Hi Kim! Thanks for your question! Of course I will respond to your question, with more questions :)
1. Based on our Venous Ulcer Algorithm (https://woundreference.com/files/1531.pdf), is this a simple, complex or mixed VLU?
2. Are there are comorbidities for which he takes the diuretics such as heart failure or renal compromise, or is this prescribed to him purely for Chronic Venous Insufficiency? I ask, as diuretics can actually be ineffective in treating his disease.
3. Does he have systemic hypertension? Is this controlled?
4. Has he had any vein mapping that would potentially make him a candidate for ablation or other therapies?
5. Is he compliant with exercise and also elevating his legs when seated or supine?
6. Are you appropriately applying the 3M wraps per manufacturer guidelines? I ask as sometimes this can be an issue with compression being appropriate and consistent.
7. What are you applying topically and what do his wounds look like? Do you think there is an infection in the wound causing it to produce copious drainage or could he just have heavy bioburden and need a topical antimicrobial under the extrasorb?
8. Does he have appropriate ankle ROM, allowing full dorsiflexion and plantarflexion? Sometimes this limits the functionality of dynamic compression like 3M wraps, as they rely on contraction of the calf muscle pump to resist against the wrap and decrease edema.
9. How is nutrition? Adequate protein for oncotic pressure and keeping fluid in his vascular space?

Hi Kim, thanks for sharing this case with us!
Samantha always have solid principles/framework when investigating complex cases, good points Sam! Agree that those are questions needed to better investigate causes for excessive weeping. A few other questions that come to mind:
10. In terms of complex VLUs, associated lymphedema is very common. Would you know if that's the case for this patient?
11. Also, how long ago did the patient initiate compression? Is this part of the initial stages of compression?
Thanks!

Wow such good food for thought. As we read the questions the biggest thing that jumps out to us is that he probably doesn't have the ROM of his ankle to allow full flexion on walking. He is a very large man who uses a walker and kind of shuffles. We agree he probably tries to keep his legs elevated but not as much as he should (stubborn man). He has been in compressions since October of 18. He has all the other issues but is well managed with his HTN, HF. He had vein mapping this year also. He wounds are actually looking better, just super wet.

I’m glad you’ve found the information helpful :) I definitely understand stubborn patients, and they take some extra work for sure! Can you give him a brief handout on ankle ROM and see if it improves? Alternatively, long stretch dressings that have higher resting pressures, assuming he has adequate arterial flow, may benefit him more for a time. Also, depending on his insurance, he may be eligible for thigh high pneumatic compression pumps. Medicare requires a diagnosis of lymphedema for this and ‘failed’ compression therapy (I.e. wounds not healing or edema not appropriately managed through standard of care). I would suggest contacting your preferred provider of PCDs to see if that is something he is eligible for. Did his vein mapping indicate that he may be a candidate for ablation?

Has he had any med changes recently, e.g., different ACE/ARB/CCBs? I know norvasc specifically can be a culprit of sudden onset or exacerbation of BLE edema.

I agree with above and have had several patients that fall into this category of persistent weeping. In my experience, if you have ruled out some obstructive process (pelvic mass, mechanical pelvic venous outlet obstruction, advanced liver dz w/ anasarca, etc) it is almost always non compliance with elevation of legs. These obese patients dont like to elevate properly and many sleep in their "barco-lounger" with their legs down or not properly elevated. My most recent patient spent his entire day at his computer or standing at his work shop bench in his garage smoking and drinking (retired English prof, go figure!). When we finally got him to properly elevate and changed his wraps 2x week he stopped weeping and closed his large, geographic lower leg ulcers.

If this patient has adequate arterial circulation (the patient above didn't) he may benefit from added layers of compression. I would use a toe pressure to guide this. I often do pre and post compression toe pressure measurements in my clinic. that way I send them out knowing their arterial circulation is intact.

All the other suggestions are good ones. I also feel its important to tell the patient there may be nothing else you can do and offer that as a wake up call to get elevated and stop with the salt intake or diuretic avoidance.

Scott Robinson, MD

Again thank you all. I will be talking with our Dr and our staff, then make a plan and talk with the pt and wife.