Escolar Documentos
Profissional Documentos
Cultura Documentos
Jessie Stewart
Morning Report
July 09
Vasodilatory Edema
• Biggest culprit drugs are arteriolar smooth
muscle relaxers.
• Minoxidil (7%): opens K channels, preventing
smooth muscle contraction.
• Hydralazine (?%): prevents Ca accumulation,
may protect nitric oxide.
CCB also guilty
• Amlodipine (2-15%, dose related). Blocks
calcium transport.
http://www.icvein.com/images/signs-of-venous-insufficiency-iowa.jpg
Venous Stasis Dermatitis
http://www.dukehealth.mobi/Services/VeinClinic/About/WhatIsVenousDisease
Stasis Eczema
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Corona Phlebectasica
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Lipodermatosclerosis (LDS)
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962006000600002&tlng=en&lng=en&nrm=iso
Venous Ulcer
•Medial Malleolus
•Shallow
•Irregular borders
•Base with granulation tissue
•Surrounding white scar (atrophie blanche)
•Surrounding hemosiderin deposition
•Surrounding Edema
•80% of LE ulcers
•$40,000
http://www.worldwidewounds.com/1997/september/Thomas-
Bandaging/bandage-paper.html
Evaluation
• VI (valvular incompetence, dilated veins)
evaluated by duplex ultrasonograhy.
• AI evaluated by ABI
• Check rest and stress
• 0.9 adequate
• <0.5 severe
• Compressive tx not helpful
http://www.vascularweb.org/graphics/northpoint_graphics_jpg/AortoOccl_03_250_darker.jpg
Duplex ultrasonography
http://www.urgomedical.com/uploaded-files/img/images/schema-ceap-02.jpg
CEAP
• A patient has painful swelling of the leg, and varicose veins,
lipodermatosclerosis, and active ulceration. Duplex
scanning on May 17, 2004, showed axial reflux of the great
saphenous vein above and below the knee, incompetent
calf perforator veins, and axial reflux in the femoral and
popliteal veins. There are no signs of postthrombotic
obstruction.
Revision of the CEAP classification for chronic venous disorders: Consensus statement.
Journal of Vascular Surgery Volume 40, Issue 6, December 2004, Pages 1248-1252.
Treatment
• Compression is the cornerstone of treatment.
• At least 40mmHg at the ankle is the goal.
• Range of 10-60mmHg (TED hose 18mmHg)
• Knee-High as good as Thigh-High.
• Open or closed toe per pt preference.
• Either graduated stockings and wraps
• Caution with CHF, invasive infection, arterial
insufficiency.
• Compliance very difficult.
• Replace every 6 months.
• Size S, M, L, XL based on ankle, calf circum.
Compression Therapy is Key!
Unna
Jobst $6
$60
Compression Plus…
• Leg Elevation. Above heart-level for 30
minutes 3 times per day.
• Diuretics. May help but can’t do much alone.
• Pentoxifylline. May improve oxygen delivery,
inhibit WBC activation. Shown to accelerate
ulcer healing. 400-800mg tid.
• Aspirin may help some.
Surgical Treatment
• UNC Vascular Surgery
– Wound Healing Clinic
– Vein Center
William Marston, MD
Grand Rounds
2/19/09
Other References
• Managing the Patient with Venous Ulcers. Tami de Araujo, MD; Isabel Valencia, MD; Daniel G.
Federman, MD; and Robert S. Kirsner, MD. 18 February 2003 | Volume 138 Issue 4 | Pages
326-334
• State-of-the-Art Treatment of Chronic Venous Disease. Michael S. Weingarten. Clinical
Infectious Diseases, Vol. 32, No. 6 (Mar. 15, 2001), pp. 949-954
• Jull AB, Waters J, Arroll B. Pentoxifylline for treating venous leg ulcers. Cochrane Database
Syst Rev. 2002.
• Wiersema-Bryant LA. Management of edema. In: Sussman C, Bates-Jensen BM, eds. Wound
Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, MD:
Aspen; 1998:179-200.