Edema: What We Should Know,

Transcription

1 Edema: What We Should Know, What Should We Do? Terry Treadwell, MD, FACS Medical Director Institute for Advanced Wound Care Montgomery, Alabama Massive Edema Photo used with permission Edema Is the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body, usually the subcutaneous tissues. Can occur in any tissue of the body Fluid contains low levels of protein Fluid containing high levels of protein--lymphedema Dorland Illustrated Medical Dictionary, 24th Edition, W.B. Saunders Co., Philadelphia, PA, 1965, p M

2 Why Worry About Edema? Sign of an important systemic condition Impairs local cell nutrition Is painful Gives rise to impaired mobility Increases risk of infection (cellulitis) Results in blistering of the skin and ulcers Mortimer PS, Levick JR. Chronic Peripheral Oedema: The Critical Role of the Lymphatic System. Clinical Medicine 2004;4(5): Complications of Edema Cellulitis Edema With Blisters Why Is Edema Important? Can be seen in 1 in 200 people > age 65 80% of patients have missed work because of edema 9% have changed employment status t as a result of edema Moffatt C, Franks PJ, Doherty DC, Williams AF, et al. Lymphedema: An Underestimated Health Problem. QJM 2003;96: M

3 Etiology of Edema The diagnosis of edema is the disease that causes it >90% of patients, diagnosis can be determined by history and physical exam 10% of patients t with edema need laboratory exam or radiologic studies for diagnosis Treadwell T, Fowler E, Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, Fourth Edition. Eds.-Carrie Sussman and Barbara Bates Jensen, Lippincott, Wilkins, and Williams, New York, NY, 2012 Bilateral 1. Cardiac disease 2. Renal disease 3. Hepatic disease 4. GI disease 5. Immune disease and allergy Causes of Edema 6. Nutritional disease 7. Endocrine disease 8. Pregnancy 9. Circulatory problems usually vena caval obstruction 10.Drugs and medications 11.Inactivity and dependency of legs Unilateral 1. Venous disease 2. Arterial disease usually A-V fistulae 3. Lymphatic disease 4. Operations 5. Trauma 6. Cancer and other tumors Acute Post Op Wound (ORIF of Leg Fracture) with Edema and Lymphedema Note Pitting! 3M

4 Drugs Causing Edema Calcium channel blockers Hydralazine Clonidine Minoxidil Reserpine Beta-blockers Cilostazol Gabapentin Pregabalin (Lyrica) Corticosteroids Estrogen Progesterone Tamoxifin Testosterone MAO-inhibitors Non-steroidal anti-inflammatory drugs Cox-2 inhibitors Treadwell T, Fowler E, Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, Fourth Edition. Eds.-Carrie Sussman and Barbara Bates Jensen, Lippincott, Wilkins, and Williams, New York, NY, 2012 Bundens WP. The Chronically Swollen Leg: Finding the Cause: Theory and Practice, in Venous Ulcers, Ed. Bergan JJ and Shortell CK, Elsevier, Boston, MA, 2007, p.73 Venous Insufficiency Chronic ambulatory venous hypertension Incompetence of valves in veins Long-standing saphenous, deep venous, and perforator incompetence Local trauma Undetected venous thrombosis Operative injury Capillary and venular dilatation Calf muscle pump failure Angle N, et al. Br Med J. 1997;314(7086): Burton CS. Am J Surg. 1994;167(1A):37S-40S. Valvular Incompetence 3M

5 Venous Hypertension with Leaky Vessels Pericapillary Fibrin in Venous Insufficiency Falanga, V, ed. Cutaneous Wound Healing. London, England: Martin Dunitz Ltd; 2001:157. Ouahes N, et al. Curr Probl Dermatol. 1995;7(4): Pathophysiology of Venous Insufficiency Capillary and venular dilatation Calf muscle pump failure Concentration of pressure at ankle Angle N, Bergan JJ. BMJ. 1997;314: Burton CS. Am J Surg. 1994;167(suppl):37S-41S. 3M

6 Capillary Pressures at Ankle Arterial end ~ mm Hg Venous end ~ 8-15 mm Hg (1) Pressures increase when person stands both arterial and venous by average of 100 mm Hg!!! (2) 1) Foldi E, Foldi M. Chronic Venous Insufficiency and Venous-lymphostatic Insufficiency. In: Foldi s Textbook of Lymphology. 2 nd Edition. Munich, Germany: Elsevier; pp ) Farrow W. Phlebolymphedema A Common Underdiagnosed and Undertreated Problem in the Wound Care Clinic. Jour Am College of Certified Wound Care Specialists 2010;2:14-23 Development of Edema Normal Circulation Venous End Arterial End 8 mm Hg ~27 Liters/day ~30 Liters/day 35 mm Hg ~3 Liters/day Lymphatics Development of Edema Increased Arterial Pressure Venous End Arterial End 8 mm Hg 135 mm Hg ~27 Liters/day >30 Liters/day ~3 Liters/day Lymphatics 3M

7 Development of Edema Increased Venous Pressure Venous End Arterial End 108 mm Hg 35 mm Hg <27 Liters/day >30 Liters/day ~3 Liters/day Lymphatics Development of Edema Leaky Capillaries Venous End Arterial End 8 mm Hg 35 mm Hg <27 Liters/day >30 Liters/day ~3 Liters/day Lymphatics Development of Edema Decreased Lymphatic Flow Venous End Arterial End 8 mm Hg 35 mm Hg ~27 Liters/day <3 Liters/day ~30 Liters/day Lymphatics 3M

8 Complications of Venous Hypertension Macromolecules trap growth factors Growth factors unavailable to repair or maintain Leukocytes accumulate and occlude capillaries Activated leukocytes release toxic metabolites Free radicals and proteolytic enzymes damage endothelium Browse NL, et al. Lancet. 1982(8292);2: Falanga V, et al. Lancet. 1983;341: Coleridge Smith PD, et al. Br Med J (Clin Res Ed). 1988;296(6638): Capillary Loss with Venous Hypertension Prolonged venous hypertension causes damage to and destruction of capillaries in skin 1 Capillary thrombosis results in decreased number of capillaries in skin and wound bed 1,2,3 1. Junger J, Steins A, Hahn M, Hafner HM. Microcirculatory Dysfunction in Chronic Venous Insufficiency. Microcirculation 2000;7:S3-S12 2.Bollinger A, Jager K, Geser A. Sgier F, Seglias J. Transcapillary and Interstitial Diffusion of Na- Fluorescein in Chronic Venous Insufficiency with White Atrophy. Int J Microcirc Clin Exp 1982;1: Leu AJ, Yanar A, Pfister G, Geiger M, Franzeck UK, Bollinger A. Microangiopathy in Chronic Venous Insufficiency. Dtsch Med Wochenschr 1991;116: Venous Disease and Ulceration Edema and Pigmentation Lipodermatosclerosis and Ulceration 3M

9 Chronic Venous Disease and Capillary Density Junger J, Steins A, Hahn M, Hafner HM. Microcirculatory Dysfunction in Chronic Venous Insufficiency. Microcirculation 2000;7:S3-S12 Examination of the Swollen Lower Extremity Medical Conditions Medicines Venous Disease Symptoms Usually none Usually none Heaviness; aching Lymphedema Heaviness; aching Bilateral Yes Yes Yes/No Yes/No Pitting Yes Yes Early-Yes; No Late - +/- Skin Changes None None Yes Yes; Can be severe Location Worse distally Leg; occasionally foot Benefit with Elevation Leg; occasionally foot Varies but worse distally Yes Yes/No Yes Minimal Adapted from Carson S, Fowler E. Management of Edema. In B Bates-Jensen Ed. Wound Care: A Collaborative Practice Manual for Health Professionals. 3rd edition. And Bundens WP. The Chronically Swollen Leg: Finding the Cause: Theory and Practice. In Eds JJ Bergan, CK Shortell. Venous Ulcers. Elsevier, Boston, MA. 2007, p. 73 Edema Severity Scale Depth of Pitting Scale of Pitting 0 to ¼ inch 1+ ¼ to ½ inch 2+ ½ to 1 inch 3+ > 1 inch 4+ Adapted from Carson S, Fowler E. Management of Edema. In B Bates-Jensen Ed. Wound Care: A Collaborative Practice Manual for Health Professionals. 3 rd edition. 3M

10 Treatment of Edema Elevation of Legs? But how high? Accessed 8/14/12 Treatment of Edema Compression! Compression!! COMPRESSION!!! Are all compression bandages the same? 3M

11 Compression Therapy Short stretch or inelastic Elastic 1. Single layer 2. Multiple layers Higher pressure better than lower pressure Compression therapy significantly increases healing compared to no compression Fletcher A, et al. BMJ. 1997;315(7108): Cullum N, et al. Cochrane Database Syst Rev. 2000;(3): CD Franks PJ, et al. Wound Repair Regen. 2004;12(2): Compartments Anterior Tibial Anterior Tibia Greater Saphenous Fibula Peroneal Lateral Deep Posterior Superficial Posterior Lesser Saphenous Posterior Tibial Skin Dr. HN Mayrovitz Pressures of Interest Tibialis m. Tibia Sub-bandage Surface Contact Fibula Pe eroneus Popliteus m. Tibialis m. Soleus m Compression Bandage or Device Tissue Interstitial Gastroc m. Skin Intramuscular Dr. HN Mayrovitz 3M

12 Resting Pressure Pressure (P) Due to Tension (T) of Bandage and the Radius (R) of the Leg R Laplace s Law Superficial vessels affected the most Dr. HN Mayrovitz Working (Dynamic) Pressure Muscles Contract Bandage Restricts Muscle Contraction High Pressure Develops on Deeper Tissues Pressure Is From WITHIN Dr. HN Mayrovitz Dynamic Pressure Depends on Bandage Material Form-fitted Steel Pipe ressure Dynamic Pr Inelastic (short stretch) Elastic (long stretch) No External Compression 0 Bandage Stretchability Mayrovitz HN, et al. Clin Physiol. 1997;17(1): M

13 Tissue Pressu ure (P T ) Working vs. Resting Pressures Role of Compression Material Emptying Emptying Dr. HN Mayrovitz Clin Physiol. 1997;17(1): Time Dr. HN Mayrovitz ml/min Arterial Flow Pulses Below Knee Blood Flow via Nuclear Magnetic Resonance Control Leg Treated Leg Before Bandage ml/min With Bandage Dr. HN Mayrovitz, Univ of Miami Venous Ulcer 99 year old lady with ulcer for 8 months ABI Informed that BK amputation was the only therapy Treated with light compression and bi-layered tissue engineered skin Wound healed after 47 weeks 3M

14 Types of Compression Therapy Unna s Boot The original short stretch compression wrap 2 Layer Compression Bandage 1 st Layer Complete Beginning 2 nd Layer Completed 3M

15 3 Layer Compression Bandage 4 Layer Compression Bandage 1 st Layer 2nd Layer 3rd Layer 4th Layer Completed Allergies and Compression Bandages Allergy to Cotton Wrap Allergy to Elastic Wraps 3M

16 Compression Bandage Too Tight Over Bony Prominences Effective Compression? Achieve the appropriate sub-bandage pressure mm Hg Use the correct techniques Use the appropriate materials Is Effective Compression Therapy Being Used? Effective compression therapy sub-bandage pressure of mm Hg. Study of compression bandages applied by skilled, experienced wound care nurses 34.9% of compression bandages -- < 20 mm Hg pressure (56.7% -- applied by nurses with > 10 years experience!) 0% of compression bandages -- > 60 mm Hg Keller A, Muller ML, Calow T, Kern IK, Schumann H. Bandage Pressure Measurement and Training: Simple Interventions to Improve Efficacy in Compression Bandaging. Int Wound J. 2009;6: M

17 Sub-bandage Pressure Measurement Pico Press Sub-bandage Pressures After Training Only 4.8% -- pressures < 20 mm Hg 12.7% -- pressures > 60 mm Hg 82.5% -- within therapeutic range (30-40 mm Hg)! Keller A, Muller ML, Calow T, Kern IK, Schumann H. Bandage Pressure Measurement and Training: Simple Interventions to Improve Efficacy in Compression Bandaging. Int Wound J. 2009;6: Effective Compression Therapy Practice PRACTICE PRACTICE! With Feedback!! 3M

18 Correct Technique Wrap to the Tibial Tubercle Always Begin at The Base of the Toes Not Good! Oops! Failure To Wrap All The Way To The Knee 3M

19 Failure to Wrap Feet! (Or to the Knees!) Wrap With Even Pressure Wrap with Appropriate Materials Leg Wrapped with Fragments of 3 Bandages! 3M

20 Fact: Patients Don t Like Compression Bandages! Only 48.8% of patients wear their compression bandages * May be as high as 80% * Determinants for NOT wearing compression bandages: a. Age b. Pain c. Wound size d. Wound depth * Miller C, Kapp S, Newell N, et al. Predicting Concordance with Multilayer Compression Bandaging. Jour Wound Care 2011;20(3): When a Bandage Won t Stay Up! actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite 10 9 Slippage in cm: after 24 and 48 hours actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite 3M

21 Good Therapy? Sponsored by an educational grant from 3M For more information on 3M Compression Therapy visit 3M is a provider approved by the California Board of Registered Nursing, Provider Number CEP Nurse participants may receive continuing education credit upon completion of education module. 3M