By Samantha Kuplicki, MSN, APRN-CNS, AGCNS-BC, CWCN-AP, CWS, RNFA
Should pain management interventions be put in place before debriding a venous ulcer?
Without question, yes. Any comprehensive wound treatment plan must include a thorough pain...
Venous leg ulcers can be slow to heal1; the longer a wound is present, the less likely it is to heal.2 To move a venous leg ulcer through the phases of wound healing may require more than just basic wound care.
Chronic venous leg ulcers can be prone to chronic inflammation.3 Changes in the microcirculation down to the capillary level can elevate levels of cytokines and proteases, thus leaving the wound stuck in the inflammatory cycle. Controlling, reducing, or eliminating inflammation is necessary to move the wound toward closure.
Medications can assist with inflammation control. For example, pentoxifylline can improve microcirculation by reducing blood viscosity. Aspirin has been known to have the same effect at higher doses. Zinc has potential anti-inflammatory effects, but the clinical evidence has yet to be studied in large study groups. Talk to a medical provider to determine whether these medications could benefit the patient or assist with wound closure. Increasing the microcirculation can contribute blood flow, nutrients, and oxygen to the periwound and therefore assist the wound bed with healing as well.4
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Wound Bed Preparation
Good wound bed preparation is more than just making sure we have healthy-looking tissue in the wound bed. We need healthy tissue free from biofilm and free from emerging infection or slough development. Wound cleansers that reduce or prevent biofilm from growing become important when treating venous leg ulcers. Keeping healthy tissue present through a variety of debridement options is important also.
Cellular and/or Tissue-Based Products
Reaching for cellular and/or tissue-based products (CTPs) or grafts can accelerate wound healing and move a wound to closure. There are several CTPs on the market approved for venous leg ulcers. If you are unsure about insurance coverage for the CTP or graft, call the insurance company to determine whether coverage is present before application of the CTP or graft and whether there are any limits to coverage (i.e., the number of applications or length of time the wound has been present). Delaying CTP application may delay wound healing.
Negative Pressure Wound Therapy
Negative pressure wound therapy (NPWT) is a modality that should absolutely be considered for wound treatment and exudate management. There is a wide variety of NPWT devices on the market to fit the needs of the wound and the desires of the patient. The variety of available NPWT devices also makes it easy to fit any patient’s lifestyle, and many NPWT devices can be placed comfortably under compression. Always review manufacturer instructions before use.
Compression is a vital component key to healing venous leg ulcers. Understanding what type of compression to choose is just as important. For example, if the patient has poor underlying arterial blood flow, choosing strong compression may stop arterial flow and cause serious complications. Many different compression stockings, compression wraps, and compression pumps are available for clinicians to choose from to assist the patient. Some compression products are available over the counter, and some require a prescription.
It is important to know the ambulatory status of the patient when choosing compression. Some compression is designed to work with the calf muscle to pump fluid up and out of the lower extremity. Other compression can work without the calf muscle. Certain types of compression are designed for patients with venous-arterial mixed ulcers who have impairments in both venous and arterial blood flow. This is important because often standard compression is not tolerable in patients with venous-arterial mixed disease, and the patient may be labeled as non-compliant when, in fact, wearing a compression product not designed for someone with venous-arterial mixed disease is quite painful. This problem can be solved by choosing compression designed to help patients with this specific pathophysiologic issue.
Surgical intervention should also be considered to reduce or eliminate venous reflux. Vein ablation can be a minimally invasive outpatient office procedure with a large and favorable impact on wound healing, if a need is identified. If the vein is obstructed, stenting can restore previously interrupted or reduced blood flow. Other surgical options are phlebectomy, vein stripping, laser therapy, or sclerotherapy. Consult a provider trained in the identification and implementation of these procedures when warranted.
Multimodality Treatment Approach
These ulcer types can have multifactorial etiologies complicating the pathophysiology that ultimately results in delay of wound healing. A single-modality approach will not be effective in healing these ulcers and keeping them healed. Recidivism rates in venous ulcers can be 60% to 70% when underlying disease is not addressed.5 If you don’t already have a vascular surgeon in your arsenal, consider establishing a relationship with one to expedite referrals and ensure proper diagnosis of underlying etiologies.
By incorporating the strategies discussed here, venous leg ulcers will have a greater chance to heal, and the clinician will have a greater chance of preventing recurrence. Considering the length of time it takes to heal venous ulcers and the expense incurred to our health care system, the more tools you can add to your wound healing toolbox, the more we all win.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.