Pressure, Venous Ulcers

1. PRESSURE ULCERS
VENOUS ULCERS

2. PRESSURE ULCERS

3. INTRODUCTION
• Pressure-induced skin and soft tissue injuries are localized areas of damage to the
skin and/or underlying tissue usually over a bony prominence, as a result of
pressure or pressure in combination with shear (eg, sacrum, calcaneus, ischium)

4. WHO IS AT RISK FOR PRESSURE ULCER
• Immobility
• Elderly people: Skin becomes thinner and more fragile, increasing the risk of skin
breakdown.
• Poor nutrition and lack of fluids
• Moisture : Incontinence of bowel movements and urine create moisture on the
skin and increase the risk of breakdown.
• Friction and shearing injuries
• Overweight and Underweight People

5. SITES ASSOCIATED WITH PRESSURE-INDUCED INJURY

6. STAGING

7. STAGING:
1
2
3
4
Unstageabl
e
STAGE
Deep tissue
pressure
injury

8. Stage 1 Stage 2
Stage 3 Stage 4

9. GENERAL CARE
• Reduce or eliminate underlying contributing factors by providing pressure
redistribution with proper positioning and support surfaces.
• Provide appropriate local wound care, which may include debridement for
patients with necrotic tissue, based on the ulcer's characteristics.
• Consider adjunctive therapies, such as negative pressure wound therapy.
• Monitor and document the patient's progress.
• Provide appropriate psychosocial support.

10. CONTROL PAIN
• Adequate pain relief should be provided.
• Oral nonopioid pain medications can be used for mild pain.
• Opioid analgesics may be needed for moderate-to-severe pain.
• Topical local anesthetics have been used and can provide pain relief for a short
period of time, but there is little evidence of effectiveness from clinical trials.
• Topical opioids, such as a morphine gel, have shown some benefit in small trials.
• Ibuprofen-releasing foam dressings can be used, if available.
• However, many patients with deep ulcers will require systemic therapy for pain.

11. TREAT INFECTION
• All open ulcers are colonized with bacteria, but only clinically evident infections
should be addressed with culture and antibiotic treatment.
• The presence of bacterial biofilm may impair wound healing.
• Patients with deep wounds should be evaluated for the presence of osteomyelitis.
• Prevent contamination of wounds from urinary or fecal soiling may impair wound
healing.

12. OPTIMIZE NUTRITION
• Patients with pressure-induced skin and soft tissue injuries often are in a chronic
catabolic state. Optimizing both protein and total caloric intake is important,
particularly for patients with stage 3 and 4 pressure injuries.
• Nutritional intake should be assessed by a nutritionist.
• Vitamin C and zinc supplementation are commonly used to promote healing, but
their efficacy has not been conclusively demonstrated
• Anabolic steroids are sometimes recommended in patients with protein depletion
and weight loss.

13. REDISTRIBUTE PRESSURE
• Proper positioning and support to minimize tissue pressure
• Support surfaces:
1. Air fluidized – pressure redistribution through a fluid-like medium created by
forcing air through beads
2. Alternating pressure – pressure redistribution via cyclic changes in loading and
unloading
3. Lateral rotation – Provides rotation about a longitudinal axis
4. Low air loss – Provides a flow of air to assist in managing the heat & humidity of the
skin
5. Multi-zoned – Different segments of the support surface have different pressure
redistribution characteristics

14. SUPPORT SURFACES
• Reactive support surface – A powered or nonpowered support surface with the
capability to change its load distribution properties only in response to applied load.
• Active support surfaces – A powered support surface, with the capability to change
its load distribution properties, with or without applied load.
• Integrated bed system – A bed frame and support surface that are combined into a
single unit whereby the surface is unable to function separately.
• Nonpowered support surface – Any support surface not requiring or using external
sources of energy.
• Overlay – An additional support surface designed to be placed directly on the top of
an existing surface.
• Mattress – A support surface designed to be placed directly on the existing bed
frame.

16. GENERAL WOUND MANAGEMENT
• Intensive preventive measures in high-risk patient’s
• Stage 1 skin injuries should be covered for protection.
• Stage 2 pressure injuries generally need little debridement and require a dressing
that maintains a moist wound environment
• Stage 3 and 4 pressure or deeper injuries generally require debridement of
necrotic tissue and possibly treatment of infection.
• Hyperbaric oxygen therapy (HBOT) has been advocated, but there have been no
studies specifically looking at the treatment of pressure injuries with HBOT.

17. MORBIDITY AND MORTALITY
• Patients who develop pressure-induced skin and soft tissue injuries are
approximately two to three times more likely to die compared with patients
without this problem.
• However, affected patients tend to have many other comorbid conditions; after
adjusting for these other factors, the presence of pressure-induced injury is at
best a weak predictor of mortality.

18. VENOUS ULCERS

19. VENOUS ULCERS
• Chronic venous disease is the most common cause of leg ulcers.
• Risk factors — In addition to venous reflux and prior deep vein thrombosis, other
risk factors associated with venous ulcer formation include older age, low
physical activity, arterial hypertension, lipodermatosclerosis, obesity, and family
history of venous ulceration.
• They are usually located low on the medial ankle over a perforating vein or
sometimes near on the lateral malleolus, or along the course of the great or small
saphenous veins they can occur more proximally on the leg if precipitated by
trauma, but never in the forefoot or above the level of the knee.

23. SYMPTOMS
• The most common symptoms are Limb discomfort (ie, tired, heavy legs), aching,
pain, itching, and limb swelling. Pain associated with venous disease is typically
worse at the end of the day than the beginning of the day and when standing or
when seated with the feet dependent for prolonged periods of time and
improves with limb elevation and walking.
• The most common clinical sign of lower extremity chronic venous disease is
abnormal venous dilation (ie, telangiectasias, reticular veins, varicose veins). The
signs of more advanced venous disease (ie, chronic venous insufficiency) include
lower extremity edema, skin pigmentation, dermatitis/eczema,
lipodermatosclerosis, and ulceration.

28. Source: UpToDate

30. DIAGNOSIS
• Complete medical history and history of ulcer and previous history of ulcers.
• A detailed physical exam with patient supine and standing. Description of ulcer,
venous dilation, edema, skin pigmentation, and venous refill time.
• Venous duplex ultrasound. If needed: MRI/CT scan/venous angiogram
• Rule out Arterial disease by pulse exam, ABI.
• If mixed venous and arterial disease, refer for arterial vascular evaluation.

31. MANAGEMENT
• General measures to manage symptoms of chronic venous insufficiency include:
1. Avoidance of prolonged standing
2. Leg elevation: Simple elevation of the feet to at least heart level for 30 minutes
three or four times per day
3. Exercise: Daily walking and simple ankle flexion exercises while seated are
inexpensive and safe strategies
4. Appropriate skin care: skin cleansing and the use of emollients and/or barrier
preparations
• These measures may be sufficient to relieve mild symptoms of chronic venous
disease but alone are not likely to be adequate for more severe cases.

32. COMPRESSION THERAPY
• Static compression therapy is an essential component in the treatment of chronic
venous disease.
• Superficial venous insufficiency and varicose veins: Many patients report rapid
symptomatic improvement but there are few high-quality data that demonstrate
the effectiveness of compression hosiery .
• Deep venous insufficiency — Randomized trials have repeatedly demonstrated
the benefits of long-term compression therapy in patients with severe chronic
venous disease associated with edema or venous stasis ulcers often due to deep
venous insufficiency.
• Active infections including cellulitis are contraindications to compression therapy

33. ULCER CARE
• Chronic venous ulcers are challenging to manage. In addition to providing
appropriate compression therapy, local treatment of chronic venous ulcers
includes using basic wound care techniques (debridement, dressings) that
minimize infection and facilitate healing but also address problems that affect the
patient's well-being, such as odor, bleeding, itching, excess exudate, and pain

34. ULCER CARE
• Systemic antibiotics should be used only in patients who have signs and symptoms of
acute cellulitis or a clinically infected ulcer.
• Routine swabbing of leg ulcers is unnecessary in the absence of signs of infection.
• Empiric treatment pending culture results should target gram-positive and negative
organisms, including Pseudomonas. Methicillin-resistant Staphylococcus aureus
(MRSA) is an important cause of soft tissue infections.
• Systemic antibiotics are reserved for patients who have one or more of the following
signs and symptoms suggesting significant infection:
● Local heat and tenderness
● Increasing erythema of the surrounding skin
● Lymphangitis (red streaks traversing up the limb)
● Rapid increase in the size of the ulcer
● Fever

35. ULCER CARE
• Ulcer debridement: Removal of necrotic tissue and fibrinous debris in venous
ulcers, using surgical, enzymatic, or biologic methods, aids in formation of
healthy granulation tissue and enhances re-epithelialization.
• Topical agents — topical antiseptics, topical antibiotics, and growth factors. Many
topically applied products are irritating and can cause contact sensitization, or are
cytotoxic, resulting in delayed healing.
• Ulcer dressings — dressings control exudate, maintain moisture balance, control
odor, and help control pain. Options include semipermeable adhesive films,
simple nonadherent dressings, paraffin gauze, hydrogels, hydrocolloids, alginates,
and silver-impregnated dressings or foams.

36. INEFFECTIVE ADJUNCTS TO ULCER CARE
• Hyperbaric oxygen
• Electromagnetic therapy
• Therapeutic ultrasound

37. ULCER HEALING AND RECURRENCE
• Ulcer healing and recurrence — The continued use of graduated compression
hosiery after ulcer healing reduces recurrence, and patients should be offered the
strongest compression (up to 40 mmHg) with which they can comply. In one
study with 36 months follow-up, ulcers recurred in 100 percent of patients who
were noncompliant versus 16 percent in those who were compliant.
• Patients with ulcers that persist (present for more than six months) or who have
recurrent ulcers should undergo venous duplex ultrasound to identify segments
of venous incompetence amenable to vein ablation therapies.

38. INDICATIONS FOR REFERRAL
• Patients with chronic venous insufficiency who are not responding to medical management
strategies (one to three months) should be referred to a venous specialist for further evaluation
and possible intervention. Many patients with deep venous insufficiency and/or superficial
venous insufficiency can be treated using venous ablation therapies, which reduce ulcer
recurrence and may improve ulcer healing.
• Arterial insufficiency
• Nonhealing ulcers
• Ulcer recurrence
• Persistent stasis dermatitis
• Suspected contact dermatitis
• Resistant or recurrent cellulitis
• Diagnostic uncertainty

40. UpToDate Algorithm

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