painful wounds consider an occlusive hydrocolloid dressing or foam dressing. 9. Graduated compression stockings should ideally be used for at least 5 years following ulcer healing, to minimise the risk of recurrence [SIGN, 1998]. Class III (high-compression) stockings are associated with less recurrence than are Class II (medium-compression) stockings, but are less well tolerated [Royal College of Nursing, 2000a]. For the bibliography see the full text: ulcer - venous Issued in June 2005 For more information see the full text at: ulcer - venous Patient information leaflets (PILs) are available at: