Lymphedema and Lipedema

Wound Management

Noreen Campbell RN BScN MA IIWCC LT(Vodder) CWS

May 9, 2014

Lymphedema and Lipedema

The hidden epidemic.

Lymphedema Framework

Recognition of chronic edema from different causes

Normal Wound Healing Cycle

Lymphedema changes

Compression considerations

Infection and Cellulitis Risk

Other Treatments

The Lymphedema Framework

Four Pillars of Lymphedema Management

Patient

Manual Lymphatic Drainage

Compression

Skin Hygiene

Exercise

Lymphatic System Insufficiency

Transport

Capacity

Lymphatic

Load

Normal Mechanical Dynamic

Diuretics only

for vascular

fluid over-load:

heart and renal

failure

Treating the whole person – not the

hole in the person.

Trauma or Surgery Cancer and Radiation Chronic Edema

Venous DiseaseLymphedema

Infection or Inflammation Obesity or Lipedema Immobility or Paralysis Fractious

Focus: Diagnosis determines care.

Lymphedema

Slow

Painless

Peripheral

Tissue soft

Stemmer Sign

Skin changes later

Cancer

Fast (weeks)

Distal to involved nodes

Collateral veins frequent

Firm tissue

Tissue and nerve damage before and after

surgery or radiation

Lipedema

Slow

Early hypertrophy

Later skin pain pressure

Bruising

Fat deposits

Deformity

Foot sparing

Lymphedema

DIET RESISTANT

Lipedema Stages

http://www.nature.com/aps/journal/v33/n2/fig_tab/aps2011153f4.html image

reference

http://www.lipedema-simplified.org/ Edu. Video 25min Catherine Seo

Edema AssessmentEdema

When - morning

Where – dependent area

Increasing

Response to elevation less effect

Skin changes (Stage)

Stage 1 – soft

Stage 2 – Stemmer sign

Stage 3 – Skin changes Fibrosis or Sclerosis

Papillomatosis

Lymphedema

Primary

Secondary

Lipedema/Lymphedema compared to

Lymphedema

Edema Assessment

+2

+3+4, leaking

Stemmer Sign

Avoid tight binding

clothing jewelry.

Veins

Thin

wasted

Ulcer

Stage 3 Lymphedema Skin Changes

Lymphostatic elephantiasis

Pronounced skin change

Hyperkeratosis

Papillomatosis

Pigmentation

Lymph cysts

Lymph fistulae

Pneumatic Compression Treatment 1980

Little support (German)

Increases fibrosis deposits

44% genital lymphedema when used on legs compared to 2.7% with compression bandages only

German Lymphedema Society DOES NOT RECOMMEND PNEUMATIC COMPRESSION without expertise and manual decompression support,

Arrow

Fibrosis

Compression Action Lymphedema

Action Contraindications High

Pressure Reduce edema

Increase reabsorption

Increase muscle and joint pump

Decrease fibrosis and sclerosis (rough packs)

Start low pressure, padding, modify, increase to best case

FINANCIAL CHALLENGE

EARLIER CHEAPER

Arterial insufficiency

Active congestive heart

failure

Acceptable with

consultation, monitoring

If discontinued must restart

from initial point

Complex regional pain

syndrome CRPS

CompressionProduct Purpose Comments

Short Stretch Elastic High walking pressure with

low resting

Must have suitable padding

for individual patient, digit

wrapped

Reusable, daily application,

some patients can self wrap

Allows skin care

Long Stretch Risk of binding, high

pressure

Not recommended, poor for

deformity management

Commercial Kits i.e.

ProFore,Coban

Single use, lack of specific or

possible sufficient padding

Single purchase increases

expense, no evidence of

superior effect

JustiFit Circaide Adjustable, good for

deformity accommodation

Patient or care provider can

be trained.

Circular knit garment Suitable early, without

deformity

Risk of binding, not if

deformity or folds

Flat knit garment Even pressure, custom made

are expensive

More comfortable

All require advanced fitting, selection and padding

Pre-compression Post Compression

CircAid Justa-Fit

Lost 90 Lbs

3 mns

Exercise,

Diet

Compression

3 months

http://www.youtube.com/watch?v=cdDPJ6m5_NY YouTube foot sock and lower leg

Compression Pressure ConsiderationsStart low, pad carefully, evaluate closely.

STAGE USE GERMAN

PRESSURES

CANADIAN

PRESSURES

I Superficial :children, elderly 18-2S1mmHg 15-24mmHg

Support stockings

II Moderate superficial: arm, leg,

mixed edema, post thrombotic

syndrome

25-32m Hg 20-30mmHg

Class 1

III Superficial deep tissue: LE

SI/II, Lipedema

36-40mmHg 30-40mmHg

Class 2

IV Increased deep tissue effect:

LE SII/III, younger patient

excellent compliance

>59mmHg 40>mmHg

class 3

Custom

Compliance is KEY to reduced edema.Boris 1997

Lymphedema Therapy

Compliance Arm Edema

Reduction

Lower Limb Edema

Reduction

100% 79% 79%

75% 58% 42%

50% 60% 36%

25% 53% 32%

None 43% 28%

Toe Edema

Digits should be wrapped

special training and very

close monitoring required

Closed stockings

Padding toes then applying

pressure

Interface between toes

Nonadherent or Inadine

Cast padding between toes

and over foot.

Include in compression wrap

Compression is forever...

Poor technique, still

better than nothing!

Lipedema - Lymphedema

Shaped TubiGrip

Compression Garments Function of garments

Pressure based on arterial

pressure

Flat knit preferred

Custom fit if deformity

Expense

Adherence

Lack of trained

professionals

Wound Healing Process

Hemostasis

immediate

Inflammation

Day 1-4

Proliferation

Day 4-21

Epithelialization

Maturation/Remodeling

Day 21 - 2 years

Kane

Homeostasis – first 24 hours

Platelets

PDGF

Inflammation 1-4 days

Debridement

Macrophages

Phagocytosis

neutrophils

Leakage of plasma and WBCs

Proliferation day 4 - 21

Granulation

Lymphocytes

Leukocytes

Angiocytes

Contractile proteins

fibroblasts

Release of growth factors from macrophages

Epithelialization (follows and overlaps proliferation)

Epithelial tissue development

keratinocytes

Resurfacing migration of skin cells

Maturation/Remodeling up to 2 years

Remodel

fibrocytes

Well healed scar – always a scar… (weaker tissue)

Infection Assessment

Heat

Erythema

Swelling

Pain*** not if neuropathy BUT if present deep infection

BLOOD SUGARS

ELEVATED

Infection

Examine after cleaning Potable water

may shower Mild soap

Wound deterioration Inappropriate

wound care Infection vascular

insufficiency Systemic

disease

Culture after cleaning ONLY if signs and symptoms

Topical Antimicrobial

Iodine (Cochrane’s) Cadexomer Iodine

Iodosorb

Povidone Iodine Inadine Betadine

Silver sulfadiazine Flamazine

Silver dressings Expensive little support

Honey Needs more support

Polysporin Increased risk of allergy Increased risk of resistance

Cellulitis (Erysipelas) Risk

Management

Risk of cellulitis 77X

Acute management

Long term antibiotics

Hold Manual Lymphatic

Massage and compression

until controlled

Surgery Debulking

Depends on amount of tissue continue compression

Liposuction

Lipedema SI/II Earlier better

Tumescent Local Anesthesia

Saline

Local Anesthetic

Adrenaline

Anti-inflammatory

Do NOT seal wounds, compresses, compression continuously 1 month

Lymph sparing surgery

MRI or PET Scan

Early symptom management

Lymphatic Reconstruction

New

Large vessel

No tension

ONLY IF LOCALIZED UNILATERAL ATRESIA

Laser Therapy

New

Needs more study

Basic Treatment Lymphedema and Lipedema

Patient

• Skin care– Clean, moisturize– Protect folds

• Exercise Planned Program• – Keep moving

– Walk– Water Exercise

• Manual decompression – Special technique

• Weight Control• Be involved with provincial

Lymphedema Association

Care Team

• Family physician

• Lymphatic Care Team

• Lymphatic Therapist

• Wound Clinician

• Physician

• Compression Provider

• Community Support

• Care providers aware of resources and access

Public Policy Goals

Recognition of the need for public and clinical education and

support.

Funding for specialized care teams

Education and support of local care providers

Patient funding

Therapy

Garments

Treatment

Research – effective therapy provision