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 doc. 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) Autolytic debridement lthe most often used method lsemi-occlusive dressings – film dressings - hydrocolloids - hydrogels lcreate a moist wound-dressing interface which enhances the activity of endogenous proteolytic enzymes within the wound lseparation of necrotic tissue from healthy tissue Autolytic debridement ladvantage : - selective l - painless l ldisadvantage : - slow l - maceration l - odour Enzymatic debridement lhighly selective lenzymatic agents derived from proteolytic enzymes extracted from bovine plasma or pancreas, fruit and plants such as papain from papaya or bromelain from pineapple lor bacterial collagenase derived from Clostridium histolyticum Enzymatic debridement lIruxol mono - bacterial collagenase derived from Clostridium histolyticum ( tzv. clostridiopeptidasis) lcleaves triple helix of collagen lselective debridement of necrotic tissue lpainless lminimal risk of bleeding l Biosurgical debridement llarval therapy (Maggot) lfast and very effective method lapplication of sterile fly larvae (Lucilia sericata) to the wound ldressing change in 2-4 days Biosurgical debridement lcomplex mechanism of action lmechanic movement of larvae lproduction of proteolytic enzymes (collagenase, trypsin) and bactericid substances lingestion of bacteria ldecrease of pH of the wound – inhibitory effect on bacterial growth Mechanical debridement lmechanical removement of necrotic tissue ldisadvantage –pain, traumatisation of healthy tissue l advantage –quick method lsharp debridement ldebridement wet-to-dry – gause – painful Hydrosurgical debridement lVersajet lpressurised water or saline lthe pressure is controlled via a handset lthe jet of fluid both cut and removes tissue while irrigating the wound ladvantage: quick ldisadvantage: - expenssive l - painful 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 Silver lInternational consensus - 2012 l„Appropriate use of silver dressings in wounds lwww.woundsinternational.com lEffectivity, safety, cost-effectiveness Iodine dressings la broad antimicrobial spectrum: lG+, G- bacteria, viruses, fungi lresistence – 0 liodine is slowly released to the wound l2 forms: cadexomer iodine l povidone iodine Iodine dressings lcontraindication: l - known sensitivity to iodine l - thyroid disease ldo not exceed 3 months continuous use – risk of systemic absorption lavailable in various forms: l - ointment l - paste l - flat sheets l IMG_0557 Chlorhexidin dressings la broad antimicrobial spectrum: lG+, G- bacteria, viruses, fungi lresistence can occur IMG_0553 Honey dressings lfirst used in ancient Egypt - 4000 years ago lmedical-grade honey dressings developed in the late 1990s la broad antimicrobial spectrum, including MRSA and VRE lthe ability of honey to produce low levels of hydrogen peroxide in the wound lthe provision of an acidic wound environment (pH 3) l Honey dressings lreduce wound odour lpromote autolytic debridement lavailable in various formulations: lflat sheets lpaste lointment l Honey dressings lContraindication: lpatients with known allergy to bee stings lhighly exudating wound – risk of maceration lmay cause stinging sensation Polihexanid lPolyhexamethylene biguanide (PHMB) la broad antimicrobial spectrum, including MRSA lused in healthcare and cosmetics for many years lno reports of bacterial resistance to date lno allergy Polihexanid lwell tolerated lcontraindication: l - pregnancy – first 4 months l - dry wounds l lProntosan – PHMB + betain l 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 Hydrogels lamorphous gels lflat sheets - gel compresses (hydrogel + polyurethan layer) la high water content (30-90%) lrehydrates dry tissue lpromote autolytic debridement lhave a cooling effect lare easily removed lare comfortable and flexible l Hydrogels lmay cause eczema or irritation lthey need secondary dressing lmay be combined with: l - silver l - hyaluronic acid Snímek 261 Hydrofibers lnonadherent dressings lability to absorb high levels of wound exudate lcomposed of sodium carboxymethylcellulose lform non-adherent gel in exuding wounds lcreate a moist wound-dressing interface Hydrofibers lpromote autolytic debridement lavailable in varius formulations: l - flat sheets l - packing rope for cavities l - combined with silver – antimicrobial activity l lcontraindication: dry wounds Polyurethane foam dressings lsemipermeable llow adherent, soft, highly absorbent louter semipermeable membrane – allows fluid to pass into the insulating fom lwaterproof lgas/water vapour permeable limpermeable to bacteria lcreate a moist wound-dressing interface Polyurethane foam dressings lavailable in various formulations: ladhesive/non-adhesive lshaped cavity devices for cavity wounds lshaped sacral or heel dressings lthin lcombined with silver or PHMB – antimicrobial activity lcombined with charcoal – reduce odour l lcontraindication: dry wounds Polyurethane foam dressings IMG_0649 Silicone dressings lsilicone – inert material latraumatic dressings l painless dressing change l lnon-adherent sheets lpolyurethane foam dressings with silicone Alginate dressings lobtained from seaweed lhigh absorbents lderived from calcium/sodium salts of alginic acid lon contact with wound fluid, sodium salts in the exudate exchange with tha calcium uin the alginate dressing to form a soft gel which maintains a moist environment l Alginate dressings lshould be cut to the shape of the wound lhemostatic properties lmay provide pain relief lavailable in various forms: lflat sheets lpacking rope for cavities lcombined with silver or charcoal l Snímek 265 Charcoal dressings lactive charcoal lreduction of odour labsorption of microorganisms and exudate Snímek 272 TIME – E - epithelization l Obr IMG_0500 IMG_0516 IMG_0503 IMG_0388 IMG_0522 Bioactive dressings lindication: hard-to-heal ulcers l l20% of leg ulcers l l bad prognosis – leg ulcers larger than 10 cm2 and lasting more than 6 months Bioactive dressings lprotease modulating dressings lhyaluronic acid dressings lcollagen dressings lgrowth factors lskin substitutes Matrix metalloproteinases (MMPs) l lgroup of zinc-dependent endopeptidases lproduced by granulocytes, keratinocytes and fibroblasts l lelevated protease activity in chronic wounds ldecreased levels of TIMPs (tissue inhibitors of MMPs) Protease modulating dressings lcomposed of collagen and ORC – oxidised regenerated cellulose lact by absorbing wound fluid and trapping proteases within their structure to render them inactive lform a non-adherent gel which binds with growth factors protecting them from degradation by MMPs l Oxidized celullose IMG_0597 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