lymphedema, venous stasis and the importance of compression timothy a. hursh, md medical director,...

LYMPHEDEMA, VENOUS STASIS ANDTHE IMPORTANCE OF COMPRESSION

Timothy A. Hursh, MDMedical Director, Wound CareKindred Hospital San Antonio

Agenda for Today’s Discussion Physiology Diagnosis Clinical Presentation Treatment Case Examples

Physiology

Lymphedema (lymphatic obstruction) Swelling due to blockage of the lymph

channels Causes include

Infection with parasites (filariasis) Injury Radiation Surgery (mastectomy) Radiation Therapy Infection (cellulitis)

Physiology

Venous Stasis (aka Venous Insufficiency) Veins unable to help blood return to the

heart Causes include:

One or more deep leg veins are compromised “One-way-valves” either broken or missing

Risk factors include: increased age, history of leg DVT, female, increased height, pregnancy, obesity, prolonged sitting/standing

Diagnosis

Lymphedema CT or MRI Lymphangiogram Lymphoscintigraphy (radioactive tracing)

Venous Stasis Clinical diagnosis

Clinical Presentation

Lymphedema Swelling of arm/leg (acute or chronic) Staging

Stage 0 – lymph vessels damaged but are coping

Stage 1 – non-pitting edema, skin bounces back Stage 2 – pitting tissue, hardening of skin

begins & increased size Stage 3 – lymphatic channels closed from

fibrosis, limbs become swollen, hard

Clinical Presentation

Clinical Presentation

Venous Stasis Pts c/o dull aching, or cramping, limbs Itching or tingling Pain worse with standing, better with legs

raised Leg swelling Chronic changes include redness, varicose

veins, color changes around distal leg/ankles (bronzing), ulcers

Clinical Presentation

Treatment

Lymphedema Manual lymph drainage Compression wraps Light exercise (milking action of muscles) Skin care to decrease risk of infection Lymphedema pumps

Treatment

Venous Stasis Compression wraps No long periods of standing/sitting Exercise Wound care if wounds/ulcers

Treatment

Compression Wraps Class I 20-30 mmHg Class II 30-40 mmHg Class III 40-50 mmHg Class IV > 50 mmHg

Application should be done carefully from distal to proximal, midpoint overlapping, no wrinkles

Treatment

Common Types of Compression Wraps ALWAYS APPLIED DISTAL TO PROXIMAL Package instructions are not a

“suggestion” Spiral versus Figure 8 Dry versus medicated $$$ Can get costly very quickly

Are ACE wraps ok? Ensure patients have after hours

instructions

Profore

Unnas Boot

Case Example #1

68 yo male with 30 year Hx venous ulceration RLE

Obese, DM II, HTN Meds: metformin, diuretics (taken only

intermittently) Tx included: Unna boot healed earlier;

compression therapy at home but non-compliant so placed in compression stockings

Case Example #1

Case Example #1

Lived with ulcers for 4 years Finally consented to treatment with

combination of: Exercise (dorsiflexion emphasized) Alginate dressings covered with foam and

light compression

After 6 weeks of COMPLIANCE………

Case Example #1

Case Example #2

54 yo male with 5 yr Hx chronic lymphedema

PMH: Avascular necrosis of the hips, HTN, EtOH abuse, liver cirrhosis, chronic Hep C

Admitted for care of Stg 3 pressure ulcer of buttocks and newly developed ulcers of legs secondary to worsening lymphedema

Case Example #2

Jan 2012

Case Example #2

Treatment consisted of wound care, debridements PRN, manual massage, compression wraps, exercise

Discharged after 4 weeks care with plans for clinic follow-up and HHC for daily treatment of his lymphedema

Condition at discharge………...

Case Example #2

Feb 2012

Thank You for Attending!

Contact Information:

Tim Hursh, MD Kindred San Antonio Medical Director for Wound Care

(210) 616-0616

Timothy.Hursh@kindredhealthcare.com