One of our success stories last year was Mrs Y, a 81 year old lady who stayed with us for 7 months. She was admitted to the Wesley Hospital under the care of a physician. When Mrs. Y first presented she was in extreme pain and had been suffering from venous ulcers of her right leg for over two years. She was reviewed by a vascular physician who confirmed 50-70% stenosis in multiple areas thus angioplasty would be of no benefit. Analgesics were given and different combinations trialled throughout the time of hospitalisation.
The impact of wounds on the individual is often neglected as is the time and cost to these patients and their families. Our aim is to assist in gaining total wound closure thus enabling the patient to be free from appointments, intensive treatments and resume everyday life.
Mrs. Y’s ulcers were on her left lower leg and were heavy exudating in nature. Her wounds were sloughy with inflammatory margins around the wounds and she experienced severe pain for an extended length of time. Her ABI (Ankle Brachial Index) result was indicative of calcified vessels. The transcutaneous oximetry (TCOM) was encouraging with hypoxic baseline levels of 11 and 13 which rose to 273 and 154 when on 100% oxygen. This is indicative that hyperbaric oxygen therapy may be of benefit.
This history and examination suggests the wound was a venous ulcer and we would take a comprehensive approach to her management to promote wound healing. This included:
- Infection management
- Pain control
- Reducing exudate
- Managing venous pressure
- Hyperbaric oxygen therapy.
Initially we worked with the ward staff to manage Mrs. Y wounds and our first goal was to address the infection and pain issues. Her wounds were heavily colonised with staph aureous and pseudomonas aeruginoa and she was prescribed long term Ciproxin for this.
Pain was controlled with regular Panadol during the day and Endone 5mg at night.
Our choice of dressings for this patient included curasalt to assist with the autolytic debridement to obtain a clean wound base. We found curasalt to be effective and reassessed this daily. Using curasalt is always a challenge due to the tolerance level as it can cause pain when applied due to the salt content in the dressing. Often the use of analgesics such as nitrous oxide prior to dressings is beneficial. Regular use of oral analgesics throughout the day and night is advantageous in enabling the patient to tolerate this choice of dressing. If curasalt was not tolerated our other choices would include the use of topical creams such as flamazine or wound aid and the use of a foam as these are non-adherent and often more comfortable. The amount of offensive exudate for this patient was an important factor to consider when choosing appropriate wound dressings and her exudate was large. As such, she required regular reinforcing throughout the day. At one stage she received twice daily dressings and this did continue for some time.
Due to the amount of exudate and this patient’s age, we considered the use of nutritional supplements such as Arginard and multivitamins to improve her overall capacity for healing.
With the use of light compression tubigrip then Coban light, the exudate decreased. Mrs.Y required much encouragement and support to tolerate this important factor in her care. External compression is vital in treating patients with venous ulcers to control oedema and reduce swelling by assisting in venous return. Many patients find it difficult to apply these garments and specific applicators are available to enable the application to be as easy as possible.
Mrs. Y had some set backs with recurrent infections and this did extend the time overall it took for her wounds to heal. This is a major factor in the care of patients with leg ulcers and often one of the most challenging issues that must be constantly addressed and evaluated regularly.
The inflammatory margins did subside eventually. This is often the cycle we see followed by pain reduction. This is a sign that the wound is usually ready to contract and active healing taking place. She made very pleasing progress from then on.
On discharge, our wound clinic provided this patient with education on how to maintain skin integrity. She was provided with information regarding the continued use of compression stockings and awareness of any signs of potential skin breakdown. She was encouraged to contact us if she had any concerns.
It was a long and often frustrating process for Mrs. Y and the team and finally, we had her healed after six months of intensive attention and care from all those who were involved in her care. We learnt how prolonged treatment and support was required to achieve total wound closure of an elderly lady with chronic venous ulcers. She had 40 treatments in the hyperbaric chamber and 47 visits to the outpatient clinic and the results were very rewarding for us all.