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Lymphedema and Lipedema
Wound Management
Noreen Campbell RN BScN MA IIWCC LT(Vodder) CWS
May 9, 2014
Lymphedema and Lipedema
The hidden epidemic.
Lymphedema Framework
Recognition of chronic edema from different causes
Normal Wound Healing Cycle
Lymphedema changes
Compression considerations
Infection and Cellulitis Risk
Other Treatments
The Lymphedema Framework
Four Pillars of Lymphedema Management
Patient
Manual Lymphatic Drainage
Compression
Skin Hygiene
Exercise
Lymphatic System Insufficiency
Transport
Capacity
Lymphatic
Load
Normal Mechanical Dynamic
Diuretics only
for vascular
fluid over-load:
heart and renal
failure
Treating the whole person – not the
hole in the person.
Trauma or Surgery Cancer and Radiation Chronic Edema
Venous DiseaseLymphedema
Infection or Inflammation Obesity or Lipedema Immobility or Paralysis Fractious
Focus: Diagnosis determines care.
Lymphedema
Slow
Painless
Peripheral
Tissue soft
Stemmer Sign
Skin changes later
Cancer
Fast (weeks)
Distal to involved nodes
Collateral veins frequent
Firm tissue
Tissue and nerve damage before and after
surgery or radiation
Lipedema
Slow
Early hypertrophy
Later skin pain pressure
Bruising
Fat deposits
Deformity
Foot sparing
Lymphedema
DIET RESISTANT
Lipedema Stages
http://www.nature.com/aps/journal/v33/n2/fig_tab/aps2011153f4.html image
reference
http://www.lipedema-simplified.org/ Edu. Video 25min Catherine Seo
Edema AssessmentEdema
When - morning
Where – dependent area
Increasing
Response to elevation less effect
Skin changes (Stage)
Stage 1 – soft
Stage 2 – Stemmer sign
Stage 3 – Skin changes Fibrosis or Sclerosis
Papillomatosis
Lymphedema
Primary
Secondary
Lipedema/Lymphedema compared to
Lymphedema
Edema Assessment
+2
+3+4, leaking
Stemmer Sign
Avoid tight binding
clothing jewelry.
Veins
Thin
wasted
Ulcer
Stage 3 Lymphedema Skin Changes
Lymphostatic elephantiasis
Pronounced skin change
Hyperkeratosis
Papillomatosis
Pigmentation
Lymph cysts
Lymph fistulae
Pneumatic Compression Treatment 1980
Little support (German)
Increases fibrosis deposits
44% genital lymphedema when used on legs compared to 2.7% with compression bandages only
German Lymphedema Society DOES NOT RECOMMEND PNEUMATIC COMPRESSION without expertise and manual decompression support,
Arrow
Fibrosis
Compression Action Lymphedema
Action Contraindications High
Pressure Reduce edema
Increase reabsorption
Increase muscle and joint pump
Decrease fibrosis and sclerosis (rough packs)
Start low pressure, padding, modify, increase to best case
FINANCIAL CHALLENGE
EARLIER CHEAPER
Arterial insufficiency
Active congestive heart
failure
Acceptable with
consultation, monitoring
If discontinued must restart
from initial point
Complex regional pain
syndrome CRPS
CompressionProduct Purpose Comments
Short Stretch Elastic High walking pressure with
low resting
Must have suitable padding
for individual patient, digit
wrapped
Reusable, daily application,
some patients can self wrap
Allows skin care
Long Stretch Risk of binding, high
pressure
Not recommended, poor for
deformity management
Commercial Kits i.e.
ProFore,Coban
Single use, lack of specific or
possible sufficient padding
Single purchase increases
expense, no evidence of
superior effect
JustiFit Circaide Adjustable, good for
deformity accommodation
Patient or care provider can
be trained.
Circular knit garment Suitable early, without
deformity
Risk of binding, not if
deformity or folds
Flat knit garment Even pressure, custom made
are expensive
More comfortable
All require advanced fitting, selection and padding
Pre-compression Post Compression
CircAid Justa-Fit
Lost 90 Lbs
3 mns
Exercise,
Diet
Compression
3 months
http://www.youtube.com/watch?v=cdDPJ6m5_NY YouTube foot sock and lower leg
Compression Pressure ConsiderationsStart low, pad carefully, evaluate closely.
STAGE USE GERMAN
PRESSURES
CANADIAN
PRESSURES
I Superficial :children, elderly 18-2S1mmHg 15-24mmHg
Support stockings
II Moderate superficial: arm, leg,
mixed edema, post thrombotic
syndrome
25-32m Hg 20-30mmHg
Class 1
III Superficial deep tissue: LE
SI/II, Lipedema
36-40mmHg 30-40mmHg
Class 2
IV Increased deep tissue effect:
LE SII/III, younger patient
excellent compliance
>59mmHg 40>mmHg
class 3
Custom
Compliance is KEY to reduced edema.Boris 1997
Lymphedema Therapy
Compliance Arm Edema
Reduction
Lower Limb Edema
Reduction
100% 79% 79%
75% 58% 42%
50% 60% 36%
25% 53% 32%
None 43% 28%
Toe Edema
Digits should be wrapped
special training and very
close monitoring required
Closed stockings
Padding toes then applying
pressure
Interface between toes
Nonadherent or Inadine
Cast padding between toes
and over foot.
Include in compression wrap
Compression is forever...
Poor technique, still
better than nothing!
Lipedema - Lymphedema
Shaped TubiGrip
Compression Garments Function of garments
Pressure based on arterial
pressure
Flat knit preferred
Custom fit if deformity
Expense
Adherence
Lack of trained
professionals
Wound Healing Process
Hemostasis
immediate
Inflammation
Day 1-4
Proliferation
Day 4-21
Epithelialization
Maturation/Remodeling
Day 21 - 2 years
Kane
Homeostasis – first 24 hours
Platelets
PDGF
Inflammation 1-4 days
Debridement
Macrophages
Phagocytosis
neutrophils
Leakage of plasma and WBCs
Proliferation day 4 - 21
Granulation
Lymphocytes
Leukocytes
Angiocytes
Contractile proteins
fibroblasts
Release of growth factors from macrophages
Epithelialization (follows and overlaps proliferation)
Epithelial tissue development
keratinocytes
Resurfacing migration of skin cells
Maturation/Remodeling up to 2 years
Remodel
fibrocytes
Well healed scar – always a scar… (weaker tissue)
Infection Assessment
Heat
Erythema
Swelling
Pain*** not if neuropathy BUT if present deep infection
BLOOD SUGARS
ELEVATED
Infection
Examine after cleaning Potable water
may shower Mild soap
Wound deterioration Inappropriate
wound care Infection vascular
insufficiency Systemic
disease
Culture after cleaning ONLY if signs and symptoms
Topical Antimicrobial
Iodine (Cochrane’s) Cadexomer Iodine
Iodosorb
Povidone Iodine Inadine Betadine
Silver sulfadiazine Flamazine
Silver dressings Expensive little support
Honey Needs more support
Polysporin Increased risk of allergy Increased risk of resistance
Cellulitis (Erysipelas) Risk
Management
Risk of cellulitis 77X
Acute management
Long term antibiotics
Hold Manual Lymphatic
Massage and compression
until controlled
Surgery Debulking
Depends on amount of tissue continue compression
Liposuction
Lipedema SI/II Earlier better
Tumescent Local Anesthesia
Saline
Local Anesthetic
Adrenaline
Anti-inflammatory
Do NOT seal wounds, compresses, compression continuously 1 month
Lymph sparing surgery
MRI or PET Scan
Early symptom management
Lymphatic Reconstruction
New
Large vessel
No tension
ONLY IF LOCALIZED UNILATERAL ATRESIA
Laser Therapy
New
Needs more study
Basic Treatment Lymphedema and Lipedema
Patient
• Skin care– Clean, moisturize– Protect folds
• Exercise Planned Program• – Keep moving
– Walk– Water Exercise
• Manual decompression – Special technique
• Weight Control• Be involved with provincial
Lymphedema Association
Care Team
• Family physician
• Lymphatic Care Team
• Lymphatic Therapist
• Wound Clinician
• Physician
• Compression Provider
• Community Support
• Care providers aware of resources and access
Public Policy Goals
Recognition of the need for public and clinical education and
support.
Funding for specialized care teams
Education and support of local care providers
Patient funding
Therapy
Garments
Treatment
Research – effective therapy provision