INTRODUCTION

Overview

Compression therapy is considered the mainstay of venous leg ulcer (VLU) treatment [1] and along with standard care, has the potential to heal 50%-75% of VLUs [1][2]. Despite existing guidance, many patients with VLU who are treated at primary care settings do not receive adequate compression therapy due to several factors, some related to patients (e.g., adherence) and to clinicians (e.g, application skills, etc).[3]

Compression is delivered through several types of devices, such as bandages, wraps or gradient compression stockings. Therapy usually starts with compression bandages or wraps and then transitions to gradient compression stockings once edema subsides and ulcer is healed. 

INSTRUCTIONS

Indications for this clinical decision support tool

For which patients: 

Patients with conditions below, being considered for compression therapy:

• VLU
• Varicose veins and edema
• Lymphedema
• Post-thrombotic syndrome
• Prevention of deep venous thrombosis (DVT)

When to use this tool: 

• During initial assessment
• Every 6 months if compression > 20 mmHg
• If ulcer deteriorates
• If ulcer is not closed within 12 weeks 
• If recurrence
• If increased pain and/or exudate, change in wound bed color

How to use this tool:

• Conduct comprehensive assessment of the patient and wound
• • Rule out absolute contraindications to any form of compression therapy:
  • • Severe peripheral artery disease (PAD) with signs and symptoms of critical limb ischemia [4]: 
    • • Rest pain: constant pain in the forefoot, relieved by dependency and worsened by elevation
      • Gangrene 
    • Acute arterial occlusion: include pain, pallor, poikilothermia, pulselessness, paresthesia, and paralysis
    • Unstable congestive heart failure (CHF) with pulmonary edema [4]
• Assess lower limb blood supply following one of the algorithms below:
• • Based on ankle brachial index (ABI): with handheld Doppler or automatic ankle brachial index system
  • Based on audible handheld Doppler ultrasound or continuous waveform analysis [5], which is preferable if [6]:
  • • Clinician is able to interpret audible Doppler signals or waveforms (see topic "Audible Handheld Doppler Ultrasound and Waveforms")
    • Patient has diabetes, age > 70 years old (populations with tendency for non-compressible vessels due to calcification) [7][8][9] 
    • ABI greater than 1.3 (may be elevated due to non-compressible vessels)
    • Active ulcer is present over the area of blood pressure cuff occlusion
    • Severe local pain limits the ability to perform the ABI test
    • Patient has lower limb lymphedema [10]
• Determine ulcer healability, create care plan, discuss with patient and caregivers
• Apply compression bandage/wrap 
• Follow up in 24 to 48 hours after compression is applied to assess adherence, adverse effects and effectiveness.

ALGORITHMS

Based on ABI

Based on audible handheld Doppler ultrasound or continuous waveform analysis

Table 1. Arterial noninvasive bedside tests and likely interpretation

See Algorithms: Based on ankle brachial index (ABI) or Based on audible handheld Doppler ultrasound or continuous waveform analysis 

ABI: ankle brachial pressure, AP: ankle systolic pressure, TP: toe systolic pressure, TcPO2 or TCOM: transcutaneous oxygen pressure, TBI: toe brachial index, SPP: skin perfusion pressure.( * ) ABI, toe pressure, TBI values are frequently falsely elevated in patients with diabetes. Patients with diabetes should have TP measurements [7][11]. If arterial calcification precludes reliable ABI or TP measurements, or if ABI is non-compressible (>1.3), ischemia should be documented by TcPO2, SPP, or Doppler continuous waveform analysis [7][12] . (**) Biphasic waveform may be normal in older individuals or when there is no clear transition from triphasic signal along the vascular tree .

Table 2. Determining ulcer healability

See Algorithms: Based on ankle brachial index (ABI) or Based on audible handheld Doppler ultrasound or continuous waveform analysis 

( * ) As determined by comprehensive patient assessment. (**) For persons without diabetes, inadequate blood supply is objectively confirmed by ankle-brachial index (ABI) < 0.5, monophasic doppler waveform, skin perfusion pressure < 30mmHg, transcutaneous oxygen < 30mmHg, absolute systolic ankle pressure < 50 mmHg OR toe pressure < 30mmHg. For persons with diabetes, perform any other testing listed above besides ABI as ABI can be falsely elevated 

Modified from Sibbald RG et al. 2011[15]

Table 3. Management of simple, complex and mixed VLU

See Algorithms: Based on ankle brachial index (ABI) or Based on audible handheld Doppler ultrasound or continuous waveform analysis 

Standard compression: 30-40 mmHg resting pressure; modified compression: low resting pressure, i.e., 20-30 mmHg. Both standard and modified levels measured at the ankle level, applied with high stiffness device. For examples of different brands, see "Compression Brands Quick Reference". VLU: venous leg ulcer, ABI: ankle brachial index, CHF: congestive heart failure, PAD: peripheral arterial disease

Modified from Harding et al. 2015 [3]. 

FOLLOW UP AFTER INITIAL APPLICATION

Follow up within 24 hours of initial application 

Follow up within 24 hours if patient has current local infection (e.g., cellulitis), CHF, mixed venous arterial ulcer.

• Assess and address issue if present:
• • Peripheral circulation
  • Adverse effects (e.g., pain, circulatory problems, decreased mobility, etc) See 'Troubleshooting adverse effects'
  • Effectiveness of compression: calf circumference and edema reduction, resulting increased exudate
  • Patient's adherence, tolerance to compression
• If a face-to-face encounter is not feasible within 24h, may follow up with a phone call or Telehealth Conferencing Tool
• Re-apply compression and reassess items above at least weekly
• Once edema subsides, at least the edge of the tibia, the fibula head, and the ankle region should be padded to avoid pressure damage

Follow up within 48 hours of initial application 

Follow up within 48 hours if patient has simple or complex VLU, and no PAD, CHF or infection:

• Assess and address issue if present:
• • Adverse effects (e.g., pain, decreased mobility, etc) See 'Troubleshooting adverse effects'
  • Effectiveness of compression: calf circumference and edema reduction, resulting increased exudate
  • Patient's adherence, tolerance to compression
• If a face-to-face encounter is not feasible within 48h, may follow up with a phone call or Telehealth Conferencing Tool
• Re-apply compression and reassess items above at least weekly
• Once edema subsides, at least the edge of the tibia, the fibula head, and the ankle region should be padded to avoid pressure damage

TROUBLESHOOTING ADVERSE EFFECTS

• Slippage of compression bandages: frequently seen as edema subsidizes or in legs with uneven contour (e.g. inverted champagne bottle). May lead to discomfort, pain, trauma to the skin, new ulcers, decreased patient adherence. Tourniquet effect, caused by excessive pressure over areas of wrinkling can increase risk for tissue ischemia [17]. ref
• • If due to expected edema reduction, change compression more frequently during this initial edema reduction phase
  • If due to uneven contour, provide additional bulk to the concave region of the leg before applying 4-layer compression [17]
• Skin problems: can arise due to excessive exudate or allergic reactions. Suggestions based on expert opinion include:
• • Fungal infection: excessive exudate can lead to fungal infection. Fungal infection needs to be treated to resolution before reapplication of occlusive dressings and compression. Prevent fungal infections by adequately managing exudate and increasing frequency of dressing and compression system change until exudate is controlled.
  • Contact dermatitis: susceptible patients may develop contact dermatitis from one of the components of the compression system (e.g., latex, zinc, wool). Remove irritant or use a cotton stockinette liner or paste bandage against the skin to avoid irritation from wool padding.
• Pain: compression, when applied appropriately should reduce pain. However, effective compression may cause initial discomfort and anxiety. 
• • Rule out any other causes of pain, such as infection, dermatitis, or PAD. Teach patient to recognize signs of PAD (e.g., changes in limb color/perfusion)
  • If pain is related to compression: offer analgesics during the initial phase (1-2 weeks) until discomfort subsides, and consider starting with a lower pressure level (i.e., modified pressure - See "Compression Brands Quick Reference")
  • If pain remains uncontrolled, perform full reassessment (see “Venous Ulcer”, section on ‘Plan Reassessment’)
• Pressure Damage: may happen once edema subsides and pressure caused by compression device over bony prominences increases (edge of the tibia, the fibula head, and the ankle). Signs of pressure damage resulting from compression therapy are erythema, blistering, altered limb shape. Among risk factors are: patients with impaired peripheral perfusion, thin or altered limb shape, foot deformities, reduced sensation/pain sensation, long-term systemic steroid use and presence of a chronic disease (eg rheumatoid arthritis) associated with reduced mobility, loss of calf muscle and foot/ankle deformity. 
• • Apply extra padding over bony prominences, especially as edema subsides
    
  • Ensure bandage is not too tight and overlap is correct mainly at the dorsum of the foot, ankle and calf, as per manufacturer's instructions
  • Avoid strong, sustained compression. Consider using inelastic compression or intermittent pneumatic compression associated with gradient compression stocking
• Circulatory problems: 
• • If signs of decreased blood supply distal to the compression bandage or stocking (e.g., pallor, decreased temperature, numbness), remove device immediately. Reassess blood supply through one of the Algorithms above. 
  •  If patient has CHF, monitor for signs of unstable CHF and pulmonary edema (e.g, dyspnea, tachycardia, decreased diuresis, etc) 
• Loss of calf muscle: may be seen in patients receiving long-term compression, most likely due to reduced patient activity and underlying comorbidities (as opposed to compression itself). 
• • Ensure compression allows patient to flex knee and ankle at or near 90 degrees
  • Ensure shoes do not restrict patient’s ankle range of motion. Flat, comfortable shoes are preferred
  • Encourage calf muscle exercise

TRANSITIONING TO STOCKINGS

• For simple VLU, when adherence is not an issue and patient is able to don gradient compression stockings: as ulcer is decreasing in size and complete healing is likely in about 2 weeks, gradient compression stockings can be prescribed and ordered (covered by Medicare if ulcer is active, not healed). After ulcer is healed, compression bandages may be applied for 1-2 weeks to avoid damaging fragile wound area. 
• For complex VLU, mixed etiology leg ulcers or when adherence is an issue: consult edema management specialist (e.g, physical therapist) early on (e.g, after initial evaluation), as patient education and choice of long-term compression according to patient preference and life-style may take several weeks.  
• See indications, contraindications and how to use gradient compression stockings in " Compression: Gradient compression stockings"

REVISION UPDATES