edema -what we should know -...

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Edema:What We Should Know,What Should We Do?What Should We Do?

Terry Treadwell, MD, FACSMedical DirectorInstitute for Advanced Wound CareMontgomery, [email protected]

Massive Edema

Photo used with permission

Edema

• Is the presence of abnormally large amounts of fluid in the intercellular tissue spaces of the body, usually the subcutaneous tissues.

• Can occur in any tissue of the bodyy y

• Fluid contains low levels of protein

• Fluid containing high levels of protein--lymphedema

Dorland’ Illustrated Medical Dictionary, 24th Edition, W.B. Saunders Co., Philadelphia, PA, 1965, p. 467

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Why Worry About Edema?

• Sign of an important systemic condition

• Impairs local cell nutrition

• Is painful

• Gives rise to impaired mobility

• Increases risk of infection (cellulitis)

• Results in blistering of the skin and ulcers

Mortimer PS, Levick JR. Chronic Peripheral Oedema: The Critical Role of the Lymphatic System. Clinical Medicine2004;4(5):448-453

Complications of Edema

Edema With BlistersCellulitis

Why Is Edema Important?

• Can be seen in 1 in 200 people > age 65

• 80% of patients have missed work because of edema

9% h h d l t t t lt f • 9% have changed employment status as a result of edema

Moffatt C, Franks PJ, Doherty DC, Williams AF, et al. Lymphedema: An Underestimated Health Problem. QJM2003;96:731-738

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Etiology of Edema

• The diagnosis of edema is the disease that causes it

• >90% of patients, diagnosis can be determined by history and physical exam

10% f ti t ith d d l b t • 10% of patients with edema need laboratory exam or radiologic studies for diagnosis

Treadwell T, Fowler E, Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, Fourth Edition. Eds.-Carrie Sussman and Barbara Bates Jensen, Lippincott, Wilkins, and Williams, New York, NY, 2012

Causes of EdemaBilateral1. Cardiac disease2. Renal disease3. Hepatic disease4. GI disease5. Immune disease and allergy

Unilateral1. Venous disease2. Arterial disease usually A-V fistulae3. Lymphatic disease4. Operations5. Trauma5. Immune disease and allergy

6. Nutritional disease7. Endocrine disease8. Pregnancy9. Circulatory problems usually vena

caval obstruction10.Drugs and medications11. Inactivity and dependency of legs

5. Trauma6. Cancer and other tumors

Acute Post Op Wound (ORIF of Leg Fracture) with Edema and Lymphedema

Note Pitting!

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Drugs Causing Edema

• Calcium channel blockers

• Hydralazine

• Clonidine

• Minoxidil

• Reserpine

• Corticosteroids

• Estrogen

• Progesterone

• Tamoxifin

• Testosteronep

• Beta-blockers

• Cilostazol

• Gabapentin

• Pregabalin (Lyrica)

• MAO-inhibitors

• Non-steroidal anti-inflammatory drugs

• Cox-2 inhibitors

Treadwell T, Fowler E, Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, Fourth Edition. Eds.-Carrie Sussman and Barbara Bates Jensen, Lippincott, Wilkins, and Williams, New York, NY, 2012

Bundens WP. The Chronically Swollen Leg: Finding the Cause: Theory and Practice, in Venous Ulcers, Ed. Bergan JJ and Shortell CK, Elsevier, Boston, MA, 2007, p.73

Venous Insufficiency

• Chronic ambulatory venous hypertension

• Incompetence of valves in veins

–Long-standing saphenous, deep venous, and perforator incompetence

Angle N, et al. Br Med J . 1997;314(7086):1019-1023. Burton CS. Am J Surg. 1994;167(1A):37S-40S.

–Local trauma

–Undetected venous thrombosis

–Operative injury

• Capillary and venular dilatation

• Calf muscle pump failure

Valvular Incompetence

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Venous Hypertension with “Leaky” Vessels

Pericapillary Fibrin in Venous Insufficiency

Falanga, V, ed. Cutaneous Wound Healing. London, England: Martin Dunitz Ltd; 2001:157.

Ouahes N, et al. Curr Probl Dermatol. 1995;7(4):114-142.

Pathophysiology of Venous Insufficiency

• Capillary and venular dilatation

• Calf muscle pump failure

• Concentration of pressure at ankle

Angle N, Bergan JJ. BMJ. 1997;314:1019-1023. Burton CS. Am J Surg. 1994;167(suppl):37S-41S.

Concentration of pressure at ankle

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Capillary Pressures at Ankle

• Arterial end ~ 35-100 mm Hg

• Venous end ~ 8-15 mm Hg (1)

• Pressures increase when person pstands—both arterial and venous by average of 100 mm Hg!!! (2)

1) Foldi E, Foldi M. Chronic Venous Insufficiency and Venous-lymphostatic Insufficiency. In: Foldi’s Textbook of Lymphology. 2nd Edition. Munich, Germany: Elsevier; 2006. pp. 434-447

2) Farrow W. Phlebolymphedema—A Common Underdiagnosed and Undertreated Problem in the Wound Care Clinic. Jour Am College of Certified Wound Care Specialists 2010;2:14-23

Development of Edema

Arterial EndVenous End

Normal Circulation

35 mm Hg

8 mm Hg

~30 Liters/day~27 Liters/day

~3 Liters/day

Lymphatics



Increased Arterial Pressure

135 mm Hg

8 mm Hg

>30 Liters/day~27 Liters/day

~3 Liters/day

Lymphatics

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Increased Venous Pressure

35 mm Hg

108 mm Hg

>30 Liters/day<27 Liters/day

~3 Liters/day

Lymphatics



Leaky Capillaries

35 mm Hg

8 mm Hg

>30 Liters/day<27 Liters/day

~3 Liters/day

Lymphatics



Decreased Lymphatic Flow

35 mm Hg

8 mm Hg

~30 Liters/day~27 Liters/day

<3 Liters/day

Lymphatics

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– Macromolecules trap growth factors– Growth factors unavailable to repair or maintain– Leukocytes accumulate and occlude capillaries– Activated leukocytes release toxic metabolites

Complications of Venous Hypertension

y– Free radicals and proteolytic enzymes damage endothelium

Browse NL, et al. Lancet. 1982(8292);2:243-245. Falanga V, et al. Lancet. 1983;341:1006-1008. Coleridge Smith PD, et al. Br Med J (Clin Res Ed). 1988;296(6638):1726-1727.

Capillary Loss with Venous Hypertension

• Prolonged venous hypertension causes damage to and destruction of capillaries in skin 1

• Capillary thrombosis results in decreased number of capillaries in skin and wound bed 1,2,3

1. Junger J, Steins A, Hahn M, Hafner HM. Microcirculatory Dysfunction in Chronic Venous Insufficiency. Microcirculation 2000;7:S3-S12

2.Bollinger A, Jager K, Geser A. Sgier F, Seglias J. Transcapillary and Interstitial Diffusion of Na-Fluorescein in Chronic Venous Insufficiency with White Atrophy. Int J Microcirc Clin Exp 1982;1:5-17

3.Leu AJ, Yanar A, Pfister G, Geiger M, Franzeck UK, Bollinger A. Microangiopathy in Chronic Venous Insufficiency. Dtsch Med Wochenschr 1991;116:447-453

Venous Disease and Ulceration

Edema and Pigmentation Lipodermatosclerosisand Ulceration

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Chronic Venous Disease and Capillary Density

Junger J, Steins A, Hahn M, Hafner HM. Microcirculatory Dysfunction in Chronic Venous Insufficiency. Microcirculation2000;7:S3-S12

Examination of the Swollen Lower Extremity

Medical Conditions

Medicines Venous Disease

Lymphedema

Symptoms Usually none Usually none Heaviness; aching

Heaviness; aching

Bilateral Yes Yes Yes/No Yes/No

Pitting Yes Yes Early-Yes; Late - +/-

No

Skin Changes None None Yes Yes; Can be severe

Location Worse distally Leg; occasionally

foot

Leg; occasionally

foot

Varies but worse distally

Benefit with Elevation

Yes Yes/No Yes Minimal

Adapted from Carson S, Fowler E. Management of Edema. In B Bates-Jensen Ed. Wound Care: A Collaborative Practice

Manual for Health Professionals. 3rd edition. And Bundens WP. The Chronically Swollen Leg: Finding the Cause: Theory and Practice. In Eds JJ Bergan, CK Shortell. Venous Ulcers. Elsevier, Boston, MA. 2007, p. 73

Edema Severity Scale

Depth of Pitting Scale of Pitting

0 to ¼ inch 1+

¼ to ½ inch 2+

½ to 1 inch 3+

> 1 inch 4+

Adapted from Carson S, Fowler E. Management of Edema. In B Bates-Jensen Ed. Wound Care: A Collaborative Practice Manual for Health Professionals. 3rd edition.

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Treatment of Edema

Elevation of Legs? But how high?

http://www.losethebackpain.com/inversion3.html Accessed 8/14/12

Treatment of Edema

Compression!Compression!!

COMPRESSION!!!

Are all compression bandages the same?

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Compression Therapy

• Short stretch or inelastic

• Elastic

1. Single layer

Fletcher A, et al. BMJ. 1997;315(7108):576-580. Cullum N, et al. Cochrane Database Syst Rev. 2000;(3):CD000265. Franks PJ, et al. Wound Repair Regen. 2004;12(2):157-162.

2. Multiple layers

• Higher pressure better than lower pressure

Compression therapy significantly increases healingcompared to no compression

D

Anterior

L

Compartments

Anterior Tibial

Greater Saphenous

Tibia

SuperficialPosterior

DeepPosterior

Lateral

Lesser Saphenous

Dr. HN Mayrovitz

Fibula

Skin

Posterior Tibial

Peroneal

Pressures of Interest

Tibialis m.

Popliteus m

Pe

• Sub-bandage• Surface• Contact

Tibia

Soleus m

Gastroc m.

Popliteus m.Tibialis m.

eroneus

•Tissue•Interstitial

Fibula

• Intramuscular

CompressionBandage or Device

Skin

Dr. HN Mayrovitz

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Resting Pressure

R

Pressure (P) Due to Tension (T) of

Laplace’sLaw

Superficial vessels affected the most

Tension (T) of Bandage and the Radius (R) of the Leg

Dr. HN Mayrovitz

Muscles Contract Bandage

Restricts Muscle

Contraction

Working (Dynamic) Pressure

High Pressure

Develops on Deeper Tissues

Pressure Is From WITHINDr. HN Mayrovitz

Dynamic Pressure Depends on Bandage Material

Form-fitted Steel Pipe

ress

ure

Mayrovitz HN, et al. Clin Physiol. 1997;17(1):105-117.

Bandage “Stretchability”

No External Compression

0

Inelastic(short stretch)

Elastic(long stretch)

Dyn

amic

Pr

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Working vs. Resting PressuresRole of Compression Material

Emptying

ure

(PT)

Emptying

TimeDr. HN Mayrovitz

Tis

sue

Pres

su

TimeDr. HN Mayrovitz Clin Physiol. 1997;17(1):105-117

Control Leg

BeforeBandage

ml/min

Arterial Flow PulsesBelow Knee Blood Flow via Nuclear Magnetic Resonance

Treated Leg

WithBandage

ml/min

Dr. HN Mayrovitz, Univ of Miami

Venous Ulcer99 year old lady with ulcer for 8 months

ABI - 0.45

Informed that BK amputation was the

l thonly therapy

Treated with light compression and bi-layered tissue engineered skin

Wound healed after 47 weeks

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Types of Compression Therapy

Unna’s Boot

The original short stretch compression wrap

2 Layer Compression Bandage

1st Layer Complete CompletedBeginning 2nd Layer

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1st Layer 2nd Layery y

3rd Layer 4th Layer Completed

Allergies and Compression Bandages

Allergy to Cotton Wrap Allergy to Elastic Wraps

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Compression Bandage Too Tight Over Bony Prominences

Effective Compression?

• Achieve the appropriate sub-bandage pressure—30-40 mm Hg

• Use the correct techniques

• Use the appropriate materials

Is Effective Compression Therapy Being Used?

• Effective compression therapy—sub-bandage pressure of 30-40 mm Hg.

• Study of compression bandages applied by skilled, experienced wound care nurses p

• 34.9% of compression bandages -- < 20 mm Hg pressure

(56.7% -- applied by nurses with > 10 years experience!)

• 0% of compression bandages -- > 60 mm Hg

Keller A, Muller ML, Calow T, Kern IK, Schumann H. Bandage Pressure Measurement and Training: Simple Interventions to Improve Efficacy in Compression Bandaging. Int Wound J. 2009;6:324-330.

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Sub-bandage Pressure Measurement

Pico Press

Sub-bandage Pressures After Training

• Only 4.8% -- pressures < 20 mm Hg

• 12.7% -- pressures > 60 mm Hg

• 82.5% -- within therapeutic range (30-40 mm Hg)!

Keller A, Muller ML, Calow T, Kern IK, Schumann H. Bandage Pressure Measurement and Training: Simple Interventions to Improve Efficacy in Compression Bandaging. Int Wound J. 2009;6:324-330.

Effective Compression Therapy

PracticePRACTICE

PRACTICE!

With Feedback!!

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Correct Technique

Wrap to the Tibial Tubercle

Always Begin at The Base of the Toes

Not Good!

Oops!

Failure To Wrap All The Way To The The Way To The

Knee

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Failure to Wrap Feet!(Or to the Knees!)

Wrap With Even Pressure

Wrap with Appropriate Materials

1 2 3

Leg Wrapped with Fragments of 3 Bandages!

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Fact: Patients Don’t Like Compression Bandages!

• Only 48.8% of patients wear their compression bandages *

• May be as high as 80% *

• Determinants for NOT wearing compression bandages:g p ga. Age

b. Pain c. Wound sized. Wound depth

* Miller C, Kapp S, Newell N, et al. Predicting Concordance with Multilayer Compression Bandaging. Jour Wound Care 2011;20(3):101-112

When a Bandage Won’t Stay Up!

10

actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite

0

1

2

3

4

5

6

7

8

9

10Slippage in cm: after 24 and 48 hours

actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite

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Good Therapy?

Sponsored by an educational grant from 3M

For more information on 3M Compression Therapy visit 3M Compression Therapy visit

www.3m.com/coban2layer

3M is a provider approved by the California Board of Registered Nursing, Provider Number CEP 5770. Nurse participants may receive continuing education credit upon completion of education module.

edema -what we should know -...

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