A Guide To Compression Dressings For Venous Ulcers
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.