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In my opinion, either practice would be acceptable. They both create a seal which promotes moist wound healing and decreases the formation of scar
tissue.
LPN wound nurse.

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Try Iodosorb ointment for heavy exudating wound. Check ABI index, then consider light compression with elevation.

unsigned

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Hello,
You are right in stopping the accuzyme if the wounds are clean. For a venous insufficiency ulcer, compression is a gold standard for healing, as long as there is not arterial insufficiency that causes the ABI (ankle/brachial index) to be less than .8 (some people will say you can go as low as .6). Compression can be accomplished by unna's boots, or layer bandaging systems like Profore. I have used silver alginates to the wound beds under these dressings if I feel there could be some troublesome bacterial colonization. These bandages can go as long as a week between changes if appropriate (not saturating the dressing). Encourage the patient to walk, but not to stand or sit with feet down. With the compression bandages, walking actually enhances the calf pump mechanism.
Vicki, MSPT, CWS

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hi I am a Rehab Nurse Coordinator dealing with wound and skin care on a daily basi....Pleeeease try Ferris Polymem, or Convatec Lyofoam...Its great for venous wounds with heavy drainage and is very user friendly. With the polymem make sure wound is not irrigated or any solution used during wound treatment, folloow directions to the "T". Please do a complete assessment ruling out pyoderma or cellulitis (culture wound if possible first).....good luck

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If the patient has had an Ankle Brachial Pressure
Index done to exclude any aretrial disease then the
gold standard treatment for venous leg ulcers is
compression bandaging with a wound care product that is able to handle large amounts of exudate such as a foam dressing.It is the bandaging which heals the wound by increasing the efficiency of the calf muscle pump to return blood to the heart.
I would also suggest that if there is odour, redness or inflammation of the surrounding skin associated with the exudate then you should do a routine wound swab.You also need to exclude any other factors associted with delayed wound healing such as diabetes anaemia and malnutrition. I had a patient with a venous leg ulcer of 30 years standing and the wound took 2 years to heal so persever.
Janine Michaelides SRN ONC DIP.HE(Wound Care).
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compression therapy is the gold standard for venous ulcers, check for active CHF or ESRD. Charles Rossetti,LPTA

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Hello Nina.

We need to look at the etiology of the wound and
any barriers to healing such as infection, presence of
necrotic tissue, nutrition, edema, conditions as diabetes and hypertension. If these are venous stasis ulcers, they will not usually heal until you provide some compression due to the deficient valves.

There is tissue congestion which will interfere with healing. Accuzyme should be discontinued if there is no necrotic tissue to debride and if there is minimal amount (like minimal patchy areas of  slough), it may be better to use other dressings instead. Unna boot dressings combine medication, and compression (although not graded compression). My experience with it, I got good results if applied properly. It worked to lift off slough as well. The other option is to use compression with graded pressure as hose to be worn or a lympedema pump.

I'd suggest the patient gets a vascular study done first as you want to be sure that a patient does not have arterial insufficiency as well. For those with arterial insufficiency, you want to limit compression pressure or not even use compression at all. If the patient is diabetic, you need to watch too as you could get a good ABI for instance, but only because you have arteries that are calcified so you still have the arterial insufficiency. In this case, compression bandages with Profore for instance (compression with less pressure) may be more appropriate.

If studies show venous insufficiency only, you can try Unna boot, applied in the morning before the patient has had legs in dependent position (to change q 3-7 days depending on amount of drainage), and place on an ambulation program. Also encourage the habit of performing ankle pumps frequently in the day, elevating the legs whenever he is not ambulating.

If with a lot of drainage, you may even want to try calcium alginate dressings first for maybe a week or so until the drainage is much less that you can switch to the Unna boot within a week. If you do try the Alginate dressings and a secondary dressing, make sure these together are not bulky and definitely use compression hose 16-18 mmHg pressure (again if there are no arterial insufficiency). And again, place on ambulation program.

The only contraindication to progressive ambulation is if your patient should show moderate to severe arterial insuffiency.

The ambulation and exercise will be good for a patient who is diabetic and with venous insufficiency problem only (no arterial problems) because the exercise should help with glycemic control.

Consult a PT for the exercises and ambulation.

Usually, venous ulcers will heal with compression. There are modalities to try for chronic wounds but as a rule, compression is tried first. (Contraindications to compression is arterial insufficiency, CHF, unchecked infection).

Check meds too. Any factors as use of steroids? protein deficiency (can result from undernourishment and also from heavily draining wounds), hypertension.

Hope these help.
Maria Carunungan, DPT, CWS

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I'm not sure if you're looking for current trials in progress, or about published studies. The major journals are Ostomy/Wound Management,
Wounds, Advances in Skin and Wound Care, The Journal of the Wound, Ostomy, and Continence Nurses Association, and Wound Repair and Regeneration. Also check out the Cochrane Library www.cochrane.org has reviews of the literature. You can access Medline on-line to get abstracts at www.PubMed.gov, and you can order articles through that service as well.

Renee C, MSPT, MPH, CWS

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You dont mention what treatment these patients are recieving. If they are wearing a compression bandage they could be allergic to the bandage material. If the ulcer is exuding then its probably this that is causing dermatitis and you need to find a dressing which will keep the exudate away from healthy skin such as Mepitel by Molyncke.
Janine Michaelides SRN ONC DIP.HE(Wound Care)
 

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Hello,
The 3 institutions I am familiar with have a protocol of sterile technique to be used in the first 24 hours following a surgical procedure, such as a surgical debridement of an ulcer, or when sharp debridement is being performed by the therapist, then back to clean technique.
Vicki, MSPT, CWS

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I would do sterile technique if they are severely immunocompromised, such as post-transplant for AIDS. All chronic wounds are contaminated,
so clean is usually sufficient. You can look at the Pressure Ulcer Treatment Guidelines available on-line.
Renee C, MSPT, MPH, CWS