Venous Ulcer Assessment and Management (copied on 01/20/23)

Assess and diagnose new or recurring Venous Leg Ulcers (VLU)..

Introduction

SCOPE

Venous Leg Ulcers (VLU) are relatively common, affecting 1% of the population in the U.S. VLU can be defined as an open skin lesion of the leg or foot that occurs in an area affected by venous hypertension, often caused by chronic venous insufficiency. It is a chronic condition, with recurrence rate within 3 months after wound closure as high as 70%. Thirty-five percent of people with VLU experience four or more episodes.

Decision Nodes

VLU Assessment

VLU History and Physical Exam

Q: History and physical exam consistent with VLU? Yes;No

Q: Risk factors for delayed healing Yes ;No

Q: Risk factors for recurrence Yes;No

Evaluate patients concerns and psychosocial aspects

Patient's concerns and psychosocial aspects:

VLU Patient's Concerns and Psychosocial Aspects

Evaluate patient's concerns:
- Pain, exudate, odor
- Ability to carry out daily activities
Evaluate patient's and caregiver/family's psychosocial aspects:
- Cognitive, functional, emotional status
- Understanding of the wound, risk factors
- Preference for treatment
- Motivation for adherence to the care plan
- Financial concerns

Q: Patient's concerns

Q: Patient's and caregiver/family's psychosocial aspects

Is blood supply to the ulcer adequate?

Evaluate blood supply to the ulcer with non-invasive arterial vascular tests. Select which test to use:

If diabetes or arterial calcification: use audible handheld

Doppler with pre/post compression toe pressure, TCOM
Resources: topic "How to Select Adequate Compression Therapy Pressure Levels"

If no diabetes or arterial calcification: use ankle brachial index (ABI)

>1.3: non-compressible arteries
0.8-1.3: no relevant ischemia
0.5-0.79: mild/ moderate ischemia
<0.5: severe ischemia

Q: Test used and value

Is the VLU healable?

Is the ulcer healable?

If patient has any of the conditions below, consider a non-healing program. VLU will likely not heal with conservative treatment only:

Co-morbidities that impede healing:
ulcer is malignant tumor,
major organ failure
Blood supply to the VLU is inadequate (ABI, Doppler, TCOM, other exams)

If patient has any of the conditions that impede wound healing below, consider a maintenance-healing program until element impeding healing is eliminated

Co-morbidities:

Uncontrolled diabetes
Immunosuppression
Obesity: BMI > 40?
Inadequate nutrition (abnormal serum protein, unintended weight loss)
Cognitive, emotional, psychological dysfunction
Calf muscle pump disfunction (arthritic conditions, paralysis, etc)

Drugs and interventions :

Steroids
Chemotherapy/ radiation

Lifestyle:

Regular smoking

Impaired mobility
Financial or resource constraints

Is the mixed arterial ulcer healable?

If ABI was used:

If ABI is between 0.5-0.8: It is a healable mixed arterial venous ulcer
If ABI < 0.5: It is a non-healable mixed arterial venous ulcer

If Doppler was used:

If Doppler is monophasic with post-compression TP or TCOM < 30 mmHg: It is a non-healable mixed arterial venous ulcer

Non-healable or Maintenance VLU

Healable mixed arterial venous ulcer

(ABI: 0.5-0.8)

Vascular specialist to determine severity of arterial occlusion

Non-healable mixed arterial venous ulcer

ABI < 0.5 or monophasic Doppler with post-compression TP or TCOM < 30 mmHg

Is it simple or complex?

Is the VLU simple or complex?

Determine if VLU is simple or complex:

Simple VLU:

Area < 100 cm2 and onset < 6 months with limited comorbidities

Complex VLU:

Area > 100 cm2 and/or wound onset > 6 months (no other comorbidities)
< 30% decrease in wound area after 4 weeks of adequate treatment
Lymphovenous disease
Associated lipedema
Leg/ulcer infection
Stable cardiac heart failure
History of non-adherence

Healable Simple VLU

Healable Complex VLU

See vascular specialist. Avoid compression.

Treat the cause and co-factors impeding healing

For non-healable or maintenance VLU

Mitigate/ eliminate any factors impeding healing
Exercise as tolerated, leg elevation, oral pentoxifylline
Compression therapy (see below)
- See topic "How to Select Adequate Compression Therapy Pressure Levels and Products"

Q: What type of compression will be applied?

Treat the cause and co-factors impeding healing

For non-healable or maintenance VLU

Mitigate/ eliminate any factors impeding healing
Exercise, leg elevation, oral pentoxifylline
Compression therapy (see below)
- See topic "How to Select Adequate Compression Therapy Pressure Levels and Products"

Q: What type of compression will be applied?

Address patient's concerns and educate patient

Q: The following patient concerns were addressed:

Q: Patient was educated on the following:

Treat the cause and co-factors impeding healing.

For non-healable or maintenance VLU

Mitigate/ eliminate any factors impeding healing
Exercise, leg elevation, oral pentoxifylline
Compression therapy (see below)
- See topic "How to Select Adequate Compression Therapy Pressure Levels and Products"

Q: What type of compression will be applied?

Treat the cause and co-factors impeding healing.

For non-healable or maintenance VLU

Mitigate/ eliminate any factors impeding healing
Exercise, leg elevation, oral pentoxifylline
Compression therapy (see below)
- See topic "How to Select Adequate Compression Therapy Pressure Levels and Products"

Q: What type of compression will be applied?

Local Wound Care for Nonhealable Venous Ulcers

Cleansing	Gently cleanse with normal saline, sterile water or commercial wound cleanser. Irrigate wound with > 100 mL of room/body temperature solution at low pressure (4-15 psi) If infected, consider antiseptic solution
Debridement	Conservative debridement of nonviable tissue only. Do not debride if circulation is severely impaired (mixed arterial ulcer)
Infection management	Use antimicrobial dressings and antibiotics only in cases of clinical infection (e.g. if increasing pain is observed) Antimicrobial dressings (with cadexomer iodine, silver, etc): Non-adherent dressing based In confirmed clinical infection, prescribe systemic antibiotics guided by culture
Periwound skin care	To protect periwound from exudate: barrier products For stasis dermatitis: moisturizers, zinc or calamine, or topical steroids if needed
Dressings	Apply appropriate non-adherent dressing OR Paint wound with antiseptics (minimal or light exudate) If dry or wet gangrene: moisture retentive dressing may cause limb threatening infection Avoid conventional dressing products that require daily dressing changes

Local Wound Care for Healable Venous Ulcers

Cleansing	Gently cleanse with normal saline, sterile water or commercial wound cleanser. Irrigate wound with > 100 mL of room/body temperature solution at low pressure (4-15 psi) If infected, consider antiseptic solution
Debridement	Topical anesthetics such as lidocaineprilocaine cream if needed to reduce debridement pain. Surgical, sharp, mechanical, autolytic, enzymatic, or combination of methods
Infection management	Use antimicrobial dressings only in cases of clinical infection (e.g. if increasing pain is observed) or if no healing is seen in 4 weeks Antimicrobial dressings (with cadexomer iodine, silver, etc): Light exudate: hydrogel or hydrogel colloidal sheet-based Moderate, heavy exudate: alginate, hydrofiber, super absorbent In confirmed clinical infection, prescribe systemic antibiotics guided by culture
Periwound skin care	To protect periwound from exudate: barrier products For stasis dermatitis: moisturizers, zinc or calamine, or topical steroids if needed
Dressings	Fill deep wounds to avoid dead space. Maintain wound moisture with: Hydrocolloid, hydrogel, moisture retentive foam Manage exudate with: Alginate, gelling fiber, foam, composite dressing, specialty absorbent

Order referrals/ consults as needed

Q: Referral or consult ordered for

Weekly follow up visits

Weekly follow up visits at a minimum

Document wound healing progress (e.g, ulcer size, etc)
Modify dressing if reduced exudate
Repeat ABI if ulcer worsens or not closed in 3 months
Notify primary care provider if new or increased pain, infection, wound probes to bone, new signs of peripheral arterial disease
Order gradient compression stocking before ulcer is healed and prepare for lifelong compression

Healable ulcers only> 30% decrease in ulcer area in 4 weeks?

Measure the area of the ulcer using the same technique to monitor the size of the ulcer

Q: Size of the ulcer

Continue treatment until complete healing Lifelong compression Refer to vein specialist for consideration of surgical intervention to prevent VLU recurrence

Continue treatment until complete healingLifelong compression
Refer to vein specialist for consideration of surgical intervention to prevent VLU recurrence

Reassess patient and ulcer, generate new care plan

References

AAWC. International Consolidated Venous Ulcer Guideline (ICVUG), 2015 (Update of AAWC Venous Ulcer Guideline, 2005 and 2010), 2015
Harding K. Simplifying venous ulcer management. Consensus recommendations. Wounds International [Internet]. 2015
South West Regional Wound Care Program. Guideline: The management of people with leg ulcers. 2015 Apr 8
Sibbald RG, Goodman L, Reneeka P. Wound bed preparation 2012. J Cutan Med Surg. 2013 Jul;17(4_suppl):S12–22.
Ratliff CR, Yates S, McNichol L, Gray M. Compression for Primary Prevention, Treatment, and Prevention of Recurrence of Venous Leg Ulcers: An Evidence-and Consensus-Based Algorithm for Care Across the Continuum. J Wound Ostomy Continence Nurs. 2016 Aug;43(4):347–64.
Gould LJ, Dosi G, Couch K, Gibbons GW, Howell RS, Brem H, et al. Modalities to treat venous ulcers: compression, surgery, and bioengineered tissue. Plast Reconstr Surg. 2016 Sep;138(3 Suppl):199S–208S