C:\Users\ing. Radomil Novak\Desktop\ICRC\propagace a marketing\loga\FNUSA - NEW!!\FNUSA_logo.jpg MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ C:\Users\ing. Radomil Novak\Desktop\ICRC\propagace a marketing\PPT prezentace\Background\budovajpeg.jpg Chronic venous disease and leg ulcers MUDr. V. Slonková, Ph.D. I. dermatovenerologická klinika FN u sv. Anny v Brně a LF MU Leg ulcers lprevalence : 1% of adults lincidence: in population over 50 l - 0,3 to 1000 inhabitants lchronic disease : - 60 % of ulcers heal more than 6 months, l - 33 % heal more than 1 year limpact on quality of life lreccurences – 2/3 of healed leg ulcers Etiology of leg ulcers l75% venous l15% arterial l10% other Snímek 274 Snímek 267 Venous leg ulcers l75% of all leg ulcers lpathogenesis – valvular insufficiency l2 types: l1) ulcus cruris varicosum – due to primary varicose veins l2) ulcus cruris posttromboticum – due to deep vein thrombosis l Chronic venous disease lCVD C:\Users\veronika\Desktop\IMG_0740.JPG CEAP classification lClassification and grading of chronic venous disease on the basis of: l lC – clinical manifestations lE – etiologic factors lA – anatomic distribution of involvement lP – pathophysiologic findings CEAP classification C 0 – no visible or palpable signs of CVD C 1 – telangiectases and reticular veins C 2 – varicose veins C 3 - edema C 4 – skin changes: pigmentation, eczema, lipodermatosclerosis, atrophia blanche C 5 - skin changes + healed ulcer C 6 – skin changes + leg ulcer http://www.urgo.co.uk/uploaded-files/img/images/schema-ceap-01.jpg Bércový vřed je terminálním stádiem žilních onemocnění – chronické žilní insuficience a postrombotického syndromu. Chronic venous disease (CVD) lVein Consult Program (2012) lepidemiologic study in Europe, Asia, Latin America, 90 000 persons lCVD – global problem lprevalence: l84% - including stage C0s ( symptomatic patients without clinical signs of the disease) l64% - from stage C1 Venous return – physiological situation lVenous – muscle pump St. C4 - pigmentation IMG_0438 Atrophia blanche + leg ulcers IMG_0504 St. C6 – venous leg ulcers IMG_0426 IMG_0646 IMG_0494 IMG_0521 IMG_0516 IMG_0531 IMG_0540 Treatment of venous leg ulcers linvasive l lconservative: l - local treatment l - pharmacological treatment l - compression l l lManagement of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. International Angiology 2018;37(3) l Invasive treatment lsclerotherapy (foam) lsurgical treatment lthermal methods (endovenous laser, radiofrequency) lnon – thermal methods (glue) l l l lGohel MS et al. A randomized trial of early endovenous ablation in venous ulceration. NEJM 2018;378:2105-14. l Conservative treatment llocal treatment lpharmacological treatment lcompression l l l l lManagement of patients with Venous Leg Ulcers - Challenges and Current Best Practice. EWMA Document 2016. l Local treatment – wound healing - TIME lT – tissue lI – inflammation, infection lM – moisture lE – epithelization l l l l lManagement of patients with Venous Leg Ulcers - Challenges and Current Best Practice. EWMA Document 2016. l Snímek 259 Snímek 277 Obr Wound healing - TIME lA structured wound assessment tool in the form of acronym l lT – tissue management lI – inflammation, infection control lM – moisture balance lE – epithelization advancement TIME – T - tissue l debridement, wound bed preparation l Snímek 259 Debridement ltreatment of wound bed and wound edges l lnecessary for wound healing l lreduces odour, exudation l limproves quality of life Debridement lautolytic lenzymatic lbiosurgical lmechanical lsurgical lhydrosurgical lTNP (topical negative pressure) TIME – I - infection l linfection, inflammation control lantiseptics l l Snímek 277 Antiseptics lsynthetic antimicrobial drugs lthey kill or inhibit microorganisms lthey are not toxic for keratinocytes lthey act non selective lbroad antimicrobial spectrum lresistance – rare Antiseptics lsilver liodine lchlorhexidin lhoney lpolihexanid Silver dressings la broad antimicrobial spectrum: lStaphylococcus aureus, including MRSA, VRE ( vancomycin-resistent enterococci), Streptococcus pyogenes, Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae lviruses, yeasts Silver dressings la variety of antimicrobial dressings containing silver la silver contect and physical and chemical properties vary greatly lavailable in various formulations: l - flat sheets l - combined with hydrogels, alginates, hydrofibres lresistance - rare l l l IMG_0649 IMG_0624 TIME – M - moisture lmoisture – management of exudate l Snímek 267 IMG_0358 IMG_0544 Moist wound healing lmoist wound necessary for good healing loptimal hydration of the wound lcopious exudate – causes leakage, maceration, odour, infection lminimal exudate delays autolytic debridement, inhibits epithelialisation and causes pain on dressing removal l Moist wound healing ldry wounds: hydrogels l lhighly exudating wounds: l - alginates l - hydrofibres l - polyurethan foams l Snímek 261 TIME – E - epithelization l Obr Dressing change lymfo 5-08 039 Dressing change lymfo 5-08 043 Dressing change Snímek 261 Dressing change lymfo 5-08 044 Dressing change lymfo 5-08 058 Dressing change lymfo 5-08 059 Dressing change lymfo 5-08 060 Compression lBasic treatment of venous leg ulcers lCompression leads to healing of 70% of venous leg ulcers smaller than 10 cm2 in 3-6 months l l l l l lManagement of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. International Angiology 2018;37(3) l l IMG_0430 Compression limprovement of venous return lreduction of venous dilatation l¯ venous reflux l¯ venous hypertension l l l lManagement of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. International Angiology 2018;37(3) l l l Compression l1. short stretch compressive bandages: l - multilayer compression l l2. compressive systems l3. compressive devices l l4. compressive stockings for leg ulcers l l lO´Meara et al. Compression for venous leg ulcers. Cochrane Review 2012 Nov 14;11:CD000265. l 1. Compressive bandages l lshort stretch compressive bandages: l l lmultilayer compression l l l lO´Meara et al. Compression for venous leg ulcers. Cochrane Review 2012 Nov 14;11:CD000265. l C:\Users\uziv\Desktop\Bandáž\IMG_1443.JPG Multilayer bandage C:\Users\uziv\Desktop\Bandáž\IMG_1440.JPG Multilayer bandage C:\Users\uziv\Desktop\Bandáž\IMG_1441.JPG Multilayer bandage C:\Users\uziv\Desktop\Bandáž\IMG_1442.JPG Multilayer bandage C:\Users\uziv\Desktop\Bandáž\IMG_1443.JPG Multilayer bandage - problems lWrong application in more than 50% patients l l l l l l l lO´Meara et al. Compression for venous leg ulcers. Cochrane Review 2012 Nov 14;11:CD000265. l l IMG_0431 G:\Foto vředy\IMG_1178.JPG G:\Foto vředy\IMG_1187.JPG IMG_0636 IMG_0558 2. Compressive systems http://www.jobstcompri2.com/uploads/tx_mwjobst/BSN_JOBST_Compri2_03.jpg http://us.hartmann.info/images/FourPress.jpg IMG_0324 KPress KTech Management of patients with Venous Leg Ulcers - Challenges and Current Best Practice. EWMA Document 2016. Compressive systems l4 basic properties: P-LA-C-E l lPressure lLAyers lComponents lElastic properties l l lManagement of patients with Venous Leg Ulcers - Challenges and Current Best Practice. EWMA Document 2016. l P - pressure lSub-bandage pressure l40 mm Hg in rest lPressure systems l l l l l l lManagement of patients with Venous Leg Ulcers - Challenges and Current Best Practice. EWMA Document 2016. l P1320327 Picopress C:\Users\veronika\Pictures\picopress2.png l l l l l l l l l l l l l l l l l l l l l l l l l l l lManagement of patients with Venous Leg Ulcers - Challenges and Current Best Practice. EWMA Document 2016. Compressive systems l l l l l l l l l lManagement of chronic venous disorders of the lower limbs. Guidelines according to scientific evidence. International Angiology 2018;37(3) l l IMG_0321 IMG_0323 Compressive systems IMG_0324 3. Compressive devices Activa ReadyWrap Výsledek obrázku pro circaid juxta fit Výsledek obrázku pro jobst garments Partsch H. reliable self-application of short stretch leg compression: Pressure measurements under self-applied, adjustable compression wraps. Phlebology 2019;34:208-213. Circaid G:\Foto vředy\IMG_1285.JPG Circaid G:\Foto vředy\IMG_1322.JPG Circaid G:\Foto vředy\IMG_1323.JPG Circaid G:\Foto vředy\IMG_1325.JPG Circaid G:\Foto vředy\IMG_1324.JPG Circaid G:\Foto vředy\IMG_1285.JPG 4. Compressive stockings for leg ulcers l lsystem of 2 stockings lpressure - 40 mm Hg l l l l l l lRabe E, Partsch H, Hafner J et al. Indications for medical compression stockings in venous and lymphatic disorders: An evidence-based consensus statement. Phlebology 2017 l ulcer_kit_220x300px Contraindication of compression lPAOD – ABPI less than 0,5 lAcute erysipelas lAcute eczema lHeart failure Pharmacological treatment lmicronized purified flavonoid fraction lpentoxifylin lsulodexid l IMG_0494