Compression therapy is the cornerstone of treatment for CVI. Compression has been shown to improve healing rates in patients with existing venous leg ulcers (VLU) and reduce the likelihood of VLU recurrence. In an effort to customize compression therapy for each individual with CVI, the Wound, Ostomy and Continence Nurses Society™ (WOCN®) set out to develop an evidence- and consensus-based algorithm on Compression for Primary Prevention, Treatment and Prevention of Recurrence of Venous Leg Ulcers. To learn more about the algorithm's development, view the accompanying Journal of Wound, Ostomy and Continence Nursing article.
The electronic version of the algorithm will guide you through a series of assessments. Click on the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box.
Tap or click the "Back" button to return to the previous page or step.
Tap or click the home icon to return to the beginning.
Click the appropriate blue box or circle to move on to the next step of the algorithm. When you reach the end of your pathway, the final results will be displayed in a green box. A hand icon will guide you to the next step in the algorithm. You cannot proceed until the hand disappears.
Tap or click any number to return to that step in the process.
Tap or click the "Full Screen" button to optimize the fit to your device's viewable area.
Obtain appropriate studies such as Ankle Brachial Index (ABI)/Ankle Brachial Pressure Index (ABPI) to exclude significant arterial disease. Refer to ABI Procedure and Value Table.
Conduct differential diagnosis (Refer to LEVD Appendices C: Differences between Edema, Lymphedema, & Lipedema and D: Venous Eczema and Cellulitis located in WOCN Society Guideline for Lower-Extremity Venous Disease [2011]) Refer to Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide (2017)
* Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide
* WOCN Society Guideline for Lower-Extremity Venous Disease: Appendix C: Differences between Edema, Lymphedema, & Lipedema and Appendix D: Venous Eczema and Cellulitis
Chronic venous insufficiency
Disease or wound of other etiology (e.g., lymphedema, lipedema, arterial, or neuropathic)
Refer to WOCN Society document: Venous, Arterial, and Neuropathic Lower-Extremity Wounds: Clinical Resource Guide
Refer to CEAP table to determine severity of chronic venous insufficiency
No wound (CEAP 1-4) or healed wound (CEAP 5)
Active wound (CEAP 6)
No visible or palpable signs of venous disease (CEAP 0)
Proceed to the CEAP 1-2 pathway
Proceed to the CEAP 3-4 pathway
Proceed to the CEAP 5 pathway
Manage Signs/Symptoms per Facility Protocol OR Clinical Guideline
Patient should be reassessed at least annually to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Determine need for compression based on symptoms (i.e., burning, itching, heaviness, aching, or pain)
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations.
Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression.
In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.
If ABI/ABPI < 0.5 or > 1.3, do not use compression.
Initiate referral for evaluation and management of significant arterial disease.
Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.
Use compression stockings or devices at a level of 30-40 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
Use compression stockings or devices at a level of 20-30 mm Hg, knee or thigh high during waking hours to prevent venous ulcers.
When measuring for compression stockings or devices, use standardized methods based on manufacturer’s recommendations.
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
If ABI/ABPI ≥ 0.8 and ≤ 1.3 proceed to compression.
In patients with mixed venous and arterial disease (ABI/ABPI 0.5 to 0.8) consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.
If ABI/ABPI < 0.5 or > 1.3, do not use compression.
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.
Consider use of pentoxifylline (Trental) to enhance microcirculation and prevent recurrence. (Refer to Pharmaceuticals Table)
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and, if needed, ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Initiate referral for evaluation and management of significant arterial disease.
Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Consider principles of wound bed preparation prior to selection of topical therapy.
Apply topical dressing that will manage venous leg ulcer exudate.
Apply emollients to intact skin underneath compression to prevent occurrence of dermatitis.
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
If ABI/ABPI < 0.5 or > 1.3, do not use compression.
In patients with mixed venous and arterial disease (ABI 0.5 to 0.8), consider use of modified light compression/support, up to 30mm Hg, based on patient tolerance.
If ABI ≥ 0.8 or greater, proceed to compression.
Determine type and level of compression based on patient dexterity, mobility, preference, pain/comfort, cost, caregiver resources and size and shape of leg.
Refer to Tables:
Compression Therapies,
Compression Stocking Classifications,
Formulary of Compression Therapy Products
Special Considerations for Compression.
Initiate referral for evaluation and management of significant arterial disease.
Patients should be reassessed every six months to identify any new or worsening problems with the legs (e.g., pain, impaired circulation, edema, and skin changes).
Identify and treat dermatitis/eczema with topical steroids for 1-2 weeks; refer to a dermatologist if treatment is ineffective.
If the wound fails to improve or deteriorates, evaluate for barriers to healing.
If treatment is effective, continue current therapy until healed
Proceed to the CEAP 5 section of the algorithm.
Refer for advanced adjuvant therapies and/or consider referral for evaluation and management of significant arterial disease. Consider further testing such as venous duplex ultrasound and referral to specialist for interventional therapies if indicated.
Patients should be reassessed every six months to identify any problems with the legs (e.g., pain, impaired circulation, edema, skin changes) and ongoing use of compression therapy (e.g., signs of compression garment deterioration, rubbing, and slippage).
Pharmaceuticals | Uses | Dose | Reference |
---|---|---|---|
Horse chestnut seed extract | Reduce symptoms of CVI such as leg pain, fatigue/tiredness, leg swelling | 300 mg of horse chestnut seed extract containing 50 mg of the active ingredient, aescin, twice daily. | Pittler MH, Ernst E. Horse chestnut seed extract for chronic venous insufficiency. Cochrane Database Syst Rev. 2012 Nov 14 |
Pentoxifylline (Trental) | Hemorheologic agent enhances microcirculatory blood flow and may be used in CVI patients in conjunction with compression therapy | 400 mg ORALLY 3 times per day with food | Jull AB, Arroll B, Parag V, Waters J. Pentoxifylline for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD001733. DOI: 10.1002/14651858.CD001733.pub3. |
ABI | Perfusion Status |
---|---|
> 1.3 | Elevated, incompressible vessels |
> 1.0 | Normal |
≤ 0.9 | LEAD |
≤ 0.6 to 0.8 | Borderline |
≤ 0.5 | Severe ischemia |
≤ 0.4 | Critical ischemia, limb threatened |
J Wound Ostomy Continence Nurs. 2012;39(2S):S21-S29.
Type of Compression | Examples | Performance Characteristics and mmHg Pressure |
---|---|---|
Light Support | Crepe, rolled gauze | Holds dressings in place No significant compression |
Light Compression, support (elastic) | Elastocrepe (BSN medical), Tubigrip (Mölnlycke), Medigrip (Medline) | Low pressure, light support 14-17 mmHg |
Cohesive bandage | Coban (3M), Co-flex (Andover), Medi-Rip (Hartmann), Sensi-wrap (Dynarex) | Self-adherent, compression well sustained |
High elastic compression | Tensopress (BSN Medical), Setopress (Mölnlycke), SurePress (Medline) | Sustained compression, wash and reuse 25-40 mmHg |
Multilayer high compression 3 or 4 layer | Profore (Smith & Nephew), Comprifore (BSN medical), Dynaflex (Systagenix), FourPress (Hartmann), Fourflex (Medline) | To maintain 35-40 mmHg at the ankle |
Table compiled from information in:
O’Meara, S., Cullum, N.A., & Nelson, E.A. (2009). Compression for venous leg ulcers. Cochrane Database Syst Rev (1), CD000265.
U.S. Class | Descriptor | Ankle Pressure | Indication |
---|---|---|---|
Class 1 | Light support | 20-30 mmHg | Treatment of varicose veins |
Class 2 | Medium support | 30-40 mmHg | Treatment of more severe varicosities and prevention of leg ulcers |
Class 3 | Strong support | 40-50 mmHg | Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent leg ulcers |
U.K. Class | Descriptor | Ankle Pressure | Indication |
---|---|---|---|
Class 1 | Light support | 14–17 mmHg | Treatment of varicose veins |
Class 2 | Medium support | 18-24 mmHg | Treatment of severe chronic venous hypertension and severe varicose veins, and to prevent venous leg ulcers in patients with thin legs |
Class 3 | Strong support | 25-35 mmHg | Used to treat more severe varicosities and to prevent venous leg ulcers |
Adapted from: O’Meara, S., Cullum, N.A., & Nelson, E.A. (2009). Compression for venous leg ulcers. Cochrane Database Syst Rev (1), CD000265; Partsch, H., Clark, M., Mosti, G., et al. (2008). Classification of compression bandages: Practical aspects. Dermatologic Surgery, 34(5), 600-609.
Category | Type | Examples * |
---|---|---|
Wraps | Multilayer Long stretch Short stretch Paste** |
Profore (Smith & Nephew), Comprifore (BSN Medical), Dyna-Flex (Systagenix) ACE bandage (3M) Comprilan (BSN Medical), Setopress (Mölnlycke) Gelocast (BSN Medical), Viscopaste (Smith & Nephew), Primer (Derma Sciences) |
Intermittent Pneumatic Compression Pumps | Tactile Systems Technology Lympha Press Bio Compression Systems, Inc. |
**Use with cohesive bandage
*Not all inclusive
Adapted with permission from Carmel, J. E. (2012). Venous ulcers. In R. A. Bryant & D. P. Nix (Eds.) Acute & chronic wounds: Current management concepts (4th ed.). St. Louis, MO: Elsevier.
Class | Clinical Signs | |
---|---|---|
0 | No visible or palpable signs of venous disease | ![]() |
1 | Teleangiectases, reticular veins, malleolar flare | ![]() |
2 | Varicose veins, distinguished from reticular veins by a diameter of 3 mm or more | ![]() |
3 | Edema without skin changes | ![]() |
4 | Skin changes ascribed to venous disease 4a – hyperpigmentation 4c – lipodermatosclerosis 4b – venous eczema 4d – atrophie blanche |
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5 | Skin changes (as defined above) in conjunction with healed ulceration | ![]() |
6 | Skin changes (as defined above) in conjunction with active ulceration | ![]() |
Special Considerations | |
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All Patients |
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Patient/Caregiver with functional limitations |
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Patient with atypical shape/size leg |
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Patient with limited financial resources |
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Non-ambulatory or bedbound patients |
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Patients unable to tolerate 30-40 mmHg compression |
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While it may be true that a patient has a Braden score of less than 18 and a pressure ulcer on the trunk or pelvis, it may not be necessary for them to have a different level of support surface. There are some factors that cannot be reflected on an algorithm and while few, they exist. At those moments, a skilled clinical assessment with critical thinking/decision making is required.
For example, a patient may have a Braden score of 17 and a Stage I or II on their sacrum or trunk but are able to turn side to side so would be able to stay on their current surface. However, if they have a medical condition that prohibits turning to one side (e.g., SOB, cardiac rhythm changes, device in place, etc.), they would need to be moved to a higher-level support surface because they have only one available turning surface.