Compression strategies in ulceration related to venous and lymphatic disease

Case 1

The patient (JC), aged 85 years, lived alone in the house she grew up in. While she had no immediate family, her social life consisted of a few friends who would regularly call her or drop in for a visit. She was always interested in current events and loved watching AFL. JC’s sense of humour was very keen and there was always a lot of jokes and laughter at each of our interactions. Despite her strength of character and positive outlook, her wounds were a source of pain and misery over a number of years and this care journey was one that required as much careful attention to the inner person as the outer person. JC’s care journey took place over a five-month period in 2019.

Medical history

• Type 2 diabetes mellitus.
• Severe osteoarthritis in the right hip.
• Osteoporosis.
• Cancer of the colon (sigmoid): 6 months chemotherapy and colonic resection with temporary ileostomy.
• Falls.
• Cellulitis in bilateral lower legs from 2015.
• Lymphoedema occurring for more than 10 years.
• Hypertension/hypercholesterolaemia.
• Aortic valve stenosis.

Wound characteristics

JC had suffered bilateral lower limb cellulitis and ulceration over a four-year period. With antibiotic therapy the legs would improve marginally and then the tissue would deteriorate back to a point where dressings could not properly contain the exudate or odour. This meant that she required daily dressings and spent considerable time interacting with the healthcare team. Her impression was that the problem she suffered could not be ‘cured’ and that she would have to live with the condition for the remainder of her life.

At our first interaction in mid-2019, JC’s daily life consisted of sitting in her chair with her legs wrapped in dressings, fluid leaking onto towels below her feet and taking multiple strong pain medications to help control the burning and stabbing sensations she was experiencing in her lower legs. As she walked, large pools of serous exudate would form a trail on the floor, which she referred to her as her ‘elephant steps’. She could not wear shoes as her feet were so swollen and she rarely slept more than 2 hours at a time due to pain and discomfort.

Treatment

JC received a full vascular assessment 6 weeks before the case study treatment was commenced. Her ankle–brachial pressure index was found to be above 1.0 due to the lymphoedema, but arterial flow to the foot was deemed to be within safe limits for compression. At first attempt of compression after this initial assessment, JC found the sensation of tightness to be unbearable. Her pain levels increased and her legs and feet were hot, adding to her discomfort. She was happier with just crêpe and dressings.

At our first interaction, we spent time talking to set a plan that would result in improvement to JC’s life and condition. It was, and always is, very important to establish a proper understanding of what the person with a wound wants to achieve, otherwise treatment does not reflect patients’ desired outcomes and therefore rarely works.

JC was afraid of compression because all previous attempts had resulted in additional pain with no improvement, so gaining insight as to the problems she experienced was vital to implementing therapy.

After a lengthy discussion, JC was clear that she wanted healing and that she was prepared to undertake the necessary steps to achieve this outcome, including compression with Lymphlex Reduce (Sentry Medical).

Plan

• GP-led oversight.
• Assess for infecting microorganisms and subsequent implementation of a 6-week course of antibiotic therapy to systemically treat cellulitis.
• Lymphlex Reduce Compression Therapy.
• Monitoring of pain levels.
• Dressings.
• Thoroughly cleanse/scrub wounds and legs with medical sponge or similar.
• Povidine/Iodine solution from knees to toes (and in between), leaving for 2 minutes then rinsing off and drying with sterile towel from dressing pack.
• Moisturiser to any areas of skin on legs that was not ulcerated.
• Super-absorbent dressings with impervious backing.
• 2 x weekly changes of Lymphlex Reduce.

Outcomes

After the first 2 weeks of treatment, JC no longer had exudate or odour escaping from her legs. Pain had reduced to intermittent only and ulcerated areas had begun to heal. After 4 weeks there was exudate only at lateral malleolar ulceration sites, but the skin had become very itchy so JC’s GP introduced steroid cream 2 x weekly to the intact skin. Itching quickly subsided with this approach.

After 8 weeks there were no active wound areas and after 12 weeks all skin was intact, the tissue had consolidated and treatment consisted of cleansing and moisturising the legs only — this was now done during JC’s showering routine rather than as a dressing procedure.

At this time JC moved to compression hosiery.

Conclusion

Lower-leg compression is the cornerstone of treating ulceration related to venous and lymphatic disease. Without compression, healing will be very slow or not occur at all. JC was able to live a life without pain and suffering and found Lymphlex Reduce to be the most comfortable form of compression she had experienced.

Case 2

Mrs L, aged 70, had suffered with unhealed lower leg ulceration and cellulitis over a 6-year period prior to August 2019. The last three of those years she had sat in her house with her legs uncovered, wrapped with absorbent paper, resting on towels and taking several showers a day to relieve pain and odour. She had cut herself off from friends and family and thought that her life was over. She was suffering significant post-traumatic stress related to the trauma she had experienced with these unhealed wounds. Mrs L had endured multiple admissions to hospital including five visits to an emergency department over the 18 months prior to the treatment period described in this case study.

Medical history

• Lymphoedema — more than 10 years.
• Hypertension.
• Rheumatoid arthritis/osteoarthritis in the right hip.
• Lower limb ulceration.
• Migraine.
• Anxiety.

Wound

Wounds were circumferential bilaterally, covered with yellow slough and leaking malodourous sero-purulent exudate that was not contained by dressings. The cellulitis and lymphoedema present on both lower legs and wound areas were between 3 and 10 mm deep. There were obvious signs of infection.

Mrs L described her wound pain as, “… ants eating her flesh …” and had not slept properly for years as a result.

Mrs L’s calf and ankle circumference was 42 cm and 30 cm, respectively.

Treatment

Vascular assessment had been carried out on Mrs L at a local hospital before the case study treatment was commenced. Her arterial inflow was found to be satisfactory and the hospital had suggested a regime of compression therapy that was refused by the client due to pain.

At the initial treatment assessment, we spent time talking about Mrs L’s significant stress. She reiterated her fear of compression and her more general fear of health professionals. After a lengthy discussion about Mrs L’s desired goals, she was very clear that she wanted to heal but doubted very much that this could be achieved. We mutually decided that a 4-week period of intensive treatment would be tried with her full engagement in the treatment plan, including compression with Lymphlex Reduce (Sentry Medical).

Plan

• GP support for treatment gained.
• Swabs were taken to determine microorganisms: heavy growth of Pseudomonas Aeruginosa.
• Antibiotic therapy as required.
• Lymphlex Reduce Compression Therapy.
• Monitoring of pain levels.

Dressings

• Thoroughly cleanse/scrub wounds and legs with medical sponge or similar.
• Povidine/Iodine solution from knees to toes (and in between), leaving for 2 minutes then rinsing off and drying with sterile towel from dressing pack.
• Moisturiser to any unulcerated areas of skin on legs.
• Super-absorbent dressings with impervious backing.
• 2 x weekly changes of Lymphlex Reduce.

Outcomes

After the first 2 weeks of treatment Mrs L no longer had exudate or odour escaping from her legs. Pain had reduced to intermittent only and ulcerated areas had begun to heal. After 4 weeks exudate had reduced but persisted from active wound areas. Slough was disappearing and revealing several demarcated wounds on postero-lateral areas of both legs. Mrs L’s pain was virtually nil and she had begun sleeping. Her GP introduced steroid cream 2 x weekly to intact skin to reduce skin scale. Itching quickly subsided.

The client was very happy and wanted therapy to continue — she especially found the Lymphlex to be comfortable and unlike other compression she had experienced. After 10 weeks there was no cellulitis, wound areas had all but disappeared and slough was completely resolved. After 16 weeks all skin was intact, tissue had consolidated and treatment consisted of cleansing and moisturising legs only. At this time Mrs L moved to compression hosiery.

Conclusion

While Mrs L’s anxiety levels had reduced during treatment, her post-traumatic stress had not. She would later seek professional help for this. The key to treatment here was coming up with a plan that the client could engage with, setting small targets to encourage continuation, acknowledging the suffering and using a compression system that was acceptable to the individual.

Lymphlex Reduce has been shown to be more comfortable, cost-effective and acceptable to clients than other comparable systems. The foam layer in particular is very soft and Mrs L stated that she barely noticed the compression was there.

Image credit: ©stock.adobe.com/au/vpardi