Use of customised pressure-guided elastic bandages to improve efficacy of compression bandaging for venous ulcers

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1 International Wound Journal ISSN ORIGINAL ARTICLE Use of customised pressure-guided elastic bandages to improve efficacy of compression bandaging for venous ulcers Nuttawut Sermsathanasawadi, Choedpong Chatjaturapat, Rattana Pianchareonsin, Nattawut Puangpunngam, Chumpol Wongwanit, Khamin Chinsakchai, Chanean Ruangsetakit & Pramook Mutirangura Division of Vascular Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand Key words Compression; Elastic bandage; Sub-bandage pressure; Venous leg ulcer Correspondence to N Sermsathanasawadi, MD, PhD Division of Vascular Surgery Department of Surgery Faculty of Medicine Siriraj Hospital Mahidol University 2 Wanglang Road Siriraj Bangkoknoi Bangkok Thailand nuttawut@gmail.com doi: /iwj Sermsathanasawadi N, Chatjaturapat C, Pianchareonsin R, Puangpunngam N, Wongwanit C, Chinsakchai K, Ruangsetakit C, Mutirangura P. Use of customised pressure-guided elastic bandages to improve efficacy of compression bandaging for venous ulcers. Int Wound J 2017; 14: Abstract Compression bandaging is a major treatment of chronic venous ulcers. Its efficacy depends on the applied pressure, which is dependent on the skill of the individual applying the bandage. To improve the quality of bandaging by reducing the variability in compression bandage interface pressures, we changed elastic bandages into a customised version by marking them with circular ink stamps, applied when the stretch achieves an interface pressure between 35 and 45 mmhg. Repeated applications by 20 residents of the customised bandage and non-marked bandage to one smaller and one larger leg were evaluated by measuring the sub-bandage pressure. The results demonstrated that the target pressure range is more often attained with the customised bandage compared with the non-marked bandage. The customised bandage improved the efficacy of compression bandaging for venous ulcers, with optimal sub-bandage pressure. Introduction Compression is the most important treatment in the management of venous leg ulcers (VLUs). Many studies have proven the effect of compression therapy in the treatment of VLUs (1 3). Insufficient compression therapy can lead to delayed ulcer healing. Compression enhances the venous flow and reduces oedema by increasing the interstitial pressure of the surrounding soft tissues (2). Application of a compression bandage (CB) is the most common and preferred treatment for VLUs. The bandage applies pressure on the external surface of the leg, and this pressure is transmitted to the underlying veins. The efficacy of the compression mainly depends on the level of pressure applied to the leg (4). The pressure that develops beneath a bandage depends on the tension in the fabric of the elastic bandage (EB), the radius of curvature of the limb, the width of the EB and the number of layers applied (5). Several studies have shown that a CB with a sub-bandage pressure of mmhg at the ankle is safe and effective for the treatment of VLUs (6,7). The efficacy of a CB depends on the applied pressure, which is mainly dependent on the skills of the individual applying the CB (8,9). High variability in bandage pressure usually occurs when CBs are applied by inexperienced staff members (9). Lower pressure leads to treatment failure, while higher pressure leads to skin complications. The use of objective devices to measure sub-bandage pressure is not a routine training standard (9). To reduce the variability in CB interface pressures and to improve CB quality, we prepared an individual EB with a visual guide, a customised pressure-guided EB (CPG-EB), by using sub-bandage pressure guidance. In this study, the sub-bandage pressure of an ordinary EB (OEB) and a CPG-EB was measured and compared. Key Messages the authors described a method to change elastic bandages into a customised version by marking them with circular ink stamps, applied when the stretch achieves an interface pressure between 35 and 45 mmhg. Repeated applications by 20 residents of both bandages to one smaller and one larger leg demonstrated that this target pressure range is more often attained with the customised bandage compared with the non-marked bandage Medicalhelplines.com Inc and John Wiley & Sons Ltd

2 N. Sermsathanasawadi et al. Pressure-guided bandage for venous ulcer Methods Twenty surgical residents from the Division of Vascular Surgery, Department of Surgery, Siriraj Hospital, Mahidol University, were included in the study. The participants were askedtoapplyanoebandcpg-ebtotwovolunteers.allparticipants applied three consecutive OEBs and three consecutive CPG-EBs to each volunteer. The participants were taught by an experienced nurse to apply the OEB for the treatment of VLUs. The CB began in the foot area at the metatarsophalangeal joint, followed the course of the toes and encompassed the heel. The starting end of the bandage was fixed with two circular routes. The pressure exerted by the bandage must be stronger in the ankle area and slowly decrease as the bandage approaches the knee. Bandaging was applied by a spiral method. Three EBs were applied, with 50% stretching and 50% overlapping from the foot to just below the knee (5). We developed a CPG-EB for each volunteer. The experienced nurse applied three EBs to each volunteer, with sub-bandage pressure monitoring. The target pressure was mmhg. Measurements of the bandage pressure were performed with a PicoPress (Microlab Elettronica, Ponte S. Nicolo, Italy). If the target pressure of mmhg was achieved, a circular ink stamp was applied to the entire bandages. The marker in each CPG-EB had an elliptical shape when the bandage was not stretched. The marker changed to a circular shape when the bandage was stretched (Figure 1). Each resident applied three CPG-EBs using the spiral method, with 50% overlap from the foot to just below the knee. The residents were taught to stretch the bandage until the elliptical marker exhibited a circular shape. The sub-bandage pressure was measured with the PicoPress. A transducer pad was placed about 12 cm above the inner ankle at the medial aspect of the lower leg, where the tendon changes into the muscular part of the gastrocnemius muscle. This point is known as the B1 point according to a previous report (4). The volunteer was placed in the supine position, and the bandage pressure during inactivity (the resting pressure) was measured. The sub-bandage pressure measurement was blinded to all participants. The EB (Medigauz, Thai Gauze Co., Ltd., Bangkok, Thailand) had a maximum stretch capacity of >100% and was 4 50 m long and cm wide. Its composition was 35% cotton, 30% polyester and 35% spandex. In the supine position (resting position), a pressure of mmhg was considered an optimal pressure (4). Surgical residents who achieved an optimal pressure in at least two of the three bandaging attempts were considered to have performed adequate-quality compression bandaging. Those who achieved an optimal pressure in only one of the three bandaging attempts were considered to have performed inadequate-quality compression bandaging. This study s protocol was approved by the institutional review board of Mahidol University [no. 292/2558(EC4)]. All residents and volunteers gave informed consent. Statistical analysis Qualitative demographic data are presented as frequencies and percentages. The Chi-square test was used to compare the quality of compression bandaging between the OEB and CPG-EB. Quantitative data are presented as means and standard deviations. Box plots of sub-bandage pressure were drawn for the minimum, lower quartile, median, upper quartile and maximum. The mean sub-bandage pressure with use of the OEB and CPG-EB was compared using at-test for paired samples. A P-value of <0 050 was considered statistically significant. Data were prepared and analysed using PASW statistics 18 0 (SPSS Inc., Chicago, IL). Results We compared the average sub-bandage pressure after the application of three consecutive CBs using both the OEB and CPG-EB performed by each resident. In Volunteer Figure 1 Customised pressure-guided elastic bandage. (A) Elliptical shape of the bandage when not stretched. (B) An elliptical-shaped marker that turns into a circle when the bandage is stretched helps to apply the bandage with the correct stretch and pressure Medicalhelplines.com Inc and John Wiley & Sons Ltd 637

3 Pressure-guided bandage for venous ulcer N. Sermsathanasawadi et al. Table 1 Optimal pressure (35 45 mmhg) of ordinary elastic bandage and customised pressure-guided elastic bandaging in resting position Participants with optimal pressure (35 45 mmhg) n (%) Volunteer Ordinary elastic bandage n = 20 Customised pressure-guided elastic bandage n = 20 P-value Volunteer A (ankle circumference 20 cm) 6 (30 0) 14 (70 0) <0 050 Volunteer B (ankle circumference 26 cm) 5 (25 0) 15 (75 0) <0 050 Figure 2 Box plot showing the mean sub-bandage pressure in the resting position (supine position). Ordinary elastic bandage (left) and customised pressure-guided elastic bandage (right), with the optimal pressure range marked in grey. (A) Volunteer A with an ankle circumference of 20 cm. (B) Volunteer B with an ankle circumference of 26 cm. A (ankle circumference of 20 cm), the mean sub-bandage pressure was ± mmhg with the OEB and ± 8 59 mmhg with the CPG-EB. In Volunteer B (ankle circumference of 26 cm), the mean sub-bandage pressure was ± mmhg with the OEB and ± 5 96 mmhg with the CPG-EB. In Volunteer A, six of 20 residents (30%) performed bandaging with an optimal sub-bandage pressure (35 45 mmhg) using the OEB, and 12 of 20 residents (70%) performed bandaging with an optimal sub-bandage pressure using the CPG-EB (P < 0 050) (Table 1). In Volunteer B, five of 20 residents (25%) performed bandaging with an optimal sub-bandage pressure using the OEB, and 15 of 20 residents (75%) achieved an optimal sub-bandage pressure using the CPG-EB (P < 0 050) (Table 1). The OEB and CPG-EB resting pressure distributions were significantly different (P < 0 050) (Figure 2). Residents who achieved an optimal pressure (35 45 mmhg) in at least two of the three bandaging attempts obtained adequate-quality compression bandaging. In Volunteer A, adequate-quality bandaging was achieved by 25% of the residents applying the OEB and 65% of the residents applying the CPG-EB (P < 0 050). In Volunteer B, adequate-quality bandaging was achieved by 25% of the residents applying the OEB and 70% applying the CPG-EB (P < 0 050) (Table 2). Discussion Compression is recognised as an effective treatment for VLUs (2). Ulcer healing is accelerated by effective compression. The efficacy of compression bandaging is highly dependent on the skills of the individual (9). Whether the sub-bandage pressure is adequate often remains unclear. In previous studies, the introduction of objective devices to measure the sub-bandage pressure in combination with training resulted in improved bandaging skills among nurses (9 11). Training using a pressure monitor for feedback improved the percentage of CBs, with adequate compression levels from 50% to 81% (8 10,12). However, the observed training effect could have been a result of the Hawthorne effect because the participants were under observation and were therefore the centre of attention during the application of the CBs (9). Participants are prone to resort to old habits under regular conditions. Ongoing training is necessary to maintain bandaging skill (9). Although some surgical residents had some experience of applying CBs in the past, we also measured sub-bandage pressure of each participant in daily practice in our pilot data. Adequate-quality bandaging was achieved only by 15 20% of the residents. To improve CB quality, we developed an individual EB with a visual guide. Compression using the EB was applied in each patient with sub-bandage pressure monitoring to achieve an interface pressure of mmhg at the B1 point. A marker that changed from elliptical to circular was placed on the bandage while it was stretching to the target sub-bandage pressure. A visual marker (change from an elliptical to circular marker) helped to apply the bandage with the correct stretch. The optimal sub-bandage pressure was defined as mmhg in the supine position. This is a widely accepted Medicalhelplines.com Inc and John Wiley & Sons Ltd

4 N. Sermsathanasawadi et al. Pressure-guided bandage for venous ulcer Table 2 Rate of adequate-quality compression bandaging when applying ordinary elastic bandage and customised pressure-guided elastic bandage in resting position. (A) Volunteer A (ankle circumference 20 cm. (B) Volunteer B (ankle circumference 26 cm) Participants n (%) A Ordinary elastic bandage (n = 20) Customized pressure-guided elastic bandage (n = 20) P-value Adequate-quality compression bandaging* 5 (25 0) 13 (65 0) Inadequate-quality compression bandaging 15 (75 0) 7 (35 0) Participants n (%) B Ordinary elastic bandage Customized pressure-guided elastic bandage P-value Adequate-quality compression bandaging* 5 (25 0) 14 (70 0) Inadequate-quality compression bandaging 15 (75 0) 6 (30 0) *Adequate-quality compression bandaging meant that the surgical resident achieved the optimal pressure (35 45 mmhg) in at least two of the three bandaging attempts. range for sufficient and safe compression and was also recommended in a recent consensus document on compression bandaging (7). In this study, the CPG-EB increased the optimal sub-bandage pressure when applied by inexperienced residents who treated volunteers with different leg circumferences. Although bandage systems with geometric marks that change their shape by stretching to a desired pressure range are available on the market, they are more expensive and are not available for different leg sizes and shapes, especially in patients with advanced lipodermatosclerosis in whom the proximal leg swells and the lower leg shrinks from chronic ulceration, resulting in an inverted champagne bottle appearance of the lower leg (13). To avoid the learning effect between each bandaging method, all the residents who applied the bandage did not know the result of sub-bandage pressures. The sub-bandage pressure in the supine position has been measured in many studies (9). The PicoPress system is a portable digital gauge specially designed to measure the pressure exerted by a bandage. Its reliability and reproducibility have already been demonstrated, and it is known as one of the best systems for measuring interface pressure (4,14). Although multicomponent compression systems are more effective than multilayer single-component compression systems in the treatment of VLUs (2,3), multicomponent compression systems are expensive and require application by experienced nurses or doctors. In patients with large VLUs who require frequent changes of the wound dressing, a multilayer single-component system with EB compression allows daily inspection of the wounds and frequent dressing changes because the systems can be reapplied and are cheaper than multicomponent compression systems. CPG-EB, a multilayer single-component compression system with an EB, can be easily applied by untrained personnel and even by the patients themselves. In addition, it is cheap and reusable. Compression systems comprising multiple layers of EB are stiffer than single-layered, long-stretch bandages because of the force of friction acting between the layers (15). However, multiple layers of an EB need to be removed overnight to prevent skin complications that may result from high pressure (16). With the CPG-EB, patients might remove the bandage at night and reapply it during the day by themselves to prevent skin complications secondary to high pressure for a long period. This hypothesis should be evaluated in a future study by measuring the sub-bandage pressure of the CPG-EB when applied and removed by patients. Our technique could be adapted for any target pressure requirement, such as a mmHg bandage pressure after varicose vein surgery or a mmHg bandage pressure requirement for treatment of lymphoedema. In addition, this method might be of interest for training courses of medical staff to attain a certain pressure range with EBs. In this study, we used the only EB available in our hospital. The different elasticities of other types of EBs might change the outcomes. Future studies should evaluate various target pressures, leg sizes and types of EBs. Conclusions The CPG-EB improved the efficacy of compression bandaging for VLUs, with an optimal sub-bandage pressure. The CPG-EB is cheap and reusable and could be an option for treatment of VLUs. Acknowledgements This study was supported by the Siriraj Research Development Fund (managed by Routine to Research: R2R no.15su00032/114/15), Faculty of Medicine Siriraj Hospital, Mahidol University. We acknowledge the Siriraj R2R team and the Siriraj Vascular Surgery (Syamindra1) nurse team for contributing to the work presented in this article. We also thank Supaporn Tunpornpituk for her statistical assistance. The authors declare no competing interests. References 1. Fletcher A, Cullum N, Sheldon TA. A systematic review of compression treatment for venous leg ulcers. 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