If the patient's lower extremity complaints and diagnostic tests are determined to be unrelated to venous disease (CEAP 0), the clinician is guided to provide education promoting leg health. These patients should be reassessed at least annually to identify any new or worsening problems with the legs; reassessment may be integrated with a general physical examination.
When assessment reveals CVI, the clinician is directed to determine the clinical CEAP level.45,46 Patients with no current or past wound are classified as clinical CEAP 1-4. Those with healed wounds are clinical CEAP 5 and those with an active wound are classified as clinical CEAP 6.
For patients classified as clinical CEAP 1-2, treatment is based on presence and severity of symptoms. The clinician must first determine the need for compression. If compression is not needed, the clinician is guided to provide education promoting leg health from an expanded list. When compression is needed, the clinician must take into consideration individual patient characteristics, such as dexterity, mobility, preference, pain level cost, caregiver resources, and size and shape of the leg, and is assisted in their decision-making process by the provision of 4 tables.
For patient classified as clinical CEAP 3-4, treatment is based on results of ABI (ABPI) measurement. If the ABI/ABPI is <0.5 (indicating clinically relevant ischemia from arterial disease) or >1.3 (indicating possible arterial disease with noncompressible vessels) compression should not be applied.47 Instead, the clinician should educate patient and caregiver on leg health and consider referral for evaluation and management of significant arterial disease and pharmacotherapy in selected cases. Periodic patient reassessment of the lower extremities should occur on a regular basis (at least every 6 months).
Patients with an ABI/ABPI of 0.5 to 0.8, indicating mixed venous and arterial disease, may be managed by modified light compression/support up to 30 mmHg, depending on the individual's tolerance.2,8 If the patient's ABI/ABPI is 0.8 to 1.3, a higher level of compression is indicated. Standardized methods based on the manufacturer's recommendations should be used when measuring for compression stockings or devices. Patient education regarding compression stockings/devices should be provided in addition to information about leg health and pharmacotherapy when indicated. A previous history of DVT also influences the desired level of compression.2 When dermatitis or eczema is observed, treatment with topical steroids is indicated, long with referral to a dermatologist if treatment is ineffective.29 The algorithm also guides the clinician to consider referral to a specialist for further testing and intervention if indicated. Periodic patient reassessment is recommended at least every 6 months to identify any new problems with the legs and to evaluate status of ongoing compression therapy.
Clinical CEAP 5 is characterized by a patient who has experienced a VLU that has now healed. Compression continues to be a mainstay of treatment for all patients with clinical CEAP 5 CVI. As with clinical CEAP 3-4, ABI/ABPI is used to determine the level of compression. If the person's ABI/ABPI is less than 0.5 or more than 1.3, further evaluation is required before compression is considered.47 The clinician should educate the patient and the caregiver on leg health including pharmaceuticals if applicable. An ABI/ABPI of 0.5 to 0.8 indicates mixed venous and arterial disease; these persons may require modified light compression/support up to 30 mmHg, based on patient tolerance.2,8 For patients whose ABI (ABPI) is 0.8 to 1.3, higher compression is indicated. When selecting the type and level of compression, the same considerations must be given to individual patient characteristics as those described earlier. Standardized methods based on the manufacturer's recommendations should be used when measuring for compression stockings or devices. If dermatitis/eczema is present, treatment with topical steroids is indicated with referral to a dermatologist if treatment is ineffective. Patient education regarding compression stockings/devices should be provided in addition to information about leg health and pharmacotherapy when indicated. The clinician is guided to consider referral to the specialist for further testing and intervention if indicated. Periodic patient reassessment of the lower extremities should occur at least every 6 months.
Individuals with a current VLU are classified as clinical CEAP 6. Topical treatment of the ulcer is the primary consideration beginning with wound bed preparation. The 3 components of wound bed preparation are debridement of nonviable tissue, recognition and treatment of wound infection, and moisture balance management within the wound. Moisture balance management is critical with exudative wounds such as VLUs to promote healing and prevent periwound moisture-associated skin damage. There are a variety of dressing categories that are absorbent (eg, hydrocolloids, alginates, gelling fibers, foams, superabsorbents) which will wick the VLU exudate from the wound and periwound area.48 However, managing periwound moisture-associated skin damage is a balancing act; avoiding both excessive dryness seen with venous stasis dermatitis, and excessive moisture in the wound and periwound skin can be challenging. In addition, a nonsensitizing emollient should be used under compression to prevent dermatitis.29 Topical steroids may be used to treat dermatitis; referral to a dermatologist if treatment proves ineffective within a period of 2 to 4 weeks.
When clinical findings indicate CVI, a reference table with photos is available to assist the user in determining the clinical CEAP level. Photographs are included to aid in rapid and accurate assessment.
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