Trip Answers

Question answered:20/02/08

The CKS guideline on venous leg ulcers, last updated this month, states:

 

• “Manage an uncomplicated venous leg ulcer by cleaning with tap water (or saline), dressing with a simple low-adherent dressing, and applying a 4-layer or 2-layer compression bandage.
• Manage an infected venous leg ulcer by first cleaning the wound and taking a swab. Then apply a simple low-adherent dressing and prescribe an empirical course of antibiotics (flucloxicillin). Do not use compression bandaging until the infection has resolved.”

 

And:

 

“How should I clean a venous ulcer?
• Irrigate the ulcer at each dressing change with warm tap water or saline, then dry. A strict aseptic technique is not required.
• Debridement is not usually necessary: any slough, or necrotic, fibrous, or excess granulation tissue should be removed by gentle washing. If debridement is being considered, the procedure should be carried out by a trained healthcare professional.
• Consider using a potassium permanganate 0.01% soak if the ulcer is malodorous.”

 

It adds:

 

• “These recommendations are based on clinical guidelines: The nursing management of patients with venous leg ulcers published by the Royal College of Nursing (RCN) [RCN, 2006], together with the best available trial evidence, informed expert opinion, and current good clinical practice.
• Irrigation:
o The aim is not to remove surface bacteria, but rather to avoid cross-infection from contamination.
o The RCN guideline found no trials comparing aseptic with clean techniques for cleaning leg ulcers. A systematic review (search date May 2001, six randomized controlled trials [RCTs], n = 1864) suggested there was a lack of evidence for or against cleaning leg ulcers versus not cleaning, cleaning with tap water versus cleaning with saline, and cleaning with antiseptics [RCN, 2006].” [1]

 

A guideline produced by Smith & Nephew Ltd in 2006 simply recommends:

 

“Cleansing of the ulcer should be kept simple and take the form of irrigation with warmed tap water or saline.
Best practice is to soak the affected leg(s) in a bucket of warm water lined with a plastic bag. This facilitates the removal of wound debris and de-scaling of dry skin. In clinical practice the use of an emollient, such as Hydromol™ or Oilatum™, may be added to the warm water to help moisturise the leg and facilitate the removal of dry scaly skin. Occasionally Potassium Permanganate may be used.” [2]

 

A 2002 Dutch guideline on venous leg ulcers advises:

 

“An infected ulcer, one with exudate and a fetid odour, should first be treated by the application of moist compresses: hydrophilic gauze, moistened with water and then squeezed to remove excess water. These compresses should be changed frequently, 3-4 times daily, until the ulcer is clean. Necrotic tissue will also be softened by this treatment, facilitating its removal. Do not apply any plastic covering, which will prevent the wound from breathing and increase the risk of infection. The use of topical antibiotics is not recommended, due to the risk of sensitization and development of resistance.

 

A clean ulcer and the surrounding area should be cleaned during each session, using oil (groundnut oil). Any necrotic tissue in the depth of the wound should be removed with scissors and thumb forceps. A fibrin layer or crusts which develop at a later stage should also be removed in this way.” [3]

 

References
1. CKS. Leg ulcers (venous) February 2008. (http://www.cks.library.nhs.uk/leg_ulcer_venous/)
2. Smith & Nephew Ltd. Grace P, editor(s). Leg ulcer guidelines: a pocket guide for practice. Dublin (Ireland): Smith & Nephew Ltd.; 2006 Jan. (http://www.guideline.gov/summary/summary.aspx?doc_id=9830&nbr=5254&ss=6&xl=999)
3. Dutch College of General Practitioners. Venous leg ulcers. 2002. (http://nhg.artsennet.nl/upload/104/guidelines2/E16.htm)

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