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Wound care management of vascular ulcers M J Sultan Slide 2 Slide 3 Wound care: leg ulcers Wound care: leg ulcers Wound care is a high cost area for patients and NHS in terms of prescribing costs, patient QoL and NHS workforce time The evidence base for therapeutics in much of this area is limited Value for money for the NHS is an important factor when choosing treatments Leg ulcers are a common, chronic, recurring condition Prevalence of active leg ulcers is between 1.5 to 3 per 1000 and increases with age. Its estimated that up to 20 per 1000 people over 80 yrs will suffer from a leg ulcer Following healing, re-ulceration rates at one year range from 26% - 69% Available treatments can reduce recurrence rates NHS CRD (1997) Effective Healthcare 3 (4), 1-12 SIGN 26 The Care of patients with Chronic Leg Ulcer Clinical Knowledge Summaries_Venous Leg Ulcer Slide 4 Leg ulcer aetiology Venous insufficiency 80 - 85% Other causes: Arterial disease Mixed arterial and venous disease Diabetes Rheumatoid arthritis Systemic vasculitis Lymphoedema Trauma Others including malignancy Clinical Knowledge Summary Venous Leg Ulcers_February 2008 Grey J.E et al. ABC Wound Healing BMJ 2006; 332: 347-50 Slide 5 Assessment of the patient - history History suggesting venous disease History suggesting arterial disease (c.10-20% patients) Varicose veins, immobility, obesityAnkle Brachial Pressure Index less than 0.8 Proven deep vein thrombosis in the affected leg Ischaemic heart disease, stroke or transient ischaemic attack Phlebitis in the affected legRheumatoid arthritis Previous fracture, trauma, or surgery Diabetes mellitus Family history of venous diseasePeripheral arterial disease/intermittent claudication Symptoms of venous insufficiency: leg pain, heavy legs, aching, itching, swelling, skin breakdown, pigmentation, and eczema Smoking Clinical Knowledge Summary Venous Leg Ulcers Royal College of Nursing Clinical Practice Guidelines Slide 6 Slide 7 Assessment of the leg - examination Measurement of Ankle Brachial Pressure Index (ABPI) is the most reliable way to detect arterial insufficiency Clinical Knowledge Summary Venous Leg Ulcers CREST Guidelines for the Assessment and Management of Leg Ulcers Slide 8 Slide 9 Assessment of the ulcer RECORDRATIONALE Size, depth, edges and site of ulcerSerial measures useful for progress Ulcer base: Epithelialisation/granulation/slough/ eschar/necrosis Aid choice of dressing and indicate progress of healing Level of exudate: Minimal/ moderate/ high Will influence dressing choice and frequency of dressing change Signs of infection: Enlarging ulcer, increased exudate, pyrexia, foul odour, cellulitis May indicate infection Pain: Assess level, frequency and duration Treat to relieve distress and aid compliance with treatment Clinical Knowledge Summary Venous Leg Ulcers CREST Guidelines for the Assessment and Management of Leg Ulcers Slide 10 Referral to a specialist clinic before treatment Uncertain diagnosis Suspected alternative causes of ulceration: - Arterial or mixed venous/arterial ulcer. Refer people with ABPI