Venous and Arterial Insufficiency Flashcards
70–90% of all LE ulcers; Managed conservatively Recurrence rate of up to 97%; 91% can be resolved by conservative measures
Venous insufficiency ulcers
- recurrence correlated with patient nonadherence
- 15-25% of VI is combined with arterial insufficiency
Carries majority of blood back to heart; Located in the calf
Deep veins
- femoral, popliteal, tibial
- Usually malfunction before superficial veins
connect deep and superficial veins
Perforating
Drain skin and subcutaneous tissues; Assist with temperature regulation;More easily damaged
Superficial veins
- grater and lesser saphenous
- thinner, more flexible and extensible
What does proximal flow of venous blood rely on?
- Respiratory pump - inspiration – diaphragm descends causing decreased thoracic pressure and increased abdominal pressure, pushes blood from abdominal veins to thoracic veins to right atrium
- Calf muscle pump - inspiration – diaphragm descends causing decreased thoracic pressure and increased abdominal pressure, pushes blood from abdominal veins to thoracic veins to right atrium
- Valves - prevent retrograde blood flow and increased venous pressure (venous HTN)
- 90 mmHg downward pressure in standing as compared to 5-15 mmHg upward pressure
What causes venous insufficiency?
Sustained venous HTN:
- Veins become incompetent and lose elasticity
- Damaged valves that cause retrograde blood flow - Damaged by trauma and inflammation
- Calf muscle pump is ineffective - Sedentary lifestyles or jobs, deconditioned patients
- Treat with weight loss, move around more, elevate legs, avoid long periods of sitting and standing
What are risk factors for developing a venous ulcer?
- Vein/valve dysfunction
- Calf muscle pump failure
- Trauma
- Previous venous ulcer - 97% recurrence rate
- Advanced age - 7x increase >65 years
- Diabetes - poor control of sugars adverse affect on wound healing
What are the signs of venous disease?
- Pain, heaviness, fatigue
- Varicose veins
- Swelling
- Hemosiderin staining - reddish brown color stained skin
- Lipodermatosclerosis - thick hard tight tissue, fibrin and lipid deposits, characterized by extremely smooth skin that turns brown in color
What are PT tests and measures for VI?
- Clinical Assessment for DVT - Doppler Ultrasound; Well’s Clinical Prediction Rule
- Venous Filling Time
- need to know pt’s ABI to rule in/out AI
What are the parameters for ABI?
- Normal 0.9-1.1 = Ok for compression
- Mild AI 0.7-0.9 = Still ok for compression
- Moderate AI 0.5-0.7 = Only light compression – never multilayer bandage
- Severe AI <0.5 = Compression totally contraindicated!!
What are the characteristics of venous ulcers?
- Mild to moderate pain
- Pain decreased with elevation or compression
- Medial knee to ankle most common
- Irregular shape
- Beefy red wound bed with little slough
- Weepy and wet, copious drainage
- Periwound area = Swelling, hemosiderin staining, lipodermatosclerosis
What should compression parameters be at ankle? knee?
30-40 mm Hg at ankle
10-15 mm Hg at knee
- If severe VI, can increase up to 50-60 mm Hg
- If mild AI, can decrease to 20–30 mm Hg
What are contraindications to compression?
- ABI <0.5
- Acute infection
- Pulmonary edema
- Uncontrolled or severe CHF
- Active DVT
What are the types of compression?
- Short stretch bandage
- Long stretch or multilayer bandage
- CircAid
- Compression stockings
- Pneumatic pump
Non-elastic; High working pressure, low resting pressure; Use spiral or figure 8; technique; Can be used for VI with moderate AI or if lymphedema is also present; 60% extensibility of original length; Only works with ambulation, works with you
Short stretch bandage
- example = unna’s boot
Treatment of choice for venous ulcers; High resting pressure; Continual compression even at rest; 140% extensibility of original length; 40mm Hg graduating to 17mm Hg at knee
Long stretch or multilayer bandage
- can’t be used with moderate or severe AI
what are the layers of the long stretch/ multilayer bandage?
1st layer absorbs excess wound drainage and provides padding - felt
2nd layer absorbs drainage – gauze wrap
3rd layer provides increased compression – ace wrap
4th layer – sticks to itself (coban)
Removable, semi-rigid orthotic; Rows of nonelastic Velcro straps that provide sustained compression; Newer versions are easier to customize based on size of leg
CircAid
Used for long-term management; Off-the-shelf and custom garments; Most garments range from 20–60 mm Hg (at the ankle); Use lowest effective level of compression possible; Most often require donning aids; Wear garments at all times except while sleeping and bathing
Compression stockings
Bilayered, multichambered sleeve; Slides over extremity and attaches to pump; Sequentially fills and empties; Used if there is also lymphedema
Pneumatic pump
What are therapeutic exercises used to improve VI?
- Range of motion exercise - improve calf muscle pump function
- Aerobic exercise - improve respiratory pump function and possibly calf m. pump; also weight loss if needed
- Gait and mobility training - safety
What are surgical interventions for VI?
- debridement
- skin grafting and skin substitutes
- vein surgery - vein ligation (tying off), vein stripping (surgical resection of varicosities), sclerotherapy (injection of an agent to scar dysfunctional veins), endoscopic procedures (SEPS and PAPS)
- Doesn’t work for system wide disease
Arterial insufficiency ulcers account for ____% of all LE ulcers. More than 80% of patients with PAD are ______.
5-10%; current or former smokers
What causes AI?
Arterial ulcers are caused by decrease in arterial blood supply:
- Arteriosclerosis
- Trauma
- Acute embolism
- Diabetes
- Buerger’s disease - similar to arteriosclerosis, young adults who smoke heavily
First signs of AI; Discomfort with activity due to local ischemia; Pain stops within 1–5 minutes of ceasing the provocative activity; Pain is described as cramping or burning; ~50% stenosis
Intermittent claudication
Burning pain ; Exacerbated with elevation and relieved by dependency; ~70% stenosis; AI ulcers more likely
Ischemic rest pain
- represents even more severe AI than intermittent claudication
- pain during rest
What are risk factors for AI?
- High cholesterol (LDLs) - enhances cholesterol deposition within vessel walls
- Diabetes – vessel walls accumulate calcium, hyperglycemia decreases all phases of healing
- Systolic HTN more damaging than diastolic – repetitive wave of higher pressure during contraction vs. sustained lower levels
- Trauma – (1) Mechanical (excessive pressure from shoes, stubbed toe); (2) Chemical – OTC agents – corn removers; (3) Thermal – c/o cold legs/feet – heating pads or soaking feet in hot water
- Age – slower immune and inflammatory response, skin more susceptible to trauma
- Smoking
What are PT tests and measures for AI?
- Pulses
- Capillary Refill
- Ankle-Brachial Index
- Rubor of Dependency
- Venous Filling Time
What are possible vascular interventions for ABI levels of mild, moderate, severe, and rest pain/ gangrene?
.7-.9 = Mild - conservative interventions .5-.7 = moderate - may perform trial of conservative care; physician may consider revascularizatino
What are the characteristics of AI ulcers?
- Severe pain
- Pain increased with elevation
- Distal toes, dorsum of feet, and areas of trauma are most common
- Regular shape
- Pale granulation tissue, black eschar, or gangrene
- Little or no drainage
- Decreased or absent pedal pulses
- Decreased temperature
- Periwound thin, shiny skin with no hair
What are the interpretations of venous filling time?
< 5s = venous insufficiency
5-15s = normal
>20s = arterial insufficiency
What are the keys to wound care with AI ulcers?
- moisture dry skin
- avoid adhesives
- reduce friction btwn toes
- provide padding to protect ischemic tissues
Address wound bed: choose dressings to moisten wound bed; decried necrotic tissue if appropriate
What are the steps to do a rubor of dependency test?
Step 1: Supine position note color of plantar foot, elevate LE 60 degrees for 1 min., again note color of plantar foot
- Pallor after 30 sec to 1 min. = mild or moderate arterial insufficiency
- Pallor within 25 sec = severe arterial insufficiency
Step 2: Bring foot into dependent position and record how long it takes to return to its original color
- A bright red color (rubor) with step 2 = severe arterial insufficiency
What are therapeutic exercises for AI ulcers?
- Gait and mobility training
- Patient positioning
- Aerobic exercise
- Resistive exercise
- Flexibility exercise
What are the modalities used for AI?
- Hydrotherapy/Whirlpool
- Therapeutic heat
- Ultrasound
- Electrical stimulation
- Hyperbaric oxygen
- Negative pressure wound therapy (VAC)
What is healing time for full thickness venous ulcers with appropriate interventions?
Avg 8 weeks
- smaller ulcers = 5-7 weeks
- larger ulcers = 10-16 weeks
What are interventions for patients with VI ulcers
- treat wound - inflammation control, infection control, absorb drainage, debridement
- treat periwound - moisturize, infection control, absorb drainage debridement
- healthcare team and pt address co-morbidities
- educate pt/ caregiver
- treat cause - venous HTN, compression, sx if needed
Pressure in the arterial system is ____ mm Hg in the larger vessels, ____ mm Hg as blood passes through capillaries, and ____ mm Hg as returns to right atrium
90–100; 25–35; 0
- Oxygen and nutrients flow via capillaries from the blood into the tissues
