So bandaging properly!

Proper and proper compression therapy is crucial for the successful treatment of venous leg ulcers (UCV). For this purpose, the suppliers need to be well accepted when dealing with materials and patients. This article explains which methods and products are available today and how to apply them professionally.

Compression therapy is divided into three phases. During the initial decongestion phase, edema reduction and healing of venous leg ulcers (UCV) should be followed by vigorous compression. This phase should be completed after three to four weeks [1]. This is followed by the maintenance phase: the condition is stable. The edema is blocked and ulcer healing progresses. Successful decongestion can be demonstrated by weekly measurements of forefoot, ankle and calf circumference. If there is no decongestion, this can u. a. in an inefficient compression supply, but also on a nonexistent or only very limited function of the venous pumps, in particular the ankle and calf muscle pump, lie [2]. After healing of the UCV, relapse prophylaxis begins. For this purpose, medical compression stockings (MKS) have to be worn by the patient, usually for a lifetime (Fig. 4)..

Initial decongestion phase

In the first phase of compression therapy, the leg circumference decreases rapidly with proper use. Therefore, materials are used, which can be individually adapted to the reduction in size. These include u. a. Short-stretch bandages, multi-component or adaptive compression systems [2, 3]. Short-stretch bandages have a low elongation capacity of less than 100% and are therefore relatively inelastic. They provide high working and low resting pressure and are used by mobile patients. The full effect of the compression therapy is achieved only in conjunction with active movement.

Short-stretch bandages should not only be changed daily for hygienic reasons, because they give way quickly, slip and lose their shape after only a few hours. In addition, the system pressure decreases due to edema reduction. Therefore, the bandaging in the initial decongestion phase is usually renewed daily [2, 3].

Important: To assist healing, short-stretch bandages in the initial decongestion phase are to be worn continuously for 24 hours. Does the patient without bandaging around, z. B. in the morning after getting up, the previous Entstauungserfolg is lost.

Multi-component systems consist of two, three or four components, eg. As padding, compression and cohesive Fixierbinden that are ready made available. They are easier to use than short-stretch bandages, as their use requires no complex investment technique. By u. a. Optical markings make it easier for some systems to estimate the generated system pressure. Fig. 1
shows the installation of a multi-component system with pressure indicator. Depending on the decongestion situation, these products can keep the system pressure constant for a relatively long time and therefore remain up to seven days [3, 4]. Studies point to the superiority of these systems over bandages with short-stretch bandages [5].

Tip: So-called "Lite"-According to the manufacturer, multicomponent systems are suitable for patients with arterial circulatory disorders – without critical ischaemia – whose ankle-brachial pressure index (KADI / ABPI) is between 0.6 and 0.8.

Adaptive compression systems, also known as Velcro or wrap dressings or bandages, are a new development as an alternative to traditional bandage bandages. The system pressure is segmentally adjusted by several Velcro fasteners. In Germany currently only one product (JuxtaCures®, medi) is available. The system pressure can be controlled by visual markings using a measuring disk and readjusted when the leg circumference changes (Figs. 2 and 3) [3, 6].

Tip: Adaptive compression systems may provide relatives or patients with guidance as needed.

maintenance phase

In this phase, the edema is blocked and a stable healing process has begun. Therefore, materials are used which ensure the required system pressure and enable the supply of the ulcer.

Ulcer stocking systems consist of two components (Fig. 5). An underwear with a low contact pressure protects and fixes the wound dressing. This remains overnight on the lower leg. A medical compression stocking, which is pulled over before getting up, creates the required compression pressure during the day. Ulcer stocking systems have proven to be superior to bandages for the treatment of UCV [2, 3, 5].

Tip: Ulkus-Stocking systems are after appropriate training, if necessary, by the relatives or sufferers on and off. In addition, they allow better mobility in the ankle.

relapse prevention

The UCV is now healed. To prevent recurrences, medical compression stockings (MCS) are used for the long-term and long-term treatment of venous diseases. They generate a constant contact pressure, do not slip and do not wear uncomfortably. This increases patient acceptance compared to a bandage compression bandage.

Depending on the indication, FMDs in various compression classes are available as finished products or custom-made, eg. B. as a stocking or tights offered. MKS are to be adapted to anatomical conditions and circumference differences, eg. B. by sewn pressure pad (so-called pads) or by a flat knitting [2, 3].

Tip: Dressing and extension aids, in particular, make it easier for patients with limited mobility to handle the MCS, since they minimize movement and effort. At the same time they protect the stocking material. There are models for open and closed systems. There is also a distinction between glides, frames and special shapes. Dressing and removal aids, like MKS, have an approval for auxiliaries and must be ordered separately on a prescription [2, 3].

Prescription-relevant indications for dressing and undressing aids are paralysis, age-related impairments of strength, arthrosis / rheumatism, obesity via magna, extensive spinal column, hip and knee stiffening, degenerative diseases of the hands or in the hand area, consequences of injuries or amputations.

According to the study, the phlebological compression bandage (PKV) is to be applied with a high pressure of 40-60 mmHg [7]. Multi-component systems are already designed by the manufacturers to obtain such a pressure. Using short-stretch bandages depends on the user’s experience and manual skills as to whether and how long PKV will produce the therapeutically relevant pressure.

Tip: Special measuring devices, eg B. Kikuhime®, PicoPress®, can be used to control equipment and to train adequate compression bandaging (Figure 6).

Deficits in the supply

In a practical test, which took place within the scope of advanced training in compression therapy, the pressure values were recorded which participants generated with short-stretch bandages, including underpadding. The values were between 6 and 143 mmHg. Of the 551 participants, not even one in ten met the requirement to reach a pressure value in the range of 50 to 60 mmHg. At 77%, the vast majority was below it [8]. Other aspects also show deficits in the reality of care. For example, up to 61% of patients with active UCV are not receiving compression therapy [9, 10]. In a survey of 891 providers, only 12% of participants had learned to cushion compression bandaging [8].

Pitfalls in bandaging

Any improperly performed compression bandaging involves the risk of constriction, blistering, pressure ulcerations, and nerve damage (Figure 7). Therefore, it should be padded and anatomical irregularities should be padded [2, 3]. There are also knowledge gaps with regard to the compression materials and the individual phases of decongestion. Neither multi-component systems nor ulcer stocking systems were known at 85% of the majority of suppliers, although these products have existed in Germany since 2000 and their efficacy has been described in studies and guidelines [8]. In a nationwide study, 71 patients with UCV reported that they had been treated with compression bandages for an average of 41 weeks [10]. These data underline the supply problems in Germany.

Conclusion

New scientific insights can not be transferred to the reality of care if users can not apply efficient compression bandaging in their daily practice. The survey of suppliers indicates that long-available information about established products and methods of compression therapy is not widely available. In daily practice, probably the fewest compression bandages are currently performed properly (Fig. 8).

Tip: Further information can be found on the homepage of Wundzentrum Hamburg e. V. (www.wundzentrum-hamburg.de). There, interested parties can also download a care standard for compression therapy as well as a patient and family brochure as a PDF document [11].

Conflicts of interest: Kerstin Protz has received fees for consultations and / or lectures from the following companies: 3M Medica, BSN medical, Paul Hartmann AG, sanafactur, Lohmann&Rauscher, URGO, Smith&Nephew, medi, Bauerfein, Bösl Medizintechnik

Published in: The GP, 2017; 39 (7) pages 36-41

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