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Identify and Treat the Cause - Implement Appropriate Compression Therapy


RNAO Evidence Levels:

LevelsA,B,C
 

Principles of Compression Therapy

In general, stockings are for prevention and compression bandages or compression wraps are for therapy, although there are a number of stockings that have been developed specifically to accommodate ulcer dressings and care, and are effective. These ulcer stockings may have a special trellis-like knit that increases pressure similar to that seen with compression bandages, or a two layer system including a low (10 mmHg stocking liner) and a zippered second stocking that increases pressure to the 30-40 mm Hg range. In situations where self-care is possible, compression stockings or devices may be seen to be more cost-effective than compression bandaging systems.

  • Therapeutic Graduated Compression Stockings, worn on a daily basis, are the best know prophylaxis to prevent venous ulcer recurrence.
  • Appropriate compression bandaging at highest level safe for, and tolerated by, the individual should be initiated within the first week.

Benefits of Compression Bandaging

  • Stimulates fibrinolysis
  • Removes sodium from subcutaneous tissue and reduction of edema
  • Facilitates fluid movement due to the pressure gradient
  • Creates an environment suitable for wound healing
  • Creates a pressure gradient extending from ankle to the knee (highest pressure at the lowest aspect and progressively diminish as it extends up the leg)
  • Overcomes gravitational effects
  • Combined effect of graduated compression plus activation of the calf muscle pump moves fluid towards the heart

Definitions

  • Tension: amount of force used to apply the bandage
  • Extensibility: ability to stretch in length with applied force
  • Power: the force required to increase the length of the elastic bandage, which determines the level of pressure exerted by the bandage
  • Elasticity: ability of the bandage to return to its original length after reducing tension
  • Stiffness: increase in pressure per square cm. increase in circumference

Pascal’s and LaPlace’s Law both form the physical basis of HOW compression works to reduce chronic venous insufficiency, but the calculations are not used by clinicians to determine how much compression is appropriate or needed for a given situation. They are included here only for interest sake, not for a practical application1.

Pascal’s Law:
  • “Pressure exerted anywhere in a confined incompressible fluid is transmitted equally in all directions throughout the fluid such that the pressure ratio (initial difference) remains same”
  • The change in pressure between two elevations is due to the weight of the fluid between the elevations
  • Any change in pressure applied at any given point of the fluid is transmitted undiminished throughout the fluid.
LaPlace’s Law
  • “the pressure in a cylinder exerted by uniform tension in the wall is inversely proportionate to the radius”
  • gradient compression therapy delivers higher pressures at the ankle where the radius is smaller, and lower pressures at the calf where the radius is higher, using the same amount of pressure all the way up
Modified LaPlace’s Law used for bandaging:
  • Pressure = Tension (KgF) x # of layers x 4620 (mmHg) Circumference (cm) x band. width (cm)

The pressures provided by compression bandages are the result of a very complex interaction between:

  • the properties of the materials used,
  • the size and shape of the leg,
  • the technique of the bandager and
  • the activities of the patient.

Compression Choices

In the absence of arterial disease, the BEST compression choice is the ONE that the patient will keep ON!

NO compression bandaging (including tubular bandaging such as tubigrip or surgigrip) is initiated until Lower Leg assessment and APBI/TBPI is completed, patient is assessed to be appropriate for bandaging and communications with physician or primary care provider has occurred.

Compression Bandaging includes single layer and multi-layer choices elastic and inelastic, with various applications to provide a range of 20 to 40 mm Hg compression, based on the patient’s vascular status and tolerance.

  • Inelastic bandages: Provide support and resistance: high pressures with exercise, minimal pressure at rest e.g. Viscopaste and kling wrap, Circaid® Boot , Short stretch Comprilan®, Coban 2™, Coban 2 Lite™
  • Elastic bandages: Provide compression with high pressures at rest but less with muscle contraction e.g. Profore™, Surepress™, Coban™ Self Adherent Wrap (Coban 4” with 20 mmHg should only be used as part of a Duke’s Boot over zinc paste
  • Velcro-strap system (inelastic): lasts about 6 months, easy to doff and don
  • Specialized stockings designed for venous ulcer care: e.g. Jobst Ulcer Care
  • Tubular support: which when combined in layers of at least 2 can provide variable amount of compression e.g. Tubigrip, Tubifast, Surgigrip (non-latex)
  • Tubular net-type that mimics the work of taping for lymphedema reduction e.g. Edema Wear

Important Considerations

Prevent pressure damage in patients with:

  • Impaired peripheral perfusion
  • Thin or altered limb shape
  • Foot deformities
  • Dependent edema
  • Achilles and tibialis anterior tendon areas
  • Rheumatoid arthritis
  • Reduced sensation
  • Long-term steroid use
  • Loss of calf muscle pump by choosing an inelastic (rigid) bandaging system
  • Applying extra padding or foam over bony prominence
 

Table 4 - ABPI and Compression Bandaging2 3

Type of Compression Examples of Products Compression Characteristics
High Compression (40mmHg pressure and higher)
Normal ABPI = 1.0 to 1.2    Mild Ischemia = 0.8 to 0.9
ABPI >1.2 or you cannot obliterate the pulse with BP cuff Calcification (Non-compressible arteries)
Request Toe Brachial Pressure Index (TBPI) or Segmental Pressures to determine safety of compression therapy
High elastic compression (Long stretch) Surepress (Convatec)
Surepress and flexible cohesive bandage
Sustained compression; can be worn continuously for up to 1 week; can be washed and re-used, but may slip.
Multilayer high compression Profore (Smith & Nephew)
4 layer bandage comprising of orthopedic padding; crepe; Elset; Coban.
Coban 2
Can use flexible cohesive for slippage.
Inelastic Compression Short-stretch bandage, e.g. Comprilan (Beiersdorf) Designed to apply 40 mmHg pressure at the ankle, graduating to 17 mmHg at the knee; sustainable for 1 week. Reusable with slight stretch giving low resting pressure but high pressure during activity.
Medium Compression (20-40 mmHg pressure)
ABPI = 0.6 to 0.8
Multilayer bandages Profore light

Coban 2 Lite
Bandages can be made by combining Kling and a Tensor (spiral or figure 8) and a flexible cohesive bandage on top. Components can be re-used.
Cohesive bandages Coban (3M), Roflex Self-adherent to prevent slippage; useful over non-adhesive bandages such as elastocrepe and paste bandages; compression well sustained. Provides approximately 23 mmHg or higher at the ankle graduating to approximately one-half this pressure at the knee.
Low Compression (15-20 mmHg pressure)
ABPI = 0.5 to 0.6
Light support only (inelastic) Kling/orthopedic wool For holding dressings in place, as a layer within the multilayer bandag
Light Compression single layer elastic Tensor/Elastocrepe
Tubi-grip
Low pressure obtained; used alone it gives only light support; a single wash reduces pressure by about 20 percent.
Light Compression multilayer Coban 2 Lite  
ABPI <0.5 - severe arterial disease → urgent vascular surgery consult
ABPI <0.3 – Critical Ischemia → urgent medical attention
NO compression to be used
 

Compression for LIFE! (compression stockings)4

  • Graduated compression stockings are the best-known method of preventing swelling of the legs and feet, after a period of being wrapped with bandages
  • These stockings provide a measured amount of compression to the lower legs
  • They come in open and closed-toe, knee or thigh-length versions
  • Stockings should go on first thing in the morning before the legs start to swell
  • They can be removed at bedtime, but CAN be worn over night if the individual cannot get them on and off by independently
  • If they wear them overnight, they should fit smoothly without causing deep creases or folds in the skin
  • It is important that certified stocking specialist measure the legs to fit them (see Toolkit item #17 for list of fitters in Waterloo Wellington Region)
  • One of the most difficult things about compression stockings is that even though they may still feel tight, they actually stretch and lose their ability to control the edema or the venous problem in your legs
  • They need to be replaced every 4-6 months
  • If the individual alternates stockings with two pairs, two pairs will last 8-12 months
  • Scientific testing shows that the stockings lose pressure after just one month of wear, and by 6 months they are not providing you with the amount of compression needed, so that skin breakdown and complications will start to happen
  • There are many devices designed to assist people with “donning” (applying) and “Doffing” (removing) medical grade compression stockings
  • There are times when a person who should be in compression stockings either cannot tolerate them or refuses to wear them. In those situations, it is believed that some compression is better than no compression in terms of prevention of recurrence. This is where the tubular stocking (i.e. Tubigrip) may be helpful
 
ABPI 0.5 to 1.39
To be worn after healing or for ulcer prevention
Long-term Compression systems
Strength is dependent on ABPI and LLA results
Compression stockings
Tubifast/Tubigrip for patients unable to ‘don and doff’ compression stockings
Juxta and Juxta lite (stocking with Velcro straps) [stiffness or resistance]


Identify and Treat the Cause - Medical Therapy: Pharmacological Treatment    
  1. Thomas, S. The use of the Laplace equation in the calculation of sub-bandage pressure. World Wide Wounds. 2003. http://www.worldwidewounds.com/2003/june/Thomas/Laplace-Bandages.html
  2. Registered Nurses Association of Ontario. Nursing Best Practice Guideline: Assessment and Management of Venous Leg Ulcers. March 2004
  3. Wellington Waterloo CarePartners, Kitchener Ontario
  4. Wellington Waterloo CarePartners, Kitchener Ontario

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