A Guide To Compression Dressings For Venous Ulcers

Author(s): 
Nancy Slone-Rivera, MS, ANP-C, CWON, CFCN, and Stephanie C. Wu, DPM, MSc

Essential Insights On Multi-Layer Bandaging

Multi-layer bandages most often have three or four layers, and are generally a combination of inelastic and elastic bandage, padding, cohesive and crepe layers. In addition to the multiple layers, a combination of spiral and figure eight wrapping techniques results in a bandage that maintains its compression gradient for extended periods of time during both activity and rest.28 Patients with poor calf pump function can benefit from the elastic components while the inelastic components provide high working pressures and can offer lower resting pressures.18 Several multi-layer kits exist that are advertised as “light.” These are two-layer bandages that researchers have shown are safe for use on patients with mild to moderate arterial insufficiency.16,29

   Multi-layer kit components vary. It is wise to review the product insert prior to application. Multi-layer bandages often have higher per unit costs. However, these bandages only need weekly changes and the literature supports improved healing times with four-layer bandages rather than single or lower compression alternatives.14,30

   Unfortunately, these bandages are often bulky and create difficulty with shoe wear.31 This can create resistance to and dissatisfaction with the plan of care. Additionally, several studies have shown that compression bandages may restrict ankle range of motion and gait capacity.21,31 This may place the patient at an increased fall risk and further decrease calf pump function. Despite these possible disadvantages, the European Wound Healing Society recommends multi-layer bandages as first line therapy in both mobile and immobile patients.16

Can Intermittent Pneumatic Compression Therapy Have An Impact?

A recent Cochrane Review by Nelson and colleagues concluded that intermittent pneumatic compression (IPC) may increase healing in comparison to no compression, but the studies have been small and more research is needed.32 Treatment with intermittent pneumatic compression may also shorten the duration of therapy, reduce cost and return the patient to activity sooner.33 In patients who have recalcitrant ulcers, lipodermatosclerosis and calf pump dysfunction, the addition of a sequential pneumatic compression device to compression bandages or stocking therapy may improve healing.

   To qualify, it is often necessary to produce documentation of venous ulcers that are unresponsive to standard treatment for at least six months. Most insurance policies will cover the unit with the appropriate documentation. There is a degree of paperwork (including a letter of necessity) involved. Manufacturers of intermittent pneumatic compression are very helpful with the acquisition, sleeve sizing, home delivery and operating instructions. Patients would use venous pumps for one to two hours a day. These venous pumps have preset and prescribed graduated intermittent compression.

   Anecdotally, we have had success with intermittent pneumatic compression to lessen the recurrence of venous ulceration in morbidly obese patients who are ambulatory, live alone and are unable to don compression garments due to mobility challenges. Collaboration with the patient’s medical team and ensuring a thorough cardiopulmonary assessment prior to initiation are important to ensure cardiac stability and avoid decompensation from an increased preload.34

Key Points To Consider With Compression Stockings

Once venous ulcers heal, one needs to consider the use of maintenance therapy to prevent recurrence. Clinicians should have patients wear some type of daily compression garment or device. Graduated compression stockings are one option and come in knee-high and thigh-high stockings. Slip-on inelastic devices with adjustable Velcro straps are also options.

Comments

As a disclosure, I am VP of Farrow Medical, which manufactures short stretch garments. This is a long comment.

I would like to clarify a point with regard to the definitions herein of inelastic versus short stretch, which I believe, as stated, allow for confusion, even historically, predating 2006.

I don't believe inelastic products are historically considered to be products with 30 to 70% stretch. In fact, Foldi specifically distinguishes between short stretch and inelastic.

Why would they be separated in textbooks and yet be referred to by others as the same or similar?

If a product with less than 15% stretch, as an example, is applied, there are several issues.
1. You are not really sure how much compression is being applied because the amount of compression is directly related to how hard the provider is pulling. Does the provider know how hard he is he is pulling? Does the next person applying know how hard he or she is pulling?
2. Products with this amount of stretch don't work terribly well over joints, such as the anterior ankle, and this can cause ulcerations.
3. True inelastic products are generally reserved in wound centers for patients with a low AB index, and they are applied with very little tension, meaning they are applying little if any significant resting compression. They depend upon a higher working compression to reduce/control edema.
4. If the leg decreases significantly in circumference as a result of higher working compression levels generated, the garment can slide down and the higher working compression advantage would be lost until readjusted.

"Short stretch" products are applied with some stretch and hence, inherent in that stretch is some tension, which translates into ~some~ compression. As the authors appropriately state, this compression level can fall of rather abruptly with time. Short stretch bandages, traditionally, are manufactured of 100% cotton and depend a good degree on the weave of the product to produce the tension and hence compression. So if a product which has some stretch but little sustained elastic compression of its own is applied near its maximal stretch, it would essentially function as inelastic, although if the leg reduced in size, it "might" shrink along with the leg, but also provide a lower working compression level.

If, however, a product with short (limited or low) stretch AND elastic fibers was used, the compression would not fall off as quickly and the performance would be hybridized with other elastic compression garments. By hybridized, I mean provide a steady lower resting compression (like a stocking) AND a higher working compression (more like inelastic).

Why is this important?

In my opinion, with elastic short stretch products ...
1. The short stretch can better cue you in to the amount of tension being applied by feeling the abruptness of the short stretch and hence the tension level.
2. The stretch allows for better functionality over joints.
3. The short stretch generally allows for more consistent low resting compression and higher working compression levels (working like a pump when the patient ambulates when properly applied). (It is sometimes referred to as a poor man's pump.)
4. The product can shrink some if the leg decreases in size, limiting slippage and the need for adjustments.

As a clinical example, in a chair-bound nursing home resident, a truly inelastic product that is properly applied might apply very little resting compression (or if too tight could be a tourniquet). A short stretch product with elastic fibers would apply some sustained resting compression with the potential for higher working compression when properly applied. Long stretch wraps have the potential to produce highest sustained resting compressions, which can be a little more hazardous if not professionally applied, and lower working compressions unless applied with a significant (potentially more dangerous) amount of tension.

Conversely, if a patient had poor arterial circulation, the provider may opt to apply a product that is "inelastic" with very little tension applied because a lower resting compression has a lower potential to block arterial circulation, but still has the potential to provide a higher working compression to help reduce/control edema. Note that this would work best if the calf muscle pump was functional.

One last point. A product that is inelastic applied and just barely snug would apply a low resting compression when vertical, but very little, if any, when lying down. Short stretch would apply more resting compression than inelastic when lying down. Long stretch would generally provide the most compression when lying down (and the least potential for high working compression when vertical). So patients with impaired arterial circulation are generally safer with inelastic, then short stretch products, when they lie down, as opposed to long stretch, IF compression is safe be applied at all depending on the situation.

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