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Chronic Wounds
Ulcers that heal within 12 weeks are usually classified as acute, and longer-lasting ones as chronic .
A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing. For example, chronic wounds often remain in the inflammatory stage for too long. In acute wounds, there is a precise balance between production and degradation of molecules such as collagen; in chronic wounds this balance is lost and degradation plays too large a role.
Chronic wounds may never heal or may take years to do so. These wounds cause patients severe emotional and physical stress and create a significant financial burden on patients and the whole healthcare system.
Acute and chronic wounds are at opposite ends of a spectrum of wound healing types that progress toward being healed at different rates.
Venous Ulcer
- Diagnosis
1.1 Arterial disease should be ruled out:
- Pedal pulses are present ABI > 0.8.
- ABI < 1.0 suggests vascular disease; if ABI < 0.7
then compression therapy is contraindicated.
- In elderly patients, diabetic patients or patients with
ABI > 1.2, Toe:brachial index > 0.6 or transcutaneous
oxygen pressure of > 30 mm Hg may help to suggest
adequate arterial flow.
1.2 Color duplex ultrasound scanning or Valsalva maneuver is
useful in confirming venous etiology.
1.3 If suspecting sickle cell disease, diagnose with sickle cell prep
and hemoglobin electrophoresis.
1.4 If ulcer is older than three months or not responsive after six
weeks of therapy, biopsy for histological diagnosis (possible
malignancy or other disease).
1.5 If worsening despite treatment or excessively painful, consider
other diagnoses such as pyoderma gangrenosum, IgA
monoclonal gammopathies, Wegener’s granulomatosis,
cutaneous chronic granulomatous disease and mycobacterial
or fungal etiologies (high suspicion for ulcers with dark color,
blue/purple border, concomitant with systemic disease such as
Crohn’s disease, ulcerative colitis, rheumatoid arthritis, other
collagen vascular diseases, leukemia). Specific cultures for
mycobacteria and/or fungi are useful, as biopsies for histology.
- Lower Extremity Compression
2.1 Use of Class 3, high-compression system is indicated.
The degree of compression must be modified when mixed
venous/arterial disease is confirmed during the diagnostic
work-up.
2.2 Intermittent pneumatic leg compression (IPC) can be used
with or without compression (other option for patients who
cannot or will not use adequate compression). Because
venous hypertension is an ongoing condition, a degree of
compression therapy should be continued constantly and
forever.
- Infection Control
Debridement
3.1 Remove necrotic, devitalized tissue by sharp, enzymatic,
mechanical, biological or autolytic debridement.
Infection Assessment
3.2 If infection is suspected in a debrided ulcer, or if
epithelialization from the margin is not progressing within
two weeks of debridement and initiation of compression
therapy, determine the type and level of infection in the
debrided ulcer by tissue biopsy or by a validated quantitative
swab technique.
Treatment
3.3 If ≥ 106 CFU/g of tissue or any beta hemolytic streptococci,
use topical antimicrobial (discontinue once in bacterial
balance to minimize cytotoxicity and development of
resistance). Systemically administered antibiotics do not
effectively decrease bacterial levels in granulating wounds;
however, topically applied antimicrobials can be effective.
3.4 Cellulitis (inflammation and infection of the skin and
subcutaneous tissue most commonly due to streptococci or
staphylococci) around ulcer should be treated with systemic
gram-positive bactericidal antibiotics.
3.5 Minimize the tissue level of bacteria, preferably to ≤ 105
CFU/g of tissue, with no beta hemolytic streptococci in the
venous ulcer prior to attempting surgical closure by skin graft,
skin equivalent, pedicled or free flap.
- Wound Bed Preparation
4.1 Examine patient as a whole to evaluate and correct causes of
tissue damage:
- A) Systemic diseases (autoimmune diseases, major surgery,
chronic smoking) and medications (immunosuppressive
drugs and systemic steroids)
- B) Nutrition
- C) Tissue perfusion and oxygenation
Debridement
4.2 Perform initial debridement and maintenance debridement
(sharp, enzymatic, mechanical, biological or autolytic).
Choose method of debridement depending on the status of the
wound, the capability of the healthcare provider and the
overall condition of the patient.
Cleansing
4.3 Cleanse wound initially and at each dressing change using a
neutral, nonirritating and nontoxic solution. Routine wound
cleansing should be accomplished with a minimum of
chemical and/or mechanical trauma.
Sterile saline or water is usually recommended. Tap water
should only be used if the water source is reliably clean.
A nontoxic surfactant may be useful, as may fluid delivered
by increased intermittent pressure.
Documentation of Wound History
4.4 Document wound history, recurrence and characteristics
(location, staging, size, base, exudates, infection condition of
surrounding skin and pain). The rate of wound healing should
be evaluated to determine if treatment is optimal.
- Dressings
5.1 Use dressing that maintains a moist wound healing environment.
5.2 Use clinical judgment to select moist wound dressing that
facilitates continued moisture. Wet-to-dry dressings are not
considered continuously moist and are an inappropriate
wound dressing selection.
5.3 Select dressing to manage exudates and protect peri-wound skin.
5.4 Select a dressing that stays in place, minimizes shear and
friction, and does not cause additional tissue damage.
VENOUS ULCER PATIENTS ARE PARTICULARLY
SUSCEPTIBLE TO CONTACT DERMATITIS RELATED
TO TOPICAL THERAPIES.
5.5 Select dressing that is cost-effective and appropriate to the
ulcer etiology, the setting and the provider. Consider healthcare
provider time, ease of use and healing rate, as well as the unit
cost of the dressing.
- Surgery
6.1 Skin grafting without attention to the underlying venous
disease is not a long-term solution and is prone to recurrent
ulceration.
6.2 Subfascial endoscopic perforator surgery (SEPS) is the
procedure of choice to address underlying venous pathologic
etiology (with or without skin grafting or use of a bilayered
artificial skin).
6.3 Less extensive surgery on the venous system, such as
superficial venous ablation, endovenous laser ablation or
valvuloplasty, especially when combined with compression
therapy, can be useful in decreasing the recurrence of venous
leg ulcers. Procedures that are less extensive than deep
ligation of multiple perforating veins can help to decrease
venous hypertension when combined with an adequate
compression system.
6.4 Free flap transfer with microvascular anastomoses can benefit
recalcitrant venous leg ulcers with severe lipodermatosclerosis
by allowing wide excision of diseased tissue and providing
uninjured venous valves in the transferred tissue.
- Use of Adjuvant Agents
This section will be limited to recommending the agents that
have sufficient data showing them to be useful in venous
ulcers. More studies are needed to clarify the benefits of other
agents in the treatment of venous ulcers. Examples of such
other agents currently under investigation include stem cells,
artificial skin, grafts, topical oxygen, electrical stimulation,
negative pressure, laser therapy, phototherapy, ultrasound and
prostaglandins. Please refer to the complete guidelines for the
current knowledge on each of these.
Devices
7b.1 Bilayered artificial skin, in conjunction with compression
therapy, is better than compression and a simple dressing.
7b.2 Cultured epithelial autografts or allografts do NOT improve
venous leg ulcer healing. They are useful for burns but not
durable enough for venous leg ulcers.
7b.5 Laser therapy, phototherapy and ultrasound therapy have NOT
been shown statistically to improve venous leg ulcers.
Systemic
7c.1 Pentoxifylline used in conjunction with compression therapy
improves healing of venous leg ulcers.
7c.5 Oral zinc supplementation is NOT useful in the treatment of
venous leg ulcers.
- Long-Term Maintenance
8.1 Patients with healed or surgically repaired venous ulcers
should use compression stockings constantly and forever.
Most treatments do not eliminate the underlying increased
ambulatory venous pressure (venous hypertension), so a
degree of compression is necessary long-term.
8.2 Exercises to increase calf muscle pump function have been
demonstrated to be helpful in long-term maintenance and
venous ulcer prevention. Calf muscle pump function has been
shown to be improved with exercises.
Pressure Ulcers
- Positioning and Support Surfaces
1.1 Establish a repositioning schedule and avoid positioning
on ulcer.
1.2 Maintain the head of the bed at the lowest degree of elevation
consistent with medical conditions and other restrictions.
Limit the amount of time the head of the bed is elevated and
elevate only when there is a compelling medical indication
(e.g., one to two hours after tube feeding, or with severe
respiratory or cardiac compromise).
1.3 Assess all patients for risk of pressure ulcer; use pressurereducing
surface for at-risk patients, since they are superior to
standard hospital mattresses.
1.4 A static support surface may be appropriate for patients who
can assume a variety of positions.
1.5 A dynamic support surface may be appropriate for patients
who cannot assume a variety of positions.
1.6 Stage 3, 4 or multiple pressure ulcers: low-air-loss or airfluidized
bed may be indicated.
1.7 Avoid prolonged sitting for at-risk patients. Reposition at least
every hour or return to bed.
1.8 Use seat cushion for pressure reduction in sitting position
(avoid donut-type devices since they have been shown to
increase venous congestion and edema).
- Nutrition
2.1 Perform nutritional assessment (weight, pre-albumin level and
serum albumin level).
2.2 Encourage dietary intake or supplementation if malnourished
and at risk for PU.
2.3 Ensure adequate dietary intake to prevent malnutrition
(if compatible with individual’s wishes).
2.4 If still inadequate, use nutritional support (tube feeding) to
place patient in positive nitrogen balance (30-35 cal/kg/day
and 1.25-1.5g protein/kg/day).
2.5 Give vitamin and mineral supplements if deficiencies are
confirmed or suspected.
- Infection Control
3.1 Treat distant infections (e.g. urinary tract, cardiac valves,
cranial sinuses) with appropriate antibiotics in pressure
ulcer-prone patients or patients with established ulcers.
Debridement
3.2 Remove necrotic, devitalized tissue by sharp, enzymatic,
mechanical, biological or autolytic debridement.
Infection Assessment
3.3 If infection is suspected in a debrided ulcer, or if contraction
and epithelialization from the margin are not progressing
within two weeks of debridement and relief of pressure,
determine the type and level of infection in the debrided ulcer
by tissue biopsy or by a validated quantitative swab technique.
Cultures should be performed to isolate both aerobic and
anaerobic bacteria.
Treatment
3.4 If ≥ 106 CFU/g of tissue or any beta hemolytic streptococci,
use topical antimicrobial (discontinue once in bacterial
balance to minimize cytotoxicity and development of
resistance). Systemically administered antibiotics do not
effectively decrease bacterial levels in granulating wounds;
however, topically applied antimicrobials can be effective.
3.5 Obtain bacterial balance (< 105 CFU/g of tissue and no
beta hemolytic streptococci) in the pressure ulcer prior to
attempting surgical closure by skin graft, direct wound
approximation, pedicled or free flap.
3.6 Obtain bone biopsy for culture and histology in cases of
suspected osteomyelitis associated with a pressure ulcer.
3.7 Once confirmed, osteomyelitis underlying a pressure ulcer
should be adequately debrided and covered with a flap
containing muscle or fascia. (Antibiotic choice, guided by
culture results, should be used for three weeks).
- Wound Bed Preparation
4.1 Examine patient as a whole to evaluate and correct causes of
tissue damage:
- A) Systemic diseases (autoimmune diseases, major surgery,
chronic smoking, sepsis, organ failure, major
trauma/burns, diabetes, uncontrolled vasculitis and
pyoderma gangrenosum) and medications
(immunosuppressive drugs and systemic steroids)
- B) Nutrition (weight, pre-albumin level, serum albumin
level and sufficient protein intake)
- C) Tissue perfusion and oxygenation (dehydration, cold,
stress and pain decrease tissue perfusion; smoking
decreases tissue oxygen)
Debridement
4.4 Perform initial debridement and maintenance debridement
(sharp, enzymatic, mechanical, biological or autolytic).
Methods of debridement (choose depending on the status of
the wound, the capability of the healthcare provider and the
overall condition of the patient. However, it is common to
combine methods of debridement in order to maximize the
healing rates).
Sharp: When the goal is to achieve fast and effective
removal of large amounts of necrotic tissue. Contraindicated
if lack of expertise, inadequate vascular supply to the
wound and absence of systemic antibacterial coverage in
systemic sepsis. Relative contraindication is bleeding
disorders or anticoagulation therapy.
Mechanical: High- or low-pressure streams or pulsed
lavage may be quite effective, provided the pressure does
not cause trauma. Effective irrigation pressures range from
4 to 15 psi. A 30-mL syringe filled with saline can be used
to flush a wound through an 18-gauge catheter. Irrigation
pressures below 4 psi may not be effective to cleanse the
wound and pressures greater than 15 psi may cause trauma
and drive the bacteria into the tissue. Whirlpools may
be used initially to loosen and remove debris, bacteria,
exudates and necrotic tissue. Prolonged use and periods
of wetness may macerate the tissue or be associated with
bacterial contamination.
Enzymatic: Topical application of exogenous enzymes.
Autolytic: Through use of moist interactive dressings.
If tissue autolysis is not apparent in one to two weeks,
another debridement method should be used. Autolytic
debridement is not recommended for infected wounds
or very deep wounds that require packing.
Cleansing
4.5 Cleanse wound initially and at each dressing change using
a neutral, nonirritating, nontoxic solution. Accomplish with
minimal trauma. A nontoxic surfactant may be useful as may
fluid delivered by increased intermittent pressure.
Mild soap (nonperfumed, without added antibacterials and
at skin pH: 4.5-5.7) and water for cleansing, used regularly,
is effective, safe and cheap. Use sterile saline or water; tap
water if reliably clean. Wound antiseptic agents, e.g. hydrogen
peroxide, hypochlorite solution, acetic acid, chlorhexamide,
providone/iodine, cetrimide and others have antibacterial
properties, but are all toxic to healthy granulation tissue.
Other
4.6 Infection control should be achieved by reducing bacterial
burden and achieving bacterial balance.
4.8 Achieve local moisture balance by management of exudates.
Documentation of Wound History
4.9 Document wound history, recurrence and characteristics
(location, staging, size, base, exudates, infection condition of
surrounding skin and pain). The rate of wound healing should
be evaluated to determine if treatment is optimal.
- Dressings
5.1 Use dressing that maintains a moist wound healing
environment.
5.2 Use clinical judgment to select moist wound dressing that
facilitates continued moisture. Wet-to-dry dressings are not
considered continuously moist and are an inappropriate
wound dressing selection.
5.3 Select dressing to manage exudates and protect
peri-wound skin.
5.4 Select dressing that stays in place and minimizes shear,
friction, skin irritation and additional pressure.
5.5 Select dressing that is cost-effective and appropriate to the
ulcer etiology, the setting and the provider. Consider healthcare
provider time, patient care goals and resources, ease of use
and healing rate, as well as the unit cost of the dressing.
- Surgery
6.1 Irregular wound extensions forming sinuses or cavities must
be explored, and unroofed and treated.
6.2 Necrotic tissue must be debrided
6.3 Infected tissue must be treated by topical antimicrobials,
systemic antibiotics or surgical debridement (See guidelines
3.2 and 3.4 in Infection on page 11). Only tissue with a low
bacterial count (≤ 105 CFU/g) and with no beta hemolytic
streptococcus will proceed to closure.
6.4 Underlying bony prominence and fibrotic bursa cavities
should be removed.
6.5 Bone excision must not be excessive.
6.6 Fecal or urinary diversions are rarely needed to obtain a
healed wound.
6.7 Consider radical procedures (amputation and
hemicorpectomy) only in rare and extreme cases.
6.8 A pressure sore should be closed surgically if it does not
respond to wound care and there is no other contraindication
to the surgical procedures. Exceptions may include the elderly
or patients with a fatal illness, for whom palliative, local
wound care is more appropriate.
6.9 Composite tissue closure leads to the best chance of sustained
closure, although recurrence and recidivism are continuing
problems. The most durable wound closure fills the ulcer with
bulk and provides padding over the underlying structures with
a tension-free closure.
6.10 Management to address muscle spasm and fixed contractures
must be done pre-op and continue at least until the wound
is healed.
- Use of Adjuvant Agents
This section will be limited to recommending the agents that
have sufficient data showing them to be useful in pressure
ulcers. More studies are needed to clarify the benefits of other
agents in the treatment of pressure ulcers. Examples of such
other agents currently under investigation include stem cells,
artificial skin, grafts, topical oxygen, electrical stimulation,
negative pressure, laser therapy, phototherapy, ultrasound and
prostaglandins. Please refer to the complete guidelines for the
current knowledge on each of these.
Systemic
7c.1 Hyperbaric oxygen therapy has NOT been shown to have
a statistically significant effect on pressure ulcer healing.
Further studies are needed to evaluate efficacy of hyperbaric
oxygen in pressure ulcers.
DIABETIC ULCER
- Diagnosis
1.1 Clinically significant arterial disease should be ruled out:
- Pedal pulses clearly palpable or ABI > 0.9.
- ABI > 1.3 suggests noncompressible arteries.
- In elderly patients or patients with an ABI > 1.2, a normal
Doppler derived wave form, a toe:brachial index of > 0.7
or a transcutaneous oxygen pressure of > 40 mm Hg may
help to suggest an adequate arterial flow.
- Color duplex ultrasound scanning provides anatomic and
physiologic data confirming an ischemic etiology for the
leg wound.
1.2 Determine presence of significant neuropathy by testing with
10g (5.07) Semmes-Weinstein monofilament.
- Offloading
2.1 Prescribe protective footwear for patients at risk for
amputation (significant arterial insufficiency, significant
neuropathy, previous amputation, previous ulcer formation,
pre-ulcerative callus, foot deformity, evidence of callus
formation).
2.2 Acceptable offloading methods:
Crutches
Walker
Wheelchair
Custom shoes
Depth shoes
Shoe modifications
Custom inserts
Custom relief orthotic
walker
Diabetic boots
Forefoot and heel
relief shoes
Total contact casts
- Infection Control
Debridement
3.1 Remove necrotic, devitalized tissue by surgical, enzymatic,
mechanical, biological or autolytic debridement.
Infection Assessment
3.2 If infection is suspected in a debrided ulcer, or if
epithelialization from the margin is not progressing within
two weeks of debridement and initiation of offloading therapy,
determine type and level of infection in a debrided diabetic
ulcer by tissue biopsy or by a validated quantitative swab
technique. Cultures should be performed to isolate both
aerobic and anaerobic bacteria.
Treatment
3.3 If ≥106 CFU/g of tissue or any beta hemolytic streptococci,
use topical antimicrobial (discontinue once in bacterial
balance to minimize cytotoxicity and development of
resistance).
Systemically administered antibiotics do not effectively
decrease bacterial levels in granulating wounds; however,
topically applied antimicrobials can be effective.
3.4 For acute diabetic foot infections not confined to the
granulating wound, systemic antibiotics are effective.
3.5 Cellulitis (inflammation and infection of the skin and
subcutaneous tissue most commonly due to streptococci or
staphylococci) surrounding the ulcer should be treated with
systemic gram positive bactericidal antibiotics.
3.6 If osteomyelitis is suspected, appropriate diagnostic measures
include probing the wound with a sterile cotton-tipped
applicator, serial X-rays, MRI, CT and radionuclide scan.
3.7 Osteomyelitis is best treated by removal of the infected bone,
followed by two to four weeks of antibiotics. When not
practical, it can be effectively treated with prolonged
antibiotic therapy.
3.8 Minimize the tissue level of bacteria, preferably to ≤ 105
CFU/g of tissue with no beta hemolytic streptococci in the
ulcer prior to attempting surgical closure by skin graft, skin
equivalent, pedicled or free flap.
- Wound Bed Preparation
4.1 Examine patient as a whole to evaluate and correct causes of
tissue damage:
- A) Systemic diseases (autoimmune diseases, major surgery,
chronic smoking, sepsis, organ failure, major trauma/burns,
diabetes, uncontrolled vasculitis and pyoderma gangrenosum)
and medications (immunosuppressive drugs and systemic
steroids)
- B) Nutrition (weight, pre-albumin level, serum albumin
level and sufficient protein intake)
- C) Tissue perfusion and oxygenation (dehydration, cold,
stress and pain decrease tissue perfusion; smoking
decreases tissue oxygen)
Debridement
4.2 Perform initial debridement and maintenance debridement
(surgical, enzymatic, mechanical, biological or autolytic).
Sharp surgical debridement is preferred for diabetic ulcers.
The method of debridement chosen may depend on the status
of the wound, the capability of the healthcare provider, the
overall condition of the patient and professional licensing
restrictions.
Cleansing
4.3 Cleanse wound initially and at each dressing change using a
neutral, nonirritating and nontoxic solution. Accomplish with
minimal trauma. A nontoxic surfactant may be useful as may
fluid delivered by increased intermittent pressure.
Mild soap (nonperfumed, without added antibacterials and
at skin pH: 4.5-5.7) and water for cleansing, used regularly,
is effective, safe and cheap. Use sterile saline or water; tap
water if reliably clean. Wound antiseptic agents, e.g. hydrogen
peroxide, hypochlorite solution, acetic acid, chlorhexamide,
providone/iodine, cetrimide and others have antibacterial
properties but are all toxic to healthy granulation tissue.
Documentation of Wound History
4.4 Document wound history, recurrence and characteristics
(location, staging, size, base, exudates, infection condition of
surrounding skin and pain). The rate of wound healing should
be evaluated to determine if treatment is optimal.
Others
4.5 If ulcer does not reduce by 40% or more after four weeks
of therapy, re-evaluate and consider other treatments.
4.6 Optimizing glucose control improves wound healing.
- Dressings
5.1 Use dressing that maintains a moist wound healing
environment.
5.2 Use clinical judgment to select moist wound dressing that
facilitates continued moisture. Wet-to-dry dressings are not
considered continuously moist and are an inappropriate
wound dressing selection.
5.3 Select dressing to manage exudates and protect
peri-wound skin.
5.4 Select a dressing that stays in place, minimizes shear and
friction, and does not cause additional tissue damage.
5.5 Select dressing that is cost-effective and appropriate to the
ulcer etiology, the setting and the provider. Consider healthcare
provider time, ease of use and healing rate, as well as the unit
cost of the dressing.
5.6 Selectively use adjuvant agents (topical, device and/or
systemic) after evaluating a patient and their ulcer
characteristics, and when there is a lack of healing
progress in response to more traditional therapies.
- Surgery
6.1 Achilles tendon lengthening improves healing of diabetic
forefoot wounds. Lengthening the Achilles tendon reduces
pressure on forefoot plantar ulcers in patients with limited
dorsiflexion and may be of benefit in healing certain diabetic
foot ulcers.
6.2 Patients with ischemia should be considered for a
revascularization procedure.
- Use of Adjuvant Agents
This section will be limited to recommending the agents that
have sufficient data showing them to be useful in diabetic
ulcers. More studies are needed to clarify the benefits of other
agents in the treatment of diabetic ulcers. Examples of such
other agents currently under investigation include stem cells,
artificial skin, grafts, topical oxygen, electrical stimulation,
negative pressure, laser therapy, phototherapy, ultrasound and
prostaglandins. Please refer to the complete guidelines for the
current knowledge on each of these.
Topical
7.1.1Platelet-derived growth factor (PDGF) is effective for diabetic
neurotrophic foot ulcers.
Systemic
7.3.1Hyperbaric oxygen therapy may be of benefit in reducing the
amputation rate in patients with ischemic diabetic foot ulcers.
- Prevention of Recurrence
8.1 Patients with healed diabetic ulcers should use protective
footwear to prevent recurrence.
8.2 Good foot care (proper bathing, nail trimming and wearing
proper footwear) and daily inspection of the feet will reduce
the recurrence of diabetic ulceration.
ARTERIAL INSUFFICIENCY ULCER
- Diagnosis
1.1 All patients with lower extremity ulcers should be assessed
for arterial disease. Suspicion of arterial disease should
prompt referral to a vascular specialist.
Criteria:
- Decreased or absent palpable pedal pulses.
- Delay in capillary refill response.
- Delay of 10-15 seconds in returning of color when
raising the leg to 45° for one minute, dependent rubor
(Buerger’s test).
- ABI ≤ 0.9 or > 1.2.
- Transcutaneous oxygen pressure of < 40 mm Hg.
- Doppler arterial waveform disparities.
- Dampened pulse volume recordings.
Pure arterial ulcers are unusual. Arterial insufficiency
frequently contributes to poor healing in ulcers with another
etiology (venous or diabetic).
1.2 Ulcer patients with risk factors for atherosclerosis (smoking,
diabetes, hypertension, hypercholesterolemia, advanced age,
obesity or hypothyroidism) are more likely to have arterial
ulcers and should be evaluated.
1.3 If ulcer appears ischemic, look for factors other than
atherosclerosis that involve arterial system (thromboangiitis,
vasculitis, Raynaud’s, pyoderma gangrenosum, thalassemia or
sickle cell disease).
1.4 Patients with rest pain or gangrene should be referred to a
vascular specialist (delay increases risk of limb loss).
- Surgery
2.1 Obtain anatomic roadmap prior to revascularization (magnetic
resonance angiography, contrast tomography angiography or
angiogram). The goal of revascularization is to restore in-line
arterial blood flow to the ulcer.
2.2 If arterial ulceration, choices are revascularization or
amputation. Adjuvant therapies may improve healing of the
ulcer, but do not correct the underlying vascular disease.
Revascularization is not always successful or durable.
Adjuvant therapies cannot replace revascularization but,
when used in combination with it, may improve the outcome.
2.3 The risk of surgery should be weighed against the likelihood
of success (of revascularization and of healing of the ulcer
after revascularization) given a patient’s co-morbidities.
- Infection Control
Debridement
If dry gangrene or scar: do NOT debride until arterial
in-flow has been re-established. Restoration of flow is
crucial to infection control in arterial ulcers and must be
addressed first.
3.1 Remove necrotic, devitalized tissue by surgical, enzymatic,
mechanical, biological or autolytic debridement.
Infection Assessment
3.2 Patients with neuro-ischemic ulcers should be considered for
a short course of systemic antibiotics even when clinical signs
of infection are not present. These chronic wounds have a
bacterial load that may impede healing before any evidence of
clinical signs of infection. However, chronic treatment with
systemic antibiotics does not prevent infection and may
worsen outcome if infection develops. Therefore, routine use
of antibiotics should be avoided, and antibiotics should be
stopped if no response occurs.
Treatment
3.3 Wounds will heal and infection will be better prevented if
environment is adequately oxygenated.
3.4 Topical antimicrobial dressings may be beneficial in
management of chronically/heavily colonized wounds,
decreasing their bacterial load and helping wound healing.
- Wound Bed Preparation
4.1 Examine patient as a whole to evaluate and correct causes of
tissue damage:
- A) Systemic diseases (autoimmune diseases, major surgery,
chronic smoking, sepsis, organ failure, major
trauma/burns, diabetes, uncontrolled vasculitis and
pyoderma gangrenosum) and medications
(immunosuppressive drugs and systemic steroids)
- B) Nutrition (weight, pre-albumin level, serum albumin
level and sufficient protein intake)
- C) Tissue perfusion and oxygenation (dehydration, cold,
stress and pain decrease tissue perfusion; smoking
decreases tissue oxygen)
Debridement
4.2 Perform debridement ONLY AFTER the revascularization
procedure. Pre-revascularization debridement should be
indicated only in a septic foot with and without ischemic
signs.
4.3 There are many debriding agents, but there is no consensus
about the best agent. The method of debridement chosen may
depend on the status of the wound, the capability of the
healthcare provider and the overall condition of the patient.
However, it is common to combine methods of debridement in
order to maximize the healing rates.
Others
4.4 Compression therapy may be beneficial in ulcers of mixed
etiologies (venous and arterial).
4.5 There is evidence that autografts, allografts and extracellular
matrix replacement can accelerate the closure of wounds but
further study is required.
- Dressings
5.1 In arterial ulcers with sufficient arterial inflow to support
healing, use dressing that maintains a moist wound healing
environment. Dry gangrene or eschar is best left dry until
revascularization is successful.
5.2 Select a dressing that is cost-effective and appropriate to
the ulcer etiology, the setting and the provider. Consider
healthcare provider time, ease of use and healing rate, as
well as the unit cost of the dressing.
Dressing changes once daily or less often should be chosen
where possible.
- Use of Adjuvant Agents
This section will be limited to recommending the agents
that have sufficient data showing them to be useful in
arterial insufficiency ulcers. More studies are needed to
clarify the benefits of other agents in the treatment of arterial
insufficiency ulcers. Examples of such other agents currently
under investigation include stem cells, artificial skin, grafts,
topical oxygen, electrical stimulation, negative pressure, laser
therapy, phototherapy, ultrasound and prostaglandins. Please
refer to the complete guidelines for the current knowledge on
each of these.
Systemic
6B.1a Hyperbaric oxygen therapy should be considered for patients
with non-reconstructable anatomy or not healing despite
revascularization. Selection criteria include hypoxia (due to
ischemia) and the hypoxia is reversible by hyperbaric
oxygenation. Tissue hypoxia, reversibility and responsiveness
to oxygen challenge are currently measured by transcutaneous
oxygen pressure.
6B.1bHyperbaric oxygen therapy should be investigated
in the treatment of ischemia-reperfusion injury after
revascularization in patients with arterial ulcers.
6B.2 Pentoxifylline does NOT improve arterial ulcer healing.
6B.3 An approach to control pain in patients with peripheral
arterial ulcer should address the cause and use local, regional
or/and systemic measures.
- Long-term Maintenance
7.1 Risk factor reduction is the most significant issue to be
addressed. It includes cigarette smoking cessation, control
of diabetes mellitus, elevated homocysteine levels,
hyperlipidemia and hypertension.
7.2 Antiplatelet therapy should be advocated. Vasodilation and
antiplatelet effects of certain drugs could theoretically
improve fibrinolytic activity, improving arterial insufficiency
and minimizing ulceration. Further studies are required.
7.3 Exercise to increase arterial blood flow has been demonstrated
to be helpful in long-term maintenance and arterial ulcer
prevention.
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