Hard-to-heal venous stasis ulcer

[RachRN11]

Hi all,

I have a patient who has been struggling with hard-to-heal venous stasis ulcers for years now. She has very fragile skin and for some reason the compression wraps cause her skin to tear and new ulcers to form (this comes from the patient and the past wound nurse). Skin grafts have been attempted on her but they got infected. She's had multiple debridements done as well. Insurance won't cover hyperbarics since she's not diabetic (patient's words). She seems to have a sensitivity/allergy to silver products. It causes her wound to burn/sting and bleed. Right now the current treatment is a whirlpool for 20 minutes three times a week, contact layer, hydrofera blue, aquacel foam, kerlix wrapped around. Recently each time she has come in there has been moderate-large amount of drainage on her dressing. I came on as a new WOCN since the old wound nurse quit so I'm not completely sure what all has been tried except the patient says that they have tried everything under the sun. It's gotten to the point where the vascular surgeon following her stated that he "doesn't know what else to do" and "we may just have to deal with these things forever"

The troublemaker ulcer is on her right lateral maleolus and it's currently measuring 11cm x 11cm and covered with yellow slough. Moderate-large amounts of serousanguinous tanish drainage comes off and she occasionally has bleeding. The wound bed is tender, the wound edges are jagged with a reddish/purplish hue. There is no odor or bogginess to the wound or periwound skin. She has the hemosideran staining and the "upside down champagne bottle" look that comes with venous disease. She states she keeps her feet up as much as possible although I think she could do better. She once told me that at one point when she was in the hospital she was in bed 24/7 and her legs healed up but once she started walking again, new blisters formed and thus new ulcers.

Can you think of anything else I can try?

Thanks!

[mommy.19, MSN, RN, APRN]

This sounds like a textbook case of pyoderma gangrenosum. The wound bed description, the violaceous colored wound margin, the pathergy (new wounds developing with tissue trauma from compression wraps). The only way to diagnose this is with a tissue biopsy. The general treatment is intralesional steroid injections and topical wound steroid treatment. Please get this patient to a wound specialist physician.

[mommy.19, MSN, RN, APRN]

I would also stop the whirlpool immediately, this is no longer an evidence based practice wound therapy, it can cause too high PSI to the wound bed, delaying healing even further, and also risking further infection. This patient should also be worked up for deep tissue or bone inflection due to the proximity of the wound to the malleolus, I would definitely look up a CWS or CWSP in your area--- http://www.abwm.org

[Kooky Korky, BSN, RN]

This probably won't help much but here goes. My Auntie had venous stasis ulcers for years and years. She was treated with painful debridements, unna boots, blood being put onto the ulcers to try to grow scabs (there is surely a professional, technical word for this, sorry I don't know it), ace wraps, and being told to elevate her legs. Nothing really helped much or for very long.

She later developed ovarian cancer. She was bedridden for a few months before her death. Somehow, the stasis ulcers closed while she was bedridden. Imagine such a thing. Her body was being eaten up by cancer, she was barely eating, she was getting chemotherapy (paclitaxel and dobirubicin? I wonder if these played any role in healing ulcers.) but the ulcers healed. Why? I think because she was finally off her feet long enough.

I am not recommending cancer, just relating this story that shows, I think, the importance of being off of one's feet to decrease venous stasis.

If your pt isn't already seeing a wound specialist, she needs to. Good luck.