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INTRODUCTION

Edema in the interstitial tissue around any wound, regardless of etiology, inhibits the healing process by trapping necrotic cells and debris and thereby preventing access of red blood cells to the injured tissue, which in turn decreases the supply of oxygen and nutrients needed for the wound to heal. Management of the edema around a wound depends on the etiology, the location, and the arterial perfusion of the periwound tissue. Determining the etiology of the edema requires a medical and pharmacologic history, surgical history (including type and access points), and joint range of motion and muscle strength in the involved extremities. In addition, evaluation of any lower extremity with edema includes a comprehensive vascular assessment. This chapter discusses wounds caused by or associated with edema, primarily in the lower extremities.

CHRONIC VENOUS INSUFFICIENCY (CVI)

FIGURE 3-1

Algorithm for determining the cause of edema and deciding what to compress.

Compression selection begins with a definitive diagnosis of the edema pathology. If the patient has bilateral lower extremity edema, systemic disorders such as congestive heart failure, kidney failure, or liver disease must be ruled out, in addition to carefully reviewing the medications. If the patient has acute congestive heart failure, compression may need to be deferred until the patient is diuresed and there is no risk of over-loading the heart. Any systemic issue must be addressed in order for local treatment to be effective.

If the edema extends above the knee, there is probably secondary lymphedema which would be treated with manual lymphatic drainage, exercise, and compression applied from toe to upper thigh, preferably by a certified lymphedema specialist. If the edema is limited to below the knee, the next step is to evaluate the vascular status to determine the type of material and the amount of compression that is best for the individual patient. (Used with permission from Rose Hamm)

FIGURE 3-2

Algorithm for selection of appropriate compression therapy.

Selection of the appropriate compression therapy is based on the vascular examination, as well as patient comfort and tolerance. Every garment, compression system, elastic or non-elastic wrap has a tension that determines the amount of pressure when properly applied. Manufacturer’s guidelines should be followed carefully to avoid complications that can occur with inappropriate compression therapy. Compression of any type is generally contraindicated if the ABI is less than 0.5; however, if the patient can tolerate multiple layers of soft gauze wrapping, it may be beneficial in activating the lymphatics as well as anchoring the appropriate primary dressing. Any compression is best applied by a trained professional until the wound is closed and the patient is ready to transition to compression stockings.

Many lower extremity wounds with edema are caused by chronic venous insufficiency (CVI); however, ...

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