Overview of presentation Brief look at the vascular physiology Ulcers (We will be concentrating on Venous Leg Ulcers) Assessment of Leg Ulcers Classification of bandages Classification of tubular bandages Sub bandage pressure Pressure guidelines Sutherland Medical Tubular Compression Bandages 3 Layer Tubular Form Compression Clinical Study Resources

Anatomy

Veins and Arteries valves close behind blood flow Structure of a Vein Structure of an Artery

Calf muscle pump The venous pressure at the ankle of a subject who is lying supine is around 10mmHg, but on standing this will rise by about 80mmHg, due to an increase in hydrostatic pressure. During walking, as the foot is dorsal flexed, the contraction of the calf muscle compresses the deep veins and soleal sinuses to a point at which they become totally collapsed, producing external pressures of up to 250mmHg and emptying them of blood. As the foot is plantar flexed, the pressure in the veins falls, the proximal valves close, and the veins are refilled by blood passing through the perforators from the superficial system. During this cycle, in a normal leg, the distal valves of the deep veins and the valves of the perforators will ensure that the expelled blood can go in only one direction – upwards, back to the heart.

So what is one of the main consequences of compromised Venous blood flow?

Ulcers An ulcer is a loss of skin integrity. The causes of leg ulcers are multifactorial and their origins may be: Arterial – involving arteries and arterioles Venous – involving veins and venules Mixed Arterial/Venous – involving arteries, arterioles, veins, venules Neuropathic – due to loss of protective sensation * An ulcer is a sign of underlying disease, trauma or allergic response

Ulcers Approx 70% of leg ulcers are due to venous disease 10% arterial disease 10-15% mixed arterial and venous disease Remainder vascular, lymphatic, trauma, blood disorders, metabolic disorders, tumours, infections, allergic response, self inflicted and neuropathy

Assessment of Leg Ulcers Medical and surgical history Clinical examination Doppler ultrasound Ankle/Brachial Pressure Index (ABPI) Calculate Ankle/Brachial Pressure Index Divide the ankle reading by the brachial reading Ankle Brachial The ischemic to normal range is expressed as: Normal> 0.9 Claudicant0.5 – 0.9 Ischemic< 0.5 Calcified>1.2

Ankle /Brachial Pressure Index < 0.5 Arterial ulcer 0.5 – 0.8 Mixed arterial/venous ulcer >0.9 Venous ulcer >1.2 Possible calcified ulcer No Bandaging Tubular stretch bandage worn during the day and removed at night when leg is elevated Pink elastocrepe bandage Light elasticated bandages Tubular stretch bandage Lightly applied compression bandage Compression bandages over padding with/without Tubular stretch bandage over compression bandage *Remember, arterial calcification can give a falsely elevated ABPI (usually > 1.2 ), in which case Compression is used with extreme caution. Seek further advice Taken from Keryln Carville wound care manual

Classification of Bandages  Class 1 : retention e.g. conforming gauze  Class 2 : support bandages e.g. heavy cotton crepe  Class 3a : light compression ( 14 – 17mmHg) e.g. Nylastic, Idea Flex  Class 3b : moderate compression (18 – 29mmHg) e.g. Tubular Form SSB, Tubular Form (double layer), Lastodur light  Class 3c : high compression (30 – 40mmHG) e.g. short stretch bandage, Lastolan, Combrilan  Class 3d : extra high compression ( up to 60mmHg) e.g. Blue line webbing Keryln Carville wound care manual

Classification of Tubular Bandages/Stockings Class 1 : Light support (14 – 17mmHg) varicose veins e.g. Ultra-sheer Class 2 : Medium support (18 -24mmHg) prevention of ulcers e.g. Tubular Form, Tubular Form SSB Class 3 : Strong support (25 – 35mmHg) server chronic venous ulcers hypertension, and to prevent venous leg ulcers e.g. JOBST, Venosan, Varisma, etc Sandy Dean compression guide

Sub-Bandage Pressure Sub bandage pressure is controlled by person applying bandage the greater the extension of the bandage the more layers applied the smaller the leg the higher the pressure generated Laplace’s law : “pressure is proportional to bandage tension and inversely proportional to limb radius” P=kNT/R (smaller circumference greater pressure & narrower bandage width greater pressure)

Sub-Bandage pressure required for specific clinical conditions Clinical indicationsRecommended ankle pressure Prevention of D.V.T mmHg Superficial or early Varices Calf muscle pump failure Varices of medium severity20-30 mmHg Ulcer prevention Mild oedema Ulcer treatment30-40 mmHg Gross Varices Post thrombotic syndrome Gross oedema Severe lymphoedema35-50 mmHg Sandy Dean compression guide

Compression Bandages Class/TypeClinical indicationsAverage ankle pressureBandage Type 3a light - Mild Varices15-20 mmHgTubular Form CompressionLayered Type 3b light -Varices of medium18-25 mmHg Tubular form SSB Compression severity Type 3c moderate -Gross Varices30-40 mmHgTruepress Compression -Post thromboticVeno 4 leg ulcersProfore -Gross oedema in ankles Combrilan of average circumference

2011 AWMA Guidelines

Sutherland Medical Tubular Compression Bandages Tubular Form Latex Free Australian Made Natural or Beige color Low fray formula 13 sizes (3cm-37cm unstretched width) Tubular Form SSB (S haped S upport B andage ) Latex Free Australian Made Provides mmHg on a single layer Unique color coding system incorporated in bandages Low fray formula 5 Sizes Half and full leg

Tubular Form The only Tubular Bandage to have practice based clinical evidence for treatment and healing of Venous Leg Ulcers

Study Overview Target 45 Patients Open randomized study Patients recruited from wound clinics in VIC and QLD Austin Repat Wound Clinic Royal Park (Melbourne Health) Wound Clinic Caulfield Wound Clinic (failed to recruit any patients) The Prince Charles Hospital (Pat Aldons-Senior Visiting Consulting Physician) Inclusion criteria – Venous Leg Ulcer 1–20cm requiring treatment Randomized to either 3 layers of Tubular Form or Short Stretch Bandage Followed up weekly for 12 weeks Assessments made on Healing of Leg Ulcer, compliance, cost/treatment,?? Sutherland Medical support acknowledgement in clinical paper Tubular Form product acknowledgement in clinical paper

Clinical Results Tubular Form Group Short Stretch Bandage Group No Patients2322 Leg Ulcer Healed17 (74%)10 (46%) Tolerance91%73% Total Treatment Cost$200$618 Time to Treat30mins60mins

Layer 1 From Base Of Toes To Back Of Knee (Long)

Layer 2 From Base of toes to Mid Calf (Medium)

Layer 3 From Base Of Toes to Mid Point Between Mid Calf And The Ankle (Short)

3 Layers Complete

Tubular Plus “Compression in both groups was applied over a padding layer (Tubular Plus. Sutherland Medical) to protect underlying bony prominences and prevent skin breakdown.” Weller et al: Wound Repair and Regeneration July 2012

Sutherland Medical Resources

3 Layers Application Posters

Compression Therapy Management Guides

Tubular Form/SSB Measuring Tapes

Tubular Form Measuring Guides

All Boxes and Brochures state circumference measurements for correct sizing

Our Tubular Range

Comparative Product Charts