Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two -- Venous Ulcerations

William J. Ennis, DO, MBA, FACOS, Patricio Meneses, PhD

Disclosures

Wounds. 2003;15(4) 

In This Article

Compression Therapy

Compression techniques have been used since the 19th century.[97] The German physician, Dr. Unna, developed a zinc-based bandage roll with a reinforcing elastic layer known today as the Unna boot. Compression therapy is accepted as a critical component in the standard of care for venous ulcers. Compression therapy is divided into two categories, inelastic and elastic, and is based on the underlying mechanism of action.[98] Elastic compression works via constant compressive forces, whereas inelastic compression (e.g., Unna boot) actually functions as a rigid strut the calf muscles contract against for effective edema control. Knowledge of these differences is important because an immobilized patient would not fully benefit from inelastic compression. Papers that have not clearly identified the method of compression used are difficult to analyze and compare. Microcirculatory effects of compression relate to the Starling equilibrium model. Compression shifts the model towards absorption and decreased filtration. A classification scheme has been published that divides compression garments into Class 1 (conforming stretch bandages), Class 2 (light support bandages), and Class 3 (compression bandages). Class 3 is further subdivided into groups 3a through 3d based on the ankle level of pressure delivered.[99] The use and effectiveness of short-stretch bandaging for the treatment of venous ulcers is well documented.[100] A comparative trial looking at short-stretch bandaging, four-layer wrap, and support bandaging failed to identify differences.[101] A four-layer system was recently shown to achieve a 67-percent healing rate at seven weeks.[102] Hydrocolloid dressings have been shown to be more effective when combined with compression bandaging.[23,103] A recent meta-analysis of the compression therapy literature revealed high compression was more effective than low compression but failed to identify any particular procedure or product as more effective than the other.[104]

Another form of compression is intermittent pneumatic compression (IPC). This device includes a leg-long cuff that applies pneumatic compression at a prescribed force with a programmed relaxation time included. This kind of compression stimulates venous return and has been shown to enhance fibrinolysis.[105] This therapy can be applied at home usually once or twice a day. IPC and stockings outperformed stockings alone in a 12-week venous ulcer healing study.[106] IPC performed equally as well as compression bandaging in another trial giving clinicians another option in the stocking-noncompliant patient.[107] Other trials have shown other benefits of IPC, such as increased TcpO2 levels, and the effectiveness of the therapy when only used twice a week.[108,109]

Standard of care clearly defines the use of compression therapy for venous ulcer care. As described above, however, appropriate care dictates that the form of compression is carefully matched to the individual patient's needs. In the cases of severe edema, lymphatic involvement, noncompliance, or inability to use compression bandages, advanced care, such as intermittent pumps, might be indicated. The ambulation status, the underlying arterial status, and financial concerns of the patient all require individualizing compression therapy to an appropriate level.

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