A medical officer recently asked me to explain my rationale and thought process for prescribing a patient a specific type of compression bandaging regime. I paused a considerable moment to compile my thoughts on how I had come to decide on a fairly specific combination of dressings and bandaging to ensure the patient received safe and effective treatment for their venous insufficiency disease, complicated by mild peripheral arterial disease.
As I attempted to answer the young doctor, it struck me just how complicated and multivariate the decision-making process to prescribe a compression therapy regime was. There was the patient’s pain tolerance to consider, the skill and capability of the community nursing team implementing the regime, the expense of the materials, the efficacy of the compression materials matched to the underlying aetiology, the wound exudate volume, the patient’s mobility, their ankle movement, their frequency of showering and what assistance they had…
It was soon made clear to the doctor and more importantly, myself, that this was a decision-making process that had departed the simple concept of
‘place a 4-layer compression bandage on their leg, coupled with appropriate primary and secondary dressings and we are done’.
There are now more compression bandaging systems and garments on the market than ever before: 4-layer bandaging systems including elastic and inelastic bandaging layers, 2-layer inelastic bandaging, reusable inelastic bandaging systems, modified compression bandaging systems (for peripheral arterial disease), single layer high elastic bandages, flat-knit and round-knit compression stockings, inelastic adjustable compression wraps and lipoedema/lipodermatosclerosis mitigating night garments.
Much like wound dressing materials – it can often be hard for clinicians to navigate through this plethora of products. There are, of course, guidelines out there to support decision making and to provide you with greater knowledge on the functionality of these products (I provide some examples below).
When making a decision about which compression solution is going to be the best for a patient, I personally start with understanding the functionality of a product and matching it to the disease/aetiology/cause of the wound and oedema disorder I am trying to treat. In the example I gave at the start of this blog, the patient had a toe pressure of 54mmHg on the limb I was aiming to treat. The patient had a robust skin profile for their age, with advanced focal lipodermatosclerosis in their gaiter region. The wound was situated just above their medial malleolus, was superficial in depth and moderately exudative. They had confirmed deep venous insufficiency complicated by moderate tibial arterial disease and diabetes. The patient walked with a 4-wheel walking aid and lived at home with some community supports. I elected to treat this patient with a modified compression regime – using a two-layer inelastic compression bandage (known to be safer in PAD patients due to lower resting sub-bandage pressures) which was the lower of the two pressure ratings (Coban 2-lite).
The second rule I follow with compression therapy – is that I always prescribe bandaging for any exuding wound, and then progress to a compression garment once the wound is healed, or decreased in size and exudate that a dressing suitable to tolerate daily donning and doffing of a compression garment is possible.
Beyond these two key rules, I always try and work with the patient to encourage and educate the patient on how the compression is making a difference to what has caused their ulcer and how it will help prevent further ulceration. Getting a patient to buy into compression therapy is often half the battle to getting a wound healed and keeping the patient ulcer free.
Below are links to a couple of resources that have helped me understand the complex world of compression therapy.
I would love to hear your thoughts and ideas on compression therapy and/or links to any other resources your have found useful in your practice!
This is a fantastic guide which provides a top down explanation of compression garment functionality and how it interacts with disease aetiology. It is heavy, but well worth coming back to over and over again.
An older article now (2006) but holds some great basic and core concepts for the application for multilayer compression bandaging systems such as Profore or Veno4
A more up to date overview of compression bandaging therapy (2014)