Debridement of chronic leg ulcers with Algivon

Jane Parker– Tissue Viability Nurse, Berkshire Healthcare Foundation Trust

Introduction

This case study shows the debridement properties of Advancis Manuka Honey dressing Algivon on a patient with chronic legs ulcers. For the purposes of confidentiality, the patient will be known as Jack.

 

Patient & wound

The patient is a 78 year old gentleman who has a past medical history of varicose veins, cardiac failure, atrial fibrillation, is on warfarin and has recovered from a Cerebral Vascular Accident (CVA). Jack was originally seen on 17th January 2012 with his practice nurse. The nurse had performed a Doppler assessment prior to my visit. Doppler assessments are used to measure the arterial flow in the lower limbs. The values given from this assessment are known as the Ankle Brachial Pressure Index (ABPI). RCN (2006) and SIGN (2010) guidance recommends this be carried out at the initial assessment and this guidance is used as the basis for local policy. There remains debate on the appropriate cut off point of the ABPI for the safe use of compression therapy, although many studies have made suggestions such as Whiston (1996), Scriven et al (1998) and Jones and Nelson (2001). Local policy recommends the following;

i. If ABPI is between 0.8 and 1.25 and sounds are bi or tri-phasic and venous disease is diagnosed as the underlying aetiology, then compression is indicated.

ii. If ABPI is less than 0.8 and venous disease is the underlying aetiology use compression with caution.

iii. If ABPI is less than 0.7 refer patient for vascular assessment.

iv. If ABPI > 1.25 refer patient for vascular assessment.

 

Assessment criteria	Venous disease	Arterial disease
Presenting history, physical and social risk factors	Previous history of DVT Varicose veins Reduced mobility Traumatic injury to the lower leg Obesity Pregnancy Non-healing ulceration Recurrent phlebitis Previous vein surgery	Diabetes Hypertension Smoking Previous history of vascular disease Obesity Inability to elevate limb
Position of ulceration	Gaiter area of the leg Common site is medial aspect	Lateral malleolus and tibial area are common sites as well as toes and feet Over pressure point
Pain	Throbbing, aching, heavy feeling in legs Improves with elevation and rest	Intermittent claudication Can be worse at night and at  rest Improves with dependency
Ulcer characteristics	Shallow with flat margins Often presents with slough at the base with granulation tissue Moderate to heavy exudate	Punched out, occasionally deep Irregular in shape Unhealthy appearance of wound bed Presence of necrotic tissue or fixed slough Low exudate unless ulcers infected
Condition of the lower leg	Haemosiderin staining Thickening and fibrosis Dilated veins at the ankle Crusty, dry, hyperkeratotic skin Eczematous, itchy skin Pedal pulses present Normal capillary refill (less than three seconds) Limb oedema is common	Thin, shiny, dry skin Reduced or no hair on lower leg Skin feels cooler to tough Pallor on leg elevation Absence or weak pedal pulses Delayed capillary refill (greater than three seconds) Development of gangrene

Table 1 (adapted from Newton H, 2011)

 

The doppler assessment should not be used in isolation, but as part of a holistic assessment. The PN was using compression bandaging, as she said the ABPI was within normal limits. However, on further discussion I discovered the pulses were monophasic. The presence of a monophasic pulse in the arteries of the lower limb provides evidence of the presence of distal arterial disease (Donnelly et al, 2000) as this suggests a greatly increased velocity through tighter stenoses. From my assessment of his lower limbs, I ascertained that he had a non-healing ulcer to his right leg only, with a dark wound bed, moderate exudate levels, oedema, haemosiderin staining  thickened toe nails and hairless legs with pain on elevation, which suggested to me there was an arterial element to the leg ulcers (see table 1). I therefore advised her to discontinue the compression, use an exudate manager under retention bandages and request a vascular referral. I also suggested his dressings were changed three times weekly instead of twice. The PN was advised to contact the Tissue Viability team if any further input was required.

No further contact was made until Jack was admitted to the local community hospital for rehabilitation on 9th March 2012, following an admission to the acute sector with abnormal warfarin levels. He was also diagnosed with Leucocytoclastic Vasculitis during his acute admission. Due to his stay in the acute sector he unfortunately missed his vascular appointment, which was in a neighbouring trust. At his initial assessment in the community hospital, he had gross oedema reaching his abdomen with bilateral leg ulcers that were sloughy with the tendons exposed. The exudate levels were high with peri-wound maceration and hyperkeratosis.

 

Photo 1 Right leg

 

Photo 1 a Left leg

 

Photo 2 Right leg

 

Photo 2a Left leg

 

Photo 1 and 1a were taken on 6th March 2012 in the acute setting, where they had commenced treatment with Advancis Manuka Honey products (permission/consent has been sought to use the photographs).

Photo 2 and 2a were taken at admission to the community hospital on 5th April 2012.

Putting the principles of Wound Bed Preparation (Shultz et al, 2003) into practice, the aim was to debride the slough and necrosis, control the exudate and decrease the bacterial burden as this is known to delay healing (White and Cutting, 2006, White et al, 2006). As Jack was not showing signs of systemic infection, this supported the use of antimicrobials over antibiotics (Wounds, 2010). Lipsky and Hoey (2009) felt one of the advantages of using antimicrobials could be a reduction of the development of antibiotic resistant bacteria such as MRSA. The use of honey in wound care is well established and Manuka honey has proven effective in treating infected wounds, including MRSA (Cooper, et al 2011).

The management plan for Jack was as follows;

• Washing the legs at least on a weekly basis with an emollient/antimicrobial soap substitute on the intact skin or cleansing the ulcers with warm normal saline as required at each dressing change. The skin was then dried and creamed with an emollient ointment.
• Algivon was applied to the sloughy/necrotic areas as a primary dressing, with an exudate
  manager as a secondary dressing, held in place with soft wool and a retention bandage, secured with an elasticated tubular bandage.
• Initially the dressings were changed daily due to the high levels of exudate, then reduced to alternate days as the exudate levels improved.
• Jack was commenced on 80mg Frusemide daily and his analgesia increased.
• His vasculitis had been treated with oral steroids and appeared to be under control.
• The ward sister took the lead in the dressing changes, with a small number of staff nurses and a senior healthcare assistant, to ensure continuity of care.
• He was encouraged to mobilise with daily input from the physiotherapy team and his nutritional intake improved.

Jack was seen by the vascular team on 12th April 2012, who recommended he return at a later date for sharp debridement. The use of larvae therapy was discussed with Jack both by myself and the consultant, but Jack was not keen to go ahead.

Photos 3 and 3a were taken on 26th April, prior to Jack’s discharge home from the community hospital.

The ulcers continue to heal under the care of the community nursing team, using exudate
managers under retention bandages, changed on alternate days. They have had to introduce honey for short periods of two weeks at a time to combat any bacterial burden. The oedema has almost resolved (as you can see from the reduction in size of the limbs). He was seen by the vascular team for follow up on 24th May 2012, whom were very pleased with his progress and discharged him. Jack was discharged from Tissue Viability on 8th June 2012 the ulcers had completely debrided, were granulating and reducing in size. He continues to be seen by the community nursing team.

 

Clinical Objectives

• Debridement
• Exudate management
• Antimicrobial activity
• Skincare
• Oedema reduction
• Pain control
• Odour control

 

Challenges in wound management

• Gross oedema
• Exudate levels
• Bacterial bioburden
• Vasculitis
• Medical condition/history

 

Benefits

Algivon debrided the ulcers, whilst controlling the bacterial burden and odour. The alginate within the dressing helped with the exudate management along with the exudate managers. The dressing did not appear to cause any increase in pain.

 

Conclusion

As part of the holistic management, Algivon exceeded my expectations. Due to the medical history and circulatory issues I was sceptical about achieving any massive improvements in the wounds. I had hoped to debride them at least, but thought Jack may have required more intervention from the vascular team in order to gain any healing. I feel the continuity of the ward staff and the trust Jack had in them and myself had a positive impact on the situation. This case has restored my faith in Manuka honey products.

 

References

Donnelly R, Hinwood D, London NJM (2000) Non-invasive methods of arterial and venous assessment.BMJ. March 11; 320(7236): 698–701.

Lipsky BA, Hoey C (2009) Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis 49(10): 1541–49

Jones J, Nelson EA (2001) Use of compression hosiery in venous leg ulceration. Nurs Stand 16(6): 57-60, 62

Newton H (2011) Leg Ulcers: Differences between venous and arterial. Wound Essential 6:20-26
Royal College of Nursing Guidelines (2006)b The nursing management of patients with venous leg ulcers. London. RCN. Available from: http://www.rcn.org.uk/development/practice/clinicalguidelines/venous_leg_ulcers

Schultz G, Sibbald G, Falanga V, et al (2003)Wound bed preparation: a systematic approach to wound management. WoundRepairRegen11: 1–28

Scottish Intercollegiate Guidelines Network(2010) Management of Chronic Venous Leg Ulcers. SIGN.http://www.sign.ac.uk/guidelines/fulltext/120/index.html

Scriven JM, Taylor LE, Wood AJ, Bell PR, Naylor AR, London NJ (1998) A prospective randomised trial of four-layer versus short stretch compression bandages for the treatment of venous leg ulcers. Ann R CollSurgEngl 80(3): 215–20

Whiston R. Wound care: Principles of Doppler Nurs Times. 1996 May 15-21;92(20):66-70.

White RJ, Cutting KF (2006) Critical colonization — the concept under scrutiny. Ostomy Wound Manage 52(11): 50–6

White RJ, Cutting K, Kingsley A (2006) Topical antimicrobials in the control of wound bioburden. Ostomy Wound Manage 52(8): 26–58

Wounds UK (2010), Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. Wounds UK. Aberdeen 2010. http://www.wounds-uk.com/article.php?contentid=141&articleid=9627&page=1[accessed 18.06.2012]