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1 TO REPAIR TO HEAL TO REPAIR TO HEAL TO LOVE TO TOUCH TO LOVE TO TOUCH TO LIVE TO MOVE TO LIVE TO MOVE TO SHARE TO CURE TO SHARE TO CURE URGO MEDICAL, HEALING PEOPLE Leg Ulcer Assessment 2016 Tissue Telephone contact Housekeeping Tissue Viability Updates 4 T.V. MODULES each ½ day. Leg ulcer assessment, Compression therapy, Wound assessment and management, and Prevention of Pressure Ulcers All new staff to complete Existing staff to complete Modules 1,2,3 every 3 years Module 4 yearly.levels 1 or 2 according to manager. Carers training- level 1 basic prevention Tissue Viability Intranet page Wound management guidance Pressure ulcer prevention & treatment information Leg ulcer management Training dates and slides from presentations Contacts and referral forms Wound Clinic information Follow us on Professionals link External to CWPT link Tissue Viability information Preferred prescribing list Products for evaluation Leg ulcer guidelines Pressure ulcer guidelines Core Care Plans Tissue Viability Link group 1

2 LEARNING OBJECTIVES Jo Lord Clinical Specialist Urgo Medical To understand normal and abnormal venous function To understand the aetiology of leg ulcers To differentiate between venous, arterial and mixed aetiology ulcers 7 Leg Ulcers Bicuspid Valve Femoral Vein The Venous System Anatomy and physiology of Venous Return LEG ULCERS Definition: Open lesion between the knee and ankle that remains unhealed for 4 weeks (SIGN guideline,1998) Causes: Chronic venous hypertension >70% Poor arterial blood supply 10% Mixed arterial and venous origin 10-15% (Moya J. Morison, 1991) 2

3 Epidemiology of leg ulcers Who does this effect? Epidemiological data suggest that between per 1000 of the population have active leg ulcers and the prevalence increases to 20 per 1000 in people over 80 years-of-age. (Fletcher et al 1997), Estimated that 70, ,000 of the UK population have an active leg ulcer at any one time Prevalence increases with age and is higher among women At age 40, women and men are equally affected. With increasing age studies show an increase of 7:1 at 80+yrs A significant proportion of patients are developing venous leg ulcers before the age of 50 Epidemiology of leg ulcers The total cost to the NHS of treating leg ulcers is estimated to be as high as 600 million a year (Douglas et al 1995) Treatment Many leg ulcers are not diagnosed Many treatments do not address the underlying problem in venous leg ulcers, many treatments only treat the wound & do not improve venous return THE CARDIOVASCULAR SYSTEM THE CARDIOVASCULAR SYSTEM The cardiovascular system is a closed circulatory system in which blood flows in one direction only. It is organized around a central organ the heart pump and is made up of three different types of blood vessels (arteries, veins and capillaries). The venous system is part of the cardiovascular system which is designed to circulate blood allowing gaseous and metabolic exchanges within the billions of cells making up the body. Arterial system carries Oxygenated blood Nutrients Hormones Immunology Venous system carries Deoxygenated blood CO2 Toxins 3

4 Anatomy Artery versus Vein THE CARDIOVASCULAR SYSTEM The arteries and veins are linked by microscopic capillaries, where oxygen, carbon dioxide and metabolite exchanges occur - known as microcirculation ANATOMY OF THE NORMAL VENOUS SYSTEM IN THE LOWER LIMB The venous system in the lower limbs is made up of a number of complex anatomical structures including: The deep venous system The superficial venous system Perforating veins - which cross the aponeurosis to link deep and superficial veins The veins of the foot - which form a complex network & create a genuine blood reservoir ANATOMY OF THE VENOUS NETWORK The superficial system is formed of fine dermal and subcutaneous venules that lines the entire sole of the foot. The deep system mainly consists of the medial and lateral plantar veins of the sole of the foot these drain blood into the posterior tibial veins. The deep network forms the true venous pump of the foot. DEEP VENOUS SYSTEM The deep venous system, located in the central axis of the leg, follows the arteries and is surrounded by the muscles and flat tendons The veins have the same names as the arteries that they run alongside: iliac, femoral, popliteal, fibular, tibial veins, etc. 4

5 SUPERFICIAL VENOUS SYSTEM The superficial venous system is located primarily in the subcutaneous adipose layer, between the wall of the skin and the aponeurosis encasing the muscles. The main two components of the superficial venous system are : Great Saphenous Vein Small Saphenous Vein Superficial network (10%) Perforating vein VENOUS BLOOD FLOW Deep network (90%) Valves stopping the blood flowing the wrong way Anatomy of the normal venous system in the lower limbs VENOUS VALVES The venous valves are mobile bicuspid structures The veins are dilated at the valves, creating a sinus space, reduces reflux Great Saphenous has up to 20 Valves Short Saphenous has up to 12 Valves Femoral and Popliteal 2-3 valves Perforator Veins- 90 per leg 1-2 valves AETIOLOGY OF VENOUS FUNCTION Calf Muscle Pump For blood to be effectively taken against gravity back to the heart the body needs valves in the veins to prevent the backflow of blood Calf Muscle relaxed Calf muscle contracting Valves closed Blood static Valves open Blood forced upwards 5

6 NORMAL VENOUS RETURN IN THE LOWER LIMBS At rest: cardiac & respiratory pumps When walking: compression of the venous plexus on the sole of the foot muscle pump activated The muscle compresses against the venous wall and pushes the blood upwards Competent valves: stop reflux back downwards Venous Working Pressure A result of the energy supplied by walking: The pressure exerted on the sole of the foot during walking ejects blood upwards The rhythmical contracting and relaxing of the calf muscles acts like a pump helping to propel the blood from the superficial veins to the deep veins Venous Working Pressure The impact of this pump can be observed by measuring the pressure at the ankle: Venous pressure at the ankle decreases significantly when walking Venous Resting Pressure Venous Resting Pressure is: Dependent on the position and posture of the subject Fluctuates mainly as a result of gravity. Measured at the ankle and recorded in millimetres of mercury (mmhg) Naturally decreases from toe to thigh In a healthy subject the pressures are: 56mmHg Sitting 85mmHg Standing Still 15mmHg Lying down Standing 85mmHg Walking 46mmHg Venous Hypertension Abnormal Venous Function Damaged valves are a predisposing factor not a cause for developing a leg ulcer Too much pressure and fluid in the veins Pushing the walls of the veins out Incompetent valves More pressure and more fluid Leg Ulcers 6

7 End Product of Venous Hypertension CHRONIC VENOUS INSUFFICIENCY Chronic venous insufficiency (CVI) is characterised by poor venous return of blood loaded with CO2 and toxins towards the heart Under the effect of high pressure (for example, prolonged standing etc.) stasis occurs and the veins dilate excessively, their diameter increases varicose veins Valves become incompetent causing blood reflux the edges of the valves no longer meet due to the increase in vein circumference CHRONIC VENOUS INSUFFICIENCY Valve incompetency Back flow from deep to superficial THE STAGES OF CHRONIC VENOUS INSUFFICIENCY Stage C0: heavy legs, pain, itching Stage C1: telangiectasia Vessel Dilation Stage C2: varicose veins Tissue flooding / ischemia Staining & Oedema Ulceration Stage C3: oedema THE STAGES OF CHRONIC VENOUS INSUFFICIENCY Stage C4: trophic disorders Varicose Eczema Atrophie blanche Haemosiderin staining Stage C5: trophic disorders with healed ulcer Definition A venous leg ulcer is the final stage (C6) of Chronic Venous Insufficiency (CVI) and is defined as: An open lesion between the knee and the ankle joint that remains unhealed for at least four weeks and occurs in the presence of venous disease * The disease is associated with a continuous cycle of healing and breakdown over decades and is associated with considerable morbidity and reduced quality of life * Stage C6: trophic disorders with an active venous ulcer *(SIGN Guideline 120 August 2010) 7

8 Cost of leg Ulcer Treatment costs of Venous Leg Ulcers are estimated at between: million per year Predisposing Risk Factors DVT & Post Thrombotic Syndrome Orthopaedic Trauma Obesity Female (Multi-gravidas) Age Standing Occupation (Nursing, Hairdressing etc) Abdominal obstruction (constipation / carcinoma) Who does this effect? Prevalence increases with age is higher among women At age 40, women and men are equally affected. With increasing age studies show an increase of 7:1 at 80+yrs A significant proportion of patients are developing venous leg ulcers before the age of 50 Causes: Chronic venous hypertension >70% Poor arterial blood supply 10% Mixed arterial and venous origin 10-15% Moffatt 2001 Uncomplicated venous in origin 43% Complex multi-factorial ulcers 35% Moffat 2004 Signs & Symptoms of a Venous Occurs between the malleolus and Ulcer gaiter area Highly exuding Irregular in shape Shallow in depth Generalised oedema Haemosiderin staining Atrophie Blanche Varicose Eczema Lipodermatosclerosis Ankle Flare Pain on dependency relieved when legs elevated Other visual signs 8

9 Atrophie Blanche Scar tissue arising from injury when blood supply is poor Chronic Venous Hypertension Star-shaped ivory-white depressed atrophic plaques Prominent red dots within the scar due to enlarged capillary blood vessels Surrounding pigmentation Cause: ARTERIAL ULCERS Insufficient arterial blood supply due to atherosclerosis resulting in tissue ischaemia and necrosis PATHOLOGY Progressive occlusion Increased oxygen demand Predisposing Risk Factors High Cholesterol levels Increased fatty deposits Hypertension Damage to arterial walls Smoking Diabetes Family history of arterial disease Male Sedentary lifestyle Obesity Signs & Symptoms of Arterial ulcers Mainly occur on the foot Localised oedema Punched out appearance Shiny hairless skin Thick hard toe-nails Pain at night when leg elevated (relieved by dependency) Pain when walking (intermittent claudication) Poor pedal pulses Develop quickly Not to be confused with pressure ulcers 9

10 MIXED AETIOLOGY ULCERS Rheumatoid ulceration Definition: Venous insufficiency with underlying arterial disease Treatment: Managed with reduced compression Vasculitic (inflammation of the blood vessels) Leg ulcers you might see Things to look out for.. Pyoderma Gangrenosum Drug-Induced Vasculitis Trauma Marjolin s Ulcer Squamous Cell Carcinoma Summary Signs & symptoms Arterial Ulcers Venous Ulcers Underlying Cause Arterial Disease / Ischaemia Chronic venous hypertension Holistic assessment Wound bed appearance Deep cliff edge margins Shallow irregular margins Evolution Rapid onset Slow / insidious onset Skin Aspect Shiny, pale & dusky / Cold to touch / Hair Haemosiderin staining / Ankle flare / warm to loss / Thickened toenails touch / Eczema / Atrophie Blanche Pedal (foot) pulses Absent or diminished Present Location Extremities: feet & toes Gaiter region above malleolus Oedema Localised / dependent Generalised & worsens during day Pain Ischaemic pain on exercise Nagging, aching pain Pain on leg elevation Dependent pain relieved by elevation Doppler Reading < 0.6 > 0.8 Associated Medical History Hypertension / Ischaemic Heart Disease / CVI / Varicose veins / Thrombophlebitis / DVT / TIA / RA / CVA Post-thrombotic Syndrome Compression Therapy No compression should be applied Application of full compression - 40mmHg at the ankle Baseline Observations- BP, Urinalysis, pulse, weight ABPI Perpetuating factors- poor diet, obesity, smoking, mobility Medical History- Venous/arterial Pain Ulcer assessment 10

11 61 Arterial Ulcers Shiny Hairless Pale Skin Hyperlipidaemia Cold to touch Pain on exercise Rapid onset Peripheral Arterial Disease Ischaemia Localised Oedema Punched out appearance ABPI <0.6 Deep Sides Located on feet and toes Thickened toe nails Pain when leg elevated Venous Ulcers ++ Exudate Shallow margins Irregular Shape Malleolus & Gaiter area Haemosiderin staining Atrophie Blanche Lipdermatoschlerosis Ankle Flare Slow Onset ABPI >0.8 Incompetent Valves Venous Hypertension Post Thrombotic Syndrome Dermatitis / Eczema Doppler Assessment Aims and Objectives Understand the theory underpinning Doppler assessment. Know why to carry out Doppler assessment. Understand how to carry out a Doppler assessment / underpin practice. Acknowledge common potential errors. Handheld Doppler How Does It Work? A crystal in the probe is oscillated and transmits an ultrasound beam which is directed towards the blood vessel Ultrasound is reflected back and detected by a second crystal If the ultrasound hits something moving then a frequency shift will occur. It is this shifted frequency which is amplified and fed through the speaker 11

12 Doppler Probe The probe will not work properly in air and needs to work in ultrasound gel. It is important that ultrasound gel is used. The probe will work most effectively at 45º. Probes for arterial and venous flow are between 5 8 MHz. The larger probe head (5MHZ) is used to assess oedematous limbs. Why is Doppler Assessment Necessary? All patients presenting with an ulcer or lower limb problems should be screened for arterial disease by Doppler measurement of ABPI. To enable effective treatment options to be established. To minimise the risk factors of compression therapy. To support holistic assessment. Holistic Assessment Patient: History, risk factors, associated disease, medication, nutritional status, social circumstances, psychological. Skin: Colour, pigmentation, temperature, cellulitis, trauma, sensitivity, fragility. Circulation: Pulses, ABPI, waveforms, capillary refill, varicose veins. Limb: Oedema, shape, ankle mobility, patient mobility. Ulcer: Site, size, surface, edge, duration, infection, exudate, pain. Preparation of the Patient Explain the procedure and reassure the patient. Ensure the ambient temperature of the room is comfortable. Remove any tight clothing from both arms and legs, enable easy access to limbs. Rest the patient for minutes in a supine position. Procedure to obtain ABPI Brachial systolic pressure Brachial Systolic Pressure Place an appropriately sized cuff around the upper arm. Ensure the equipment and arm are at the heart level, with the patient rested and supine. Locate the brachial pulse and apply ultrasound contact gel. Angle the Doppler probe at 45º and move it to obtain the best signal. Inflate the cuff until the signal is abolished, deflate slowly and record the pressure at which the signal returns, being careful not to move the probe from the line of the artery. Repeat the procedure on the other arm. Take the highest reading from the two brachial 12

13 Procedure to Obtain ABPI Ankle systolic pressure Ankle Systolic Pressure Place an appropriately sized cuff around the ankle immediately above the malleoli, having first protected any ulcer or fragile skin that may be present. Examine the foot, locating the anterior tibial pulse or dorsalis pedis pulse and apply contact gel. Continue as for brachial pressure, recording the pressure in the same way with the equipment at heart level. Repeat the procedure locating the posterior tibial pulse. Repeat the procedure on the other leg recording at least two readings, the doralis pedis / anterior tibial and the posterior tibial. Sounds Triphasic 3 distictive beats Biphasic 2 distinctive beats Monophasic 1 distinctive beat First Appearances can be deceiving! False Readings Obesity, Oedema, Lymphoedema, Hypertension Diabetes (high risk of peripheral vascular disease) Calcification Renal Disease Inappropriate investigation due to fluctuation of blood pressure Pain and anxiety increase heart rate/blood pressure Rheumatoid Arthritis Vasculitic pain and calcification Arteriosclerosis Hardening of arteries causing falsely elevated readings Cardiac Arythmias (Vowden, K.P. 1996) More difficult to assess sound 13

14 Potential Factors Affecting Accuracy Incorrect size of the cuff. Incorrect pressure measurement Inappropriate selection of probe ultrasound cannot penetrate the depth of the vessel. Incorrect positioning of the patient. Falsely elevated ankle pressures Rest. Only 68% rested patients adequately. Knowledge of nurse Variety of errors noted including only using one arm, only taking a single reading. Meaning of ABPI not understood Potential Factors Affecting Accuracy Over inflation of the cuff Repeatedly inflating or inflating of the cuff for long periods of time can give inaccurate reading and send artery into spasm Rapid deflation The true systolic pressure may be missed Low ambient room temperature Vaso constriction Site of the cuff Pressure measurement relates to cuff position Calculation of ABPI ABPI is a comparison between the highest ankle pressure on each leg and highest overall brachial pressure ABPI calculations Highest ankle systolic pressure (for each leg) Highest brachial systolic pressure Right ABPI = = 0.56 How to Calculate ABPI Brachial Brachial Left ABPI = = 0.80 Calculated using this formula: Highest ankle pressure for that leg Highest of the brachial systolic pressures Posterior Tibial Anterior Tibial Posterior Tibial 120 Normal ABPI ratio is equal or greater than 1.00 but not greater than 1.3 (check local policy) Interpretation of ABPI Need to be confident with the results obtained mmhg = Normal mmhg = Slight Arterial Impairment mmhg = Degree of arterial disease / mixed aetiology 0.6 > = Arterial aetiology ABILITY VASCULAR ASSIST 14

15 When Not to Perform a Doppler A Doppler ABPI should not be undertaken if the patient is unable to tolerate the pressure cuff or: SUSPECTED DEEP VEIN THROMBOSIS (within 6 weeks) PRESENTS WITH CELLULITIS / VASCULITIS ISCHAEMIA PATIENT NON-COMPLIANCE OR When you are not comfortable Environment not safe Loss of confidence in skills or knowledge Know your limitation Ask for help Thank you Reference List Enjoy your lunch! 87 British Association for Parenteral and Enteral Nutrition (2003) Malnutrition Universal Screening Tool: 'MUST', Redditch: BAPEN Callam MJ, Ruckley CV, Harper DR, et al. Chronic ulceration of the leg: extentof the problem and provision of care. Br Med J (Clin Res Ed)1985;290: costs- Posnett & Franks 2008 Deborah Simon, FrancisP.Dix. Charles. N McCollum BMJ of venous leg ulcers) Moffatt, C.J.Franks, P.J. Doherty, D.C.Martin,R.,Blewett,R & Ross,F.2004 Prevelance of leg ulceration in a london population.quaterly Journal of Medicine 97: Moffatt C (2001) Leg ulcers. In: MurrayS (ed) Vascular Disease: Nursing and Management. Whurr, London: Morison MJ, Moffatt C (2004) Leg ulcers.in: Morison MJ, Ovington LG, Wilkie K (eds) Chronic Wound Care: A ProblemBased Learning Approach. Mosby, Edinburgh: RCN (2006) Clinical Practice Guidelines. accessed 15/03/ Guidelines. Management of Chronic Venous ulcers Williams, L., Leaper,D.J.Nutrition and wound healing. Clin Nut Update 2000; 5: 1, Foperations%2FCHWS%2FTissueViabilityService%2FWound%20Management%20Documents%2FAll%20preferred%2 0prescibing%20lists%20and%20dressing%2 References RCN (2006) The management of patients with venous leg ulcers. London; RCN. Vowden, P. and Vowden, K. (1996) Hand held Doppler assessment for peripheral arterial disease. Journal of Wound Care. 5(3): Vowden, P. and Vowden, K. (2001)Doppler and the ABPI: how good is our understanding? Journal of Wound Care. 10(6): in/files/ pdf REFERENCES Elastic properties of extensible bandages, British standard BS7505: 1995 Thomas S., 1998 Compression bandaging in the treatment of leg ulcers SIGN guidelines Morison MJ, and Moffatt C (2004) Leg Ulcers. In Morison MJ, Ovington LG and Wilkie K. Chronic Wound Care London, Mosby. Dale J.J. et al, 1985, Chronic ulcers of the leg: a study of prevalence in scottish community, Health bulletin, 41, Nelson E.A., 1996, The management of leg ulcers, JWC, 5(2), Blair et al, 1988, Sustained compression and healing of chronic venous leg ulcers, Br med J, 297, 1159, 1161 Netzer C. & Rudofsky G., 1991, Practical ambulant phrenology, Germany, Schorsch-Druck Nelson, Iglesias et al, 2004, Randomized, clinical trial of four layer and short stretch compression bandages for venous leg ulcers, BJS, Vol 91, No 10 Callam M.J. et al, 1987, Chronic leg ulcer of the leg: clinical history, BMJ, 294 (6584); Ballard K. et al, 2000, An evaluation of the Parema four-layer bandage system, BJM, vol. 9, No 16; Nelson et al, 1995, Improvements in bandaging technique following training, JWC, 4, 4: Taylor and Taylor, 1999, A comparison of sub-bandage pressures produced with two multi-layer bandaging systems, JWC, vol 8, No 9 SMTL, March 1999, Comparison of elastic properties and predicted sub bandage pressure of two cohesive bandages, 99/1076/1 Vowden et al, 2000, Comparison if the healing rates and complications of three four-layer bandage regimens, JWC, vol 9, No 6 Vowden et al, may 2001, The K-four bandage system: evaluating its effectiveness on recalcitrant venous leg ulcers, JWC, vol 10, No 5 Smith et al, 2004, Evaluation of Urgotul plus K Four compression for venous leg ulcers, BJN, vol 13, No 16 Hannah R. Sub-Bandage pressure measurements and usability between three compression bandage systems Hünger M. Interface pressures of three different multi-layer bandage systems in healthy volunteers Begnini Efficacy, safety and acceptibility of a new two layer compression bandage system in the management of venous leg ulcers 15