Grade Complications Action by GP Referral?

Transcription

1 Varicose vein steps to be followed prior to referral Summary table Grade Complications Action by GP Referral? Class 1 Thread veins or reticular None Support stockings (FP10); British class 2 Activa or Scholl (same as European class 1); wear on affected leg only; GP issue 1 pair for 6 months use. Not under NHS Prevent constipation, exercise advice, elevate legs when resting, and info leaflet. Class 2 Varicose veins None Support stockings - try treating as per grade1. Not under NHS Class 3 Varicose veins with skin changes Skin pigmentation secondary to varicose veins. Can be referred in exceptional circumstances. Class 3 British RAL stocking if necessary. If this fails refer Refer for of veins and arteries, and assess for surgery. Include TRAQS preoperative dataset with referral. Varicose eczema (has to overly varicose veins) Support stockings. Topical steroids then may need referral to varicose vein clinic if unsuccessful. Refer for of veins and arteries. Include TRAQS preoperative dataset with referral. Ankle oedema Support stockings Refer if persistent for Superficial thrombophlebitis Support stockings and topical hirudoid or ibuprofen gel 10% Class 4 Class 5 and 6 Oedema/ venous eczema/ lipodermatoscler osis/ recurrent thrombophebitis despite steps at class 3/ venous ulceration Severe skin changes and or active ulceration Support stockings. Refer for and possible surgery Refer tissue viability nurse in community and discuss with them timing for varicose vein referral for later Page 1 of 7

2 Detailed information Grade Symptoms Complicati ons Action by GP Referral? Class 1 Thread veins or reticular Cosmetic none Support stockings (FP10) British class 2 Activa or Scholl (same as European class1); wear on affected leg only. GP issue 1 pair for 6 months use, prevent constipation, exercise advice, elevate legs when resting, and info leaflet. Not under NHS Class 2 Varicose veins Cosmetic, Aching, Heavy at end day, Cramps, Restless legs, Itch, Swelling Tingling none Support stockings. Try treating as per grade1. Can be referred in exceptional circumstances. Not under NHS Page 2 of 7

3 Grade Symptoms Complicati ons Action by GP Referral? Class 3 Varicose veins with skin changes Cosmetic, Aching, Heavy at end day, Cramps, Restless legs, Itch, Swelling Tingling Skin pigmentation 2 to vv Varicose eczema (has to overly VV) Ankle oedema Superficial thrombophle bitis Class 3 British RAL stocking if necessary. and if this fails refer Support stockings.topical steroids then may need referral vv clinic if unsuccessful and if this fails refer Support stockings Support stockings and topical hirudoid or ibuprofen gel 10% Refer for assess of veins and arteries, and assess for surgery. Include TRAQS preoperative dataset with referral. Refer for assess of veins and arteries. Include TRAQS preoperative dataset with referral. Refer if persistent for Page 3 of 7

4 Grade Symptoms Complicati ons Action by GP Referral? Class 4 Cosmetic, Aching, Heavy at end day, Cramps, Restless legs, Itch, Swelling Tingling Oedema/ven ous eczema/lipod ermatosclero sis/recurrent thrombopheb itis despite steps at class 3/ venous ulceration Support stockings. Refer for and possible surgery Class 5 and 6 Severe skin changes and or active ulceration Refer tissue viability nurse in community and discuss with them timing for varicose vein referral for assesment later Page 4 of 7

5 Referral should be; 1. Via Traqs 2. Class of varicose veins; 3. Affected leg left/ or right or both 4. Complications present 5. Interventions in above table already tried 6. Referral date 7. Previous referrals to vascular team; when? 8. Other significant morbidity 9. TRAQS preoperative sheet completed. Additional Information The availability of off-the-shelf hosiery to fit patients with Lipodermatosclerosis / disproportion of calf to ankle. Full length hosiery is really only advantageous in the presence of PTL (post thrombotic limb) - which is I have observed (although there is no research that I know of to support my observation) usually secondary to proximally occlusive thrombus in the deep veins. Most people find it difficult to tolerate full length unless whole leg swelling is present to a add tangible rational for use. Below knee hosiery is better tolerated than full length. It is efficacious in reducing aching towards the end of the day by assisting venous return - even when the VV's are present above knee. As a result concordance with advice to wear for work / while standing for long periods / while travelling is better achieved. Men & some women prefer a Unisex sock style to a sheer stocking; these are available in most brands / compression ranges. Unisex socks tend to wear better if safety footwear / work boots are worn. There are or should be protocols in the community to assess for arterial disease using history and ABPI which should be implemented prior to prescribing graduated compression. My recommendation is that only affected limbs are put into hosiery unless both are fully assessed. Hosiery should be removed at night. For those who due to infirmity / arthritis in the hands or for other reasons are not able to don & doff hosiery easily, flight socks or anti-embolism hosiery can be considered as these offer graduated compression. These patients can be referred for and advice. Phlebitis or thrombophlebitis Topical rather than oral anti-inflammatory applied directly to these inflamed or hard lumpy /thrombosed varicose veins. If this was more than a one-off episode then referral should be considered once the inflammation / pain had subsided or referral may be necessary while still present if it is persistent. If thrombophlebitis is occlusive varicosities often "disappear" as the discomfort settles otherwise the vein will re-consulate. Reassurance should be given that thrombophlebitis is not and does not give rise to Deep Vein Thrombosis (DVT). Page 5 of 7

6 How to deal with bleeding veins These are normally bleeds from thin walled thread veins, rather than varicose veins. These occurrences, often after a bath or shower when towelling dry, are very stressful and a significant concern to those affected, who feared bleeding unnoticed, particularly at night. Attention to a good daily skincare regime can reduce the likelihood of recurrent bleeds as a supple skin is more resilient. These patients should be referred as they may need sclerotherapy (or perhaps surgery) to prevent recurrence. Exercise good or bad? Exercise is good as it strengthens the calf muscle pump. If patients are not walking then plantar & dorsi flexion can be used to encourage venous return. Sitting with legs elevated relieves the hydrostatic venous pressure & can relieve aching symptoms. Elevating the legs at lunchtime can reduce the degree of swelling / aching present by end of day. Weight is it a factor? Weight plays little in the risk of developing of varicose veins. Family history appears to be of much greater significance. Having said that weight gain such as during pregnancy can be the triggering event for varicose vein appearance. Weight would be a risk factor for elective varicose vein surgery under general anaesthetic. If the location of the varicosities is amenable surgical procedures under local anaesthetics may be a better option. Leg Ulcer referral This should be to the hospital based leg ulcer clinic rather than to a varicose vein clinic. A nurse led one-stop service in conjunction with Community Tissue Viability, Ultrasound scanning and Vascular Consultant input if necessary allowed for better care co-ordination across primary and secondary services. Leg ulcer clinic is for leg ulcers that are not responding to "best practice" treatment. The exception to this advice would be if significant arterial disease is suspected when referral should be to a Vascular Consultant clinic as the limb could be threatened by waiting. Community Tissue Viability are available for advice on dressing choice and skincare issues without the need to refer to leg ulcer clinic, district and practice nurses can access them directly through their Hortonwood office. Prevention is paramount and referral to a varicose vein clinic for further of: Page 6 of 7

7 Those with haemosiderin pigmentation / brown skin staining (not to be confused with thread veins) around the lower leg / ankles. Those with varicose eczema i.e. eczema that overlies a varicose vein. Those who have had venous ulcers. Patients who have reversible venous stigmata particularly if they are treated early when the complications begin. The treatment should include a daily skin care regime and use of graduated compression hosiery to reverse pigmentation which can take time dependent on severity. Resolutions of these complications are better achieved if varicose vein removal is possible. Created March 2012 Version Number 6 Last Updated n/a Next Review Date Document Author Heather Griffiths, Vascular Nurse Practitioner, Dr Andy Inglis, GP, T & W CCG Board Member May 2012 Document Validated by Practice Forum Apr 2012 by Church Close, Woodside, Dawley, Wellington Road, Donnington, Hadley, Hollinswood, Trinity, Holliwell, Shawbirch, Malling PRH, Stirchley, Linden Hall, Madeley, Sutton Hill, Malling Wrekin. Page 7 of 7