Venous Stasis Ulcer & RA

[kc319]

I have a pt with a HUGE venous stasis ulcer encompaassing nearly her entire left lower leg. Her co-morbidities: age (83), advanced RA, wheelchair bound, diabetes, HTN, OA, arterial insufficiency. She just completed IV ABX for osteomyelitis in the ulcer, skin is paper-thin, has multiple allergies. She was with another physician and switched when she kept getting worse. Her current doctor insists on using a wound vac, even though the pain level is rated as 15 on scale of 1-10. She has an odor to the wound that will knock your socks off, the wound bed is yellow, (yeast infection) orders to clean w/Accuzyme! Whenever I remove the wound vac, the entire wound bleeds. I would like to use a UNNA boot on her or some type of compression bandage system with zinc oxide and maybe use a Curafoam on the wound bed. Can anyone give me any other ideas for treatment or should I continue to "torture" my pt and use the wound vac?

[RN1989]

Compression is not indicated for someone with arterial insufficiency. It could completely obliterate blood flow causing loss of limb.

Is the pain under adequate control normally whent the pt doesn't have the wound vac on? You need to be sure that it is the wound vac causing the pain before you get rid of it. It is much easier to control the fluid with the wound vac.

If the wound vac IS the pain problem then you still have the issue of getting the ooze under control. You could try antibiotic powder directly on the wound, covered in silver alginate, ABDs, and kerlix.

Sounds like this woman needs to have a wound care doc eval things. If it is a wound care doc writing the orders - perhaps a second opinion would be in order so the lady can get some pain control.

[kc319]

Yes, the pain is controlled w/ wound vac off, increases significantly when on. You're right, I forgot about not using compression w/ arterial insufficiency. A wound care doc would be good, she's just seeing Infectious Disease. I'll talk to her & family about getting 2nd opinion.

[Codypatody, BSN, RN]

Have you tried lowering the pressure on the VAC? Sometimes this helps with painful wounds. Usually the VAC is at 125 mmHg...try lowering it to 75 or 100. If the wound is draining copious amounts, you may have some pooling of drainage. If this happens, you may need to increase it again. Also, sometimes using a layer of adaptic or mepitel can help with pain. I would also suggest switching to the white foam but you may have problems with drainage control...I would first try the adaptic and lowering the pressure. You can also lower the intensity on the VAC. The default is 10. Lower it to 1. This makes the VAC apply the pressure at a slower, gentler pace when you initially turn it on.

Does she have any pain meds on board? If this doesn't help, you may need to get an order for something to take the edge off.

[Tash4nvyblues, RN]

This sounds very similar to a case we had recently, mixed ulcer, diabetic, RA and extremely frail. The 85 year old client was due to have a below knee amputation, the wound was +MRSA, the lady was in extreme pain. Like your person, they had tried the vac and had debrided the wound numerous times. She eventually sought the opinion of a reputable plastic surgeon, of all people. He debrided the wound as far as he could go, with MRSA and all. This surgeon took 20cm by 10cm from the donor site and grafted the wound. That was four weeks ago, this lady does not even need a dressing on the leg any more. When all else fails think outside the square, because when you have a client that has a mixed ulcer, with RA and diabetes, that is all you can do or they will lose their leg. Good luck!

[kc319]

She actually uses Dilaudid for pain control. But with the use of the wound vac, it does not help.