The Best Practice Statement: Addressing complexities in the management of venous leg ulcers (Wounds UK, 2019) recognises the importance of undertaking vascular assessment, however it also states that only 22% of patients had an ankle brachial pressure index (ABPI) documented (Guest et al, 2018) and that omission of an ABPI can lead to delayed healing.
The best practice statement goes on to state that it can be difficult to obtain ABPI in patients with chronic swelling and as a reviewer of the document I was keen to highlight the BLS position paper for ankle brachial pressure index (ABPI), informing decision making prior to the application of compression therapy.
Literature suggests that the value of an ABPI is limited in people with lymphoedema due to the presence of hyperkeratosis, tissue thickening and oedema.
Some of these issues can be addressed through the use of a larger blood pressure cuff and a 4 or 5 MHz probe. However, some patients cannot tolerate this investigation and some readings will be inaccurate. In these situations practitioners need to rely on information obtained from a detailed history of the presenting complaint and the clinical examination.
The British Lymphology Society (BLS) has published a position paper to support the application of compression in the absence of ABPI in those patients with lymphoedema.
The paper accepts that ABPI is not necessary in the absence of critical ischaemia or loss of sensation following thorough vascular assessment and includes a vascular assessment tool to record past medical history and signs and symptoms. There is also a standardised letter to be shared with any members of the patient’s health care team to inform them of the decision making process for not undertaking ABPI and commencing compression therapy.
The BLS document also recommends the application of therapeutic levels of compression to be applied, as it could be argued that it is neglect or an omission of care for patients to be left with extensive lymphorrhoea (leakage of lymph through the skin) for many weeks or even months whilst they await ABPI.
For more information, to become a FREE friend of BLS member or to download the BLS position paper for ankle brachial pressure index (ABPI) informing decision making prior to the application of compression therapy visit www.thebls.com
Rebecca Elwell, Lymphoedema Clinical Lead, University Hospitals of North Midlands NHS Trust and BLS Trustee
For more information follow Rebecca on Twitter: @Rebeccaelwell3