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WOUND CARE TODAY
2014,Vol 1, No 1
the hosiery groups — median time
to ulcer healing was 99 days in the
hosiery group and 98 days in the
bandage group. The proportion of
ulcers healed was also similar in both
— 70.9% in the hosiery group and
70.4% in the bandage group.
The researchers did, however,
report significant differences in
changes in treatment — 38.3% of
patients in the hosiery group changed
from their allocated treatment
compared to 27% in the bandage
group, suggesting that hosiery may
not be suitable for all patients (Ashby
et al, 2013).
PATIENT ASSESSMENT
Accurate assessment of every
patient is vital before considering
the application of any form of
compression therapy, as considerable
damage can be caused by
inappropriately applying compression
to patients who have peripheral
arterial disease (SIGN, 2010).
Peripheral arterial disease
can be asymptomatic, therefore,
patients do not always express the
main symptoms of intermittent
claudication or arterial pain when
resting. Arterial insufficiency can
only be ruled out by assessment of
the patient. A comprehensive arterial
assessment involves a combination
of measures — palpation of the
peripheral pulses and assessment
using a hand-held Doppler to
measure the ankle brachial pressure
index (ABPI). ABPI compares
the systolic pressure in the arm
to that of the lower leg — these
measurements are then used to
calculate the patient’s pressure ratio.
When this ratio is greater than 0.8, it
is safe to apply compression therapy
(European Wound Management
Association [EWMA], 2005).
However, if the ABPI result is above
1.2, care should be taken that the
results are not falsely elevated due
to arterial wall calcification — a
problem that is of particular concern
in patients with diabetes (Vowden
andVowden, 2001).
ABPI assessment is an effective
way of ruling out any evidence of
peripheral arterial disease, but it
has been shown to be unreliable
when carried out by inexperienced
clinicians and reliability can be
considerably improved with training
(Cullum, 1997). Therefore, clinicians
must ensure that they have adequate
knowledge and skills before
undertaking ABPI assessments.
Also, ABPI must be avoided in the
following instances (Ruff, 2003):
›
Patients with suspected deep vein
thrombosis (DVT), due to the risk
of emboli
›
Those with cellulitis — the
procedure may be too painful
›
Those with severe ischaemia —
the procedure can cause further
tissue damage.
Clinicians should also exercise
caution in patients with certain
conditions, which can cause
unreliable readings, for example,
diabetes, atherosclerosis or oedema.
It is important to remember that
ABPI should be one element of the
patient assessment and should not be
used in isolation. Also, if the results
to be worn to provide appropriate
levels of compression. Patients
require sufficient dexterity to be able
to remove and reapply the stockings,
which can be a barrier to use. Two-
layer hosiery kits may offer some
advantages to certain patients, as
they are less bulky and, therefore,
do not restrict patients’ choice of
footwear or clothing. Hosiery kits,
like hosiery in general, are available
in both European classification
and British Standard. Additionally,
hosiery kits provide guaranteed
levels of compression, which is not
practitioner-dependent — this also
has the major advantage of allowing
the patient to self-care if they wish.
One large randomised controlled
multi-centre study compared
the clinical benefits and cost-
effectiveness of compression hosiery
versus compression bandages in
the treatment of venous leg ulcers,
(Ashby et al, 2013). Researchers
randomised 457 patients to be treated
with either compression bandages or
compression hosiery kits — the study
did not dictate which manufacturer of
bandage or stockings should be used,
leaving this decision to the patient
and clinicians. Results showed that
compression hosiery was effective
at healing venous leg ulcers and
is a viable alternative to four-layer
bandaging. The study found similar
results in both the bandaging and
›
Wound facts... what is ABPI?
Measuring the patient’s ankle brachial pressure index (ABPI) with a hand-held
Doppler machine can help to confirm or exclude the presence of arterial disease.
This is recommended in national guidelines on leg ulcer assessment (RCN,
2006; SIGN, 2010). Measuring the direction and velocity of blood with a Doppler
can show whether the arterial vessels are diseased.The technique requires the
clinician to measure the brachial and ankle systolic pressures with the Doppler
probe.The ankle pressure is then divided by the brachial pressure to provide
an ABPI reading (Beldon, 2010). If the systolic readings are the same, or just
slightly different, there is unlikely to be arterial disease in the patient’s lower
limb. However, where there is significant difference between the two readings,
the arterial flow in the lower limb may be impaired to an extent that renders
compression therapy dangerous.To summarise (RCN, 2006):
›
ABPI of 0.5–0.8 shows significant arterial impairment
›
ABPI of 0.6–0.7 means that reduced compression can be used, although
this should be supervised by an experienced clinician
›
ABPI of 0.8 indicates the patient’s suitability for compression (patients
with venous ulcers tend to have an ABPI of 0.8 or greater).
Did you know:
Venous leg ulcers are less
likely to recur once healed if
hosiery is used consistently
(Ashby et al, 2013).
FOCUS ON COMPRESSION THERAPY
›
