Last updated on 2/4/22 | First published on 6/5/18 | Literature review current through Sep. 2024
[cite]
Authors:
Elaine Horibe Song MD, PhD, MBA,
Scott A. Robinson MD,
Kathryn Whiston-Lemm ACNP, CWON-AP,
Topic editors:
Cathy Milne APRN, MSN, CWOCN-AP,
more...
Coauthor(s)
Elaine Horibe Song, MD, PhD, MBACo-Founder and Editor, Wound Reference, Inc;
Professor (Affiliate), Division of Plastic Surgery, Federal University of Sao Paulo;
Chair, Association for the Advancement of Wound Care;
Google Scholar Profile
Disclosures: Nothing to disclose
Kathryn Whiston-Lemm, ACNP, CWON-AP
Disclosures: Nothing to disclose
Scott A. Robinson, MD
Disclosures: Nothing to disclose
Editors
Cathy Milne, APRN, MSN, CWOCN-AP
Disclosures: Nothing to disclose
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.
This topic provides practical guidance to wound care clinicians on the selection of appropriate compression devices and pressure levels for persons with leg ulcers who are candidates for compression therapy. Algorithms illustrate how audible handheld Doppler ultrasound and waveform analysis or ankle-brachial index (ABI) can be utilized to determine appropriate pressure levels and types of compression across different clinical scenarios. For interpretation of audible handheld Doppler ultrasound and waveform, see topic "Audible Handheld Doppler Ultrasound and Waveforms" For background information on compression therapy, see "
Compression Therapy"
. For a list of brands of commonly used compression products, see "
Compression Brands Quick Reference"
. For assessment, treatment and prevention of VLU see "
Venous ulcers"
.
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:
-
- 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 .
Interpretation |
ABI (no diabetes) [7]
|
ABI (with diabetes)* [8]
|
Ankle Pressure (mmHg) [7]
|
TcPO2 or TCOM (mmHg) [11]
|
Toe Pressure (mmHg) [7]
|
Doppler waveform [8][13]
|
TBI (diabetes) [8][13]
|
Skin Perfusion Pressure (mmHg) [8] [14]
|
Non-compressible arteries |
>1.3 |
>1.3 |
|
|
|
|
|
|
No relevant ischemia |
0.8-1.3 |
0.9-1.3 |
>100 |
>40 |
>=60 |
triphasic or
biphasic **
|
>=0.75 |
>40 |
Mild/ Moderate ischemia |
0.4-0.79 |
0.5 -0.89 |
50-100 |
30-40 |
30-59 |
biphasic or
biphasic/monophasic
|
0.25-0.74 |
30-40 |
Severe ischemia |
<0.4 |
<0.5 |
<50 |
<40 |
<30 |
monophasic |
<0.25 |
<30 |
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
Can underlying cause be treated? | How is blood supply to the wound? | Co-existing medical conditions/drugs... | Then wound prognosis is...
|
Yes | Adequate | Are not an obstacle for healing | Healable
|
No (*) | Adequate | May or may not prevent healing | Maintenance
|
No | Usually inadequate (**) | May inhibit healing | Non-healable |
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
Condition |
Pressure
|
Comments |
Follow up |
Referrals |
Healable, simple VLU: ABI 0.8-1.3, can be treated at primary care or community setting
|
Area < 100 cm2 and onset < 6 months |
Standard |
If low adherence, start with lower level compression and increase gradually (e.g., tubular dressing with 10 mmHg in the first week, then 2 layers of tubular dressing in the second week, and 3 layers in the third week) |
48h |
Wound specialist if:
- VLU has not decreased by 30% in 4 weeks despite adequate treatment
- Edema does not improve in 2 weeks
- Any of the conditions below arise
|
Healable, complex VLU: ABI 0.8-1.3, treated at specialized service/clinic that also manages VLU
|
Area > 100 cm2 and/or wound onset > 6 months (no other co-morbidities)
|
Standard |
- Reassess, revisit differential diagnoses, consider malignancy
- Review compression and wound management
- Assess adherence
- Consider skin grafting if wound >25cm2 [16]
|
48h |
As needed, according to reassessment findings |
Wound area has not decreased by 30% in 4 weeks despite adequate treatment |
Standard |
- Same as above
- Consider adjunctive therapies (See "Venous ulcers")
|
48h |
As needed, according to reassessment findings
|
Phlebolymphedema (chronic venous insufficiency and lymphatic insufficiency) See "Lymphedema - Introduction and Assessment" |
Standard |
- Specialized bandaging techniques may be required if unusual limb shape
- Skin care due to increased risk of infection
|
48h |
Lymphedema therapist |
Leg/ ulcer infection |
Standard
(or
Modified)
|
- Current: manage as appropriate (see "Venous ulcers"), may apply compression after 24 hours of systemic antibiotics and if afebrile. Consider reducing level of compression if difficult to tolerate. Inspect dressing more frequently to monitor infection
- Recurrent: examine wound regularly and mitigate factors that may contribute to recurrence
|
24h
48h
|
If needed, infectious disease specialist |
History of non-adherence |
Standard
or
Modified
|
- Reassess, revisit differential diagnoses
- Determine reasons for non-adherence and address modifiable reasons
- Start with lower level compression and increase gradually (e.g., tubular dressing with 10 mmHg in the first week, then 2 layers of tubular dressing in the second week, and 3 layers in the third week)
- Consider use of ulcer gradient compression stocking or intermittent pneumatic compression if within indications
|
48h |
|
Stable CHF |
Modified
|
- Ensure CHF is stable due to risk of pulmonary edema once leg edema starts to clear
- Diuretics can be increased upon application of compression for the first time
- Monitor closely for sigs of CHF instability, such as peripheral edema, dyspnea, altered mental status, etc.
|
24h |
Cardiologist |
Maintenance or non-healable VLU without PAD
|
Cause not treatable with conservative interventions due to patient risk factors, comorbidities, lifestyle (See table 2) |
-
|
- May apply low pressure levels (e.g, tubular dressing, with 10 mmHg)
|
|
As needed, depending on findings |
Mixed etiology leg ulcers: ABI <0.8 or >1.3, treated at specialized service/clinic or with collaboration with specialist who manages VLU
|
Non-compressible arteries |
-
|
- May apply tubular dressing (10 mmHg) while waiting for vascular assessment
|
48h |
Vascular specialist |
Healable mixed arterial ulcer with mild/moderate ischemia |
Modified
|
- May apply modified compression with low resting pressure (high stiffness), with instructions to contact provider if increased pain, changes in limb color/perfusion, frequent assessment and monitoring for ischemia and pressure damage
|
24h |
Vascular specialist |
Non-healable mixed arterial ulcer with severe ischemia |
- |
- Ulcer will not heal without prior revascularization to increase blood supply to lower limb
|
- |
Vascular specialist
Emergency department
|
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].
-
- 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
Official reprint from WoundReference® woundreference.com ©2024 Wound Reference, Inc. All Rights Reserved
NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.