Download - Lower Extremity Ulcer
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LowerExtremity
UlcerBagus Andi PramonoSupervisors:
dr. Hariadi Hariawan, SpPD, SpJPK
Dr. dr. Budi Yuli Setianto, SpPDK, SpJPK
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Background
Chronic ulceration of the lower leg is a frequent condition,with a prevalence of 35% in the population over 65 years ofage.
The incidence of ulceration is rising as a result of the ageingpopulation and increased risk factors for atheroscleroticocclusion such as smoking, obesity and diabetes.
A leg ulcer is a loss of skin below the knee in the leg or foot which takesmore than 4 - 6 weeks to heal
Mekkes et al., 2003
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Background An appreciation of evidence-based treatment pathways
and an understanding of the pathophysiology of chronicwounds are important elements in the management ofpatients with chronic wounds
Vascular contribution in ulcer pathogenesis
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Common causes Venous insufficiency (post-thrombotic syndrome)
Peripheral arterial disease (arteriosclerosis)
Diabetes (neuropathy and or arterial occlusion)
Decubitus (pressure) Infection (mostly Streptococcus haemolyticus)
Vasculitis (small vessel leucocytoclastic vasculitis)
Mekkes et al., 2003
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Leg ulcers Causes Poor circulation, often caused by arteriosclerosis
Venous insufficiency (a failure of the valves in the veins of the leg that
causes congestion and slowing of blood circulation in the veins)
Other disorders of clotting and circulation that may or may not be related
to atherosclerosis
Diabetes
Renal (kidney) failure
Hypertension (treated or untreated)
Lymphedema (a buildup of fluid that causes swelling in the legs or feet)
Inflammatory diseases including vasculitis, lupus, scleroderma or other
rheumatological conditions
Other medical conditions such as high cholesterol, heart disease, high
blood pressure, sickle cell anemia, bowel disorders History of smoking (either current or past)
Pressure caused by lying in one position for too long
Genetics (ulcers may be hereditary)
A malignancy (tumor or cancerous mass)
Infections
Certain medications
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Percentage
81%
10%
7%
1%
1%1%
Causes
VenousArterial
Mixed
Diabetic
Malignancy
Rheumatoid
O Brien et al., 2000
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Philips et al, 1991
Venous ulcers
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Venous ulcer
History of venous diseaseDVTs
Recurrent Painless Signs of venous hypertension
Haemosiderin Lipodermatoclerosis Eczema Flares/spider nevi
Note : Normal ABIs Painless
Tierney, 2009
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Commonly noted in the"gaiter" region of the legs.
Larger but shallower Moist granulating base,
irregular border. This base oozes venous
blood when manipulated. The tissue surrounding these
ulcers may exhibit signs of
stasis dermatitis. mild pain that is relieved by
elevation.
Venous ulcers
Gabriel, 2012
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Arterial ulcers
Atherosclerosis
Skin crack
Arterial embolization
Inadequateperfusion
Ulcer
Ischemia
Necrotic tissue
Mekkes et al., 2003
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Arterial
History of intermittent claudication
Pain
Absent pulses
Reduced ABIs
Beware
Colour
Temperature
Capillary filling unreliable
Tierney, 2009
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Located distally and on the dorsum of the foot or
toes. Irregular edgesa better-defined appearance.
Grayish, unhealthy-appearing granulation tissue. Debridingbleed very little or not at all. Characteristic pain
Characteristic findings of chronic ischemia(hairlessness, pale skin, and absent pulses)
Gabriel, 2012
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Anders et al., 2010
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Wong, 2014
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Chadwick et al.,2013
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Pressure
Neuropathic
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Chadwick et al.,2013
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Management
Debridement
Pressure control
Infection control
Exudate management
Mustoe et al., 2006
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TIME framework
issue debridement
Inflammation and infection control
Moisture balance (optimal dressing selection)
Epithelial edge advancement
Chadwick et al.,2013
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Debridement
Methods of debridement used including surgical/sharp, larval,autolytic and, more recently, hydrosurgery and ultrasonic
The requirement for further debridement should be determined ateach dressing change.
No one debridement method has been shown to be more effectivein achieving complete ulcer healing
Removes necrotic/sloughy tissue and callus
Reduces pressure, allows full inspection of the underlying tissues Helps drainage of secretions or pus
Helps optimise the effectiveness of topical preparations Stimulates healing
Chadwick et al.,2013
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Pressure control
The key to the successful healing of chronic venous ulcers will be tocorrect the underlying venous hypertension using graduatedcompression therapy
Education for patients regarding the need for life long support ofthe veins in their legs is paramount and should be emphasised fromthe beginning of treatment.
Several different types of bandaging systems are available, each of
which may have advantages over the others for particularapplications.
EWMA, 2003; Moffatt, 2007
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Infection control
Start empiric oral antibiotic therapy targeted at Staphylococcusaureus and -haemolytic Streptococcus
Change to an alternate antibiotic if the culture results indicate amore appropriate antibiotic
Obtain another optimum specimen for culture if the wound does
not respond to treatment.
Topical antimicrobials benefit in: Concerns regarding reduced antibiotic tissue penetration
poor vascular supply clinical suspicion of increased bacterial bioburden
Chadwick et al.,2013
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Common topical antimicrobial agents
Silverdressings containing silver (elemental, inorganiccompound or organic complex) or silver sulphadiazine cream/dressings
Polyhexamethylene biguanide (PHMB)solution, gel or
impregnated dressings Iodinepovidone iodine (impregnated dressing) or cadexomer
iodine (ointment, beads or impregnated dressings) Medical-grade honeygel, ointment or impregnated dressings
Topical antimicrobial agents should not be used alone in those withclinical signs of infection
Chadwick et al.,2013
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Exudate management
Dressings that can help to manage wound exudate optimally andpromote a balanced environment are key to improving outcomes
Consider :
Location of the wound Extent (size/depth) of the wound Amount and type of exudate The predominant tissue type on the wound surface Condition of the periwound skin Compatibility with other therapies (eg contact casts)
Wound bioburden and risk of infection Avoidance of pain and trauma at dressing changes Quality of life and patient wellbeing
Chadwick et al.,2013
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The best dressing
There is no consensus about the best agent. The method of debridement chosen may depend on the status of
the wound, the capability of the healthcare provider and theoverall condition of the patient.
It is common to combine methods of debridement in order to maximize the healing rates.
Barbul, 2007
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Adjunctive therapy
Considered when needed and available
Ulcers not healed with conventional therapy
Growth factor (PDGF, GCSF)
Negative pressure wound therapy Biological dressing
Bioenginered skin equivalent
Hyperbaric oxygen therapy Platelet rich plasma
Greer, 2012
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Conclusions Knowledge about etiology and pathophysiology of
the lower extremity ulcers is needed to managepatients with ulcer in lower extremity;
Vascular contribution plays major role in the ulcer of
the lower extremity;
Three important components of ulcer management: treat the causes, treat persons related complaints,
treat the wound
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Chadwick et al.,2013
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Gist, 2009
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Stages of chronic venous
insufficiency(Expert meeting in Moscow, 2000.)
0 - no symptoms;
1 - heavy feet syndrome;
2 - intermittent edema;
3 - persistent edema, hyper- or
hypopigmentation, lipodermatosclerosis,eczema;
4 - venous ulcer.
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