Current Insights On Managing Lower Extremity Wounds With Edema

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CPT Code Update For Compression Dressings

Wound care practitioners have been using multi-layer compression bandages for decades. Dr. Suzuki notes the introduction of a new Category I CPT code for the application of multi-layer compression bandages that are commercially available.

   The CPT code 29581 is for “Application of multi-layer venous wound compression system, below the knee” and became effective on January 1, 2010. If one is applying one of these multi-layer compression bandages on both legs, Dr. Suzuki suggests modifying the CPT 29581 with -50 to indicate bilateral placement.

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Edema is a major impediment to proper and timely wound healing. Accordingly, our expert panelists discuss how to work up and manage lower extremity wounds with edema, and share their insights on effective compression bandages.

Q:

What is the basic assessment and workup that you do with patients with leg edema?

A:

Kazu Suzuki, DPM, CWS, says clinicians often cannot pinpoint a single cause for edema as there are many possible factors. Both he and Kathleen Satterfield, DPM, believe problems with the heart (congestive heart failure), kidney (end-stage renal disease), liver (hepatitis), varicose veins (i.e. venous insufficiencies), malignancy or congenital or acquired lymphedema can all be possible sources of lower extremity edema.

   Due to the variety of possible etiologies for edema, Dr. Satterfield will perform a thorough medical workup in addition to her standard podiatric workup. She says the clinical exam will catch the venous stasis aspect of the disease. Dr. Suzuki’s edema workup also consists of a basic medical history and physical. He documents pitting or non-pitting as well as the amount of pitting (+1 degree for every 5 mm depression).

   In his workup, Eric Lullove, DPM, includes a vascular exam, specifically for venous reflux. He will perform a venous reflux ultrasound if the patient has not received one in the previous three months. Dr. Lullove will also evaluate skin integrity and perform assessments for gait/walking and dexterity. Bilateral circumferential measurements of the foot, ankle, high calf and thigh are also part of Dr. Lullove’s exam. He will also determine the patient’s exercise, elevation of lower limbs and compression failures in the four weeks before presentation.

   Dr. Satterfield’s exam is mostly hands-on. She will also use a Doppler but notes that with a severe case of lymphedema, the Doppler can be futile since the density of the tissues will not allow the reflected sound waves to move freely through the huge mass of fluid-filled muscle and fat.

   Dr. Suzuki’s wound care center uses the Sensilase (Vasamed) laser Doppler to obtain the skin perfusion pressure (SPP) and pulse volume recordings (PVRs) to rule out leg ischemia at the initial visit prior to debriding the wounds and applying compression bandages. He cites the importance of assessing arterial perfusion in order to avoid compression of ischemic legs.

Q:

How do you treat or control the wounds with leg edema?

A:

Dr. Satterfield emphasizes that one must first and foremost control the edema in order to help facilitate wound healing. For Dr. Suzuki, treatment begins with medical management and he will communicate and collaborate with primary care physicians, cardiologists and nephrologists. Since leg wounds will not heal if the edema is uncontrolled, he advises adding or increasing diuretics, even temporarily, to eliminate the excess water that the patient is retaining.

    “I also give a face-to-face educational lecture to the patient, telling (him or her) about reading the food label to minimize the sodium intake and removing the salt shaker from the table,” says Dr. Suzuki. “Also, I do a quick ‘show and tell’ by drawing a small wound on a balloon, inflating and deflating the balloon, to show how detrimental the leg edema can be for the wound healing.”

   Following treatment for medical problems, one should choose among various methods of leg compressions that are acceptable for the particular patient, suggests Dr. Suzuki.

   When it comes to these compression methods, Dr. Lullove primarily employs compression bandaging to manage wounds with leg edema. He prefers to use short-stretch multilayer compression, such as Coban 2 or Coban 2 Lite (3M), with the appropriate wound contact layer to control drainage, infection, etc.

   Dr. Satterfield will prescribe manual lymphatic drainage (MLD), which was offered through her physical therapy department by a specially trained therapist, and combine that with Profore (Smith and Nephew).

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