Current Opinion in Critical Care; 19: 4, 282-289. Silicone plays a key role: it forms a coating that the fluid sits on, rather than resting directly on the skin. Chronic Oedema is the term used to describe oedema which has been present for at least 3 months and does not reduce when the limb is elevated. This article describes the pathophysiology, management strategies, and clinical and practical issues associated with the condition; it updates an article published in 2003. Figure 1 Pitting oedema of the abdominal wall. So-called barrier products come in various forms, including creams, sprays and sticks. Compression Compression comes in many shapes and forms, including bandages, hosiery, wrap systems and pneumatic compression.
Dressings Dressing technology has steadily improved in the past decade. This conservative management can also be combined with methods abolishing superficial venous reflux and with ulcer surgery and skin grafting. A basic stocking exerting a pressure of 20 mmHg or less keeps the local ulcer dressing in place and remains in place overnight: a second stocking 20—30 mmHg is applied over it during the daytime Fig. Future studies comparing different compression devices should also report details concerning the compression material used and the pressure exerted. The volume of fluid in the interstitial space is normally kept constant at around 20% of body weight. Hosiery is not normally used when the leg is leaking, because applying and removing it when the skin is so fragile increases the risk of trauma, while constant contact with wet material can also damage the skin.
Edema in foot and ankle Swelling of the foot, ankle and leg can be severe enough to leave an indentation pit when you press on the area. Some are present from birth e. Beldon P 2014 The judicious use of antimicrobial dressings. Damage to the tiny, filtering blood vessels in your kidneys can result in nephrotic syndrome. Due to the immediate reduction in oedema the initial pressure drops while stiffness is maintained. This terminology should be used only to characterize single bandages, because the elastic behaviour of a bandage on the leg consisting of a mixture of materials can no longer be characterized by these categories. In the presence of infection, the skin will be particularly vulnerable to breakdown and the patient may experience intense pain, so compression and limb management will need to be conducted more frequently, and compression can be applied at lower pressures than normal.
There is usually evidence of chronic venous hypertension, e. Acute infection itself results in tissue oedema, and will therefore add to the existing oedema. Renshaw 2007 suggests that short-stretch bandaging can be more comfortable than medium- or long-stretch, as it applies a low pressure when the patient is resting. The main points in this scholarly review on the use of compression therapy in leg ulcers are the different modes of action of this treatment and the tools that are available including their practical applicability and use for self management. The key is to select a technique that applies pressure firm enough to counteract the tissue pressure, thereby squeezing the veins and valves to stop the backwards flow of venous blood. However, the dogma that compression needs always to be graduated providing higher pressures over the distal than the proximal parts has been questioned concerning venous haemodynamics in the ambulatory patient.
Nurses should refer to local dressing formularies and discuss any challenges with a tissue viability nurse or other professional with responsibility for the formulary. Nursing Times; 99: 31, 61. There are many reports of patients resorting to placing their leg in plastic bags or using nappies, sanitary towels or incontinence pads in an effort to manage the volume of fluid. This answer depends on the local hygiene requirements, which may be different across centres. In people with reduced mobility, the clinical features can be similar to those of a dependency-type oedema.
His main interest is peripheral vascular diseases and his scientific research publications focus on compression therapy and on the diagnosis and management of acute and chronic venous disease, vascular malformations, leg and foot ulcers and lymphoedema. European Wound Management Association Focus Document. With every muscle contraction during walking, blood is shifted against gravity towards the heart while intact venous valves prevent reflux during muscle diastole. It is often caused by an underlying medical condition and clears up when this is diagnosed and treated. The haemodynamic effect of inelastic material can be explained by an intermittent narrowing of incompetent veins during muscle contractions during walking, blocking reflux and increasing the ejection fraction of the calf pump.
Despite these advances, many challenges remain. By using a simple pocket Doppler ultrasound device we can measure the systolic ankle pressure which closely corresponds to the arterial perfusion pressure in patients with arterial occlusive disease see Box. Conclusion Managing oedematous and leaking legs is a clinical challenge for health professionals and for patients. Not well recognized is the fact that compression is also able to increase arterial blood flow, even in patients with arterial occlusive disease. Modern materials such as alginate, hydrofibres and absorbent granules increase the capacity of dressings to absorb fluid. Clinical investigations focusing on a dose—response relationship have revealed that in patients with chronic leg oedema, there is a correlation between exerted pressure of compression stockings and oedema reduction in a pressure range between 10 and 40 mmHg. When large volumes of fluid are leaking it may be necessary to apply more sub-bandage padding than usual, but this can be reduced once the leakage diminishes Renshaw, 2007.
This usually happens because the valves in the veins fail to close properly, resulting in a backflow of venous blood leading to higher than normal pressures in the veins venous hypertension. Oedema is an accumulation of interstitial fluid. If you have purchased a print title that contains an access token, please see the token for information about how to register your code. Figure 4 — Severe skin changes in advanced lymphoedema of the lower leg. Public users are able to search the site and view the abstracts for each book and chapter without a subscription. When super-absorbent dressings are swollen with fluid, they may exert additional localised pressure, leading to changes in the pressure profile and possibly to pressure damage. Such devices may be helpful to improve patient compliance.
Lymphatic drainage is impaired in leg ulcers, but microlymphangiopathy has also been shown in lipodermatosclerotic skin areas before ulceration. Venous hypertension may also be caused by severe outflow obstructions, e. Oedema must be managed to reduce congestion and swelling but treating infection, if present, is a priority. However, lower-limb swelling and fluid leakage can have various causes, including renal disease, cancer, drug therapy and heart failure Keeley, 2008 , and diuretics may help reduce lower-limb oedema caused by heart failure Khatib, 2011. Nursing and Residential Care; 12: 5, 228-232. Jacob M, Chappell D 2013 Reappraising Starling: the physiology of the microcirculation. It seems to develop in teenage years and occurs exclusively in women.
Often people with leg ulcers will suffer from Chronic Oedema. There are a number of types of primary lymphoedema, some of which are inherited. In lymphorrhoea, the skin is broken and very wet, which increases the risk of infection; the risk of sepsis is also high Elwell and Craven, 2015. The patient was instructed to walk as much as possible. There is still much that we do not understand Levick and Michel, 2010 , but we know that improving lymphatic drainage as much as possible is a priority. Quéré I, Sneddon M 2012.