Case Study of Eclypse under Multi-Layered Chronic Oedema Bandaging

Rebecca Elwell - Macmillan Lymphoedema Nurse Specialist City General Hospital

Introduction/background

The management of lymphorrhoea remains a very real challenge in the patient with chronic oedema. Generally these patients have been mismanaged for many months and sometimes even years. There are many terms used to describe lymphorrhoea including leaky, weepy and wet legs. There is a general feeling that the leakage will eventually stop of its own accord (which is rarely the case) and management in the community largely consists of absorbent dressings, undercast wadding and a retention bandage.  In the acute setting this is usually not the case as dressings and bandages are a scarcity and many patients are left to drip on incontinence sheets or draw sheets in the bed or on the floor.

The fact that a patient has lymphorrhoea means that there is a port of entry for infection and many patients have associated cellulitis. Cellulitis is an acute, spreading, oedematous infection of the subcutaneous tissues and fat which requires treatment with antibiotics. Many patients with lymphoedema/chronic oedema suffer recurrent cellulitis which may require prophylactic antibiotics, for more information and advice please download the Management of Cellulitis in Lymphoedema consensus document available at www.thebls.com

Method

A new dressing became available through Advancis called the Eclypse Boot with the power to absorb large quantities of fluid and lock it away from the limb. This technology is available in other dressings but none shaped like a leg or boot to fit around the whole of the leg, foot and ankle, enclosing all the affected areas. This innovation means that where there are multiple sites for the leakage of lymphorrhoea or copious amounts of leakage, all of affected areas can be treated without the need for trying to piece together dressings which often move underneath bandaging. The conformability of the Eclypse Boot means that the dressing can be wrapped over itself so that there are no areas exposed and nothing can move under the bandages to dig in or cause discomfort.

Mr X is a 78 year old gentleman, who resides in a residential home, he has chronic oedema mainly related to immobility. For more than 6 months he has been under the care of his local district nursing service for dressings and bandages and was being seen three times per week. The care home staff though who attended the lymphoedema clinic with the gentleman to his outpatient appointment stated that the patients bandages were wet within a few hours after they had been replaced by the nurses but the district nurses they could not commit any further visits to this man due to time and resources. Mr X had not been able to have a bath for more than 6 months as the care home staff were not permitted to remove the dressings as they could not reapply them and there was also a generalised belief that the legs should not be soaked. 

After his appointment at the lymphoedema clinic, a treatment plan of skincare, exercise and multi layered, above knee, short stretch chronic oedema bandaging with the Eclypse Boot was prescribed.

1.      Skincare – Daily washing, thorough drying, especially between the digits and in the skin creases and daily moisturisation to be carried out by the care home staff.

2.      The Lymphoedema clinic liaised with the district nurses to increase their visits to daily for 2 weeks (weekdays only, the bandages were to be left in situ over the weekend) to allow the skin to improve with the daily cleansing.

3.      The district nurses applied the Eclypse Boot next to the skin with under cast wadding over in a spiral bandage and then a cohesive short stretch bandage again in a spiral application. For more information on multi layered lymphoedema/chronic oedema bandaging please visit http://www.lymphormation.org/downloads/position-documents/Management-of-Lymphoedema.pdf

Initially it was a difficult proposition for the district nursing team already stretched to capacity to increase their visits and also there is a cost implication to the Eclypse Boot as this is a very innovative and large garment. However the results spoke from themselves. 

Results

In just one week the skin was much less angry looking and the ‘strike through’ had been reduced from just a few hours after dressings to nil in between dressings. The under cast wadding was therefore able to be reused each day from day one which was a cost saving.  The Eclypse Boot dressing had locked away all of the leakage allowing the healthy skin to dry and therefore damage to the surrounding skin was reduced. Lymph fluid is acidic and it will macerate healthy skin where it is able to come into contact with it.

By Tuesday of the second week (after just 6 changes per leg, that is 12 individual dressings) the Eclypse Boot was no longer needed. The right leg was completely dry was fitted with compression hosiery, this meant that no further intervention by the district nurses for this leg was necessary and the left lower leg now had 2 clear points of lymphorrhoea which could be dressed with much smaller Eclypse dressings.  

At the end of the 2 week period the left leg was also fitted with hosiery over the Eclypse dressing and although the district nurses input was still required this was for 3 times a week for the third week and then just twice a week for the fourth week and just once as a final visit the fifth week. A total of 16 district nursing visits before it was possible for Mr. X to be cared for by the residential home carers without the input of the district nurses. The biggest improvement in the quality of life for Mr. X was that he was able to return to having his regular baths.

Conclusion

Chronic oedema management often involves numerous health care professionals and must always take into account the patients’ health status and wishes. However in this instance the innovative Eclypse Boot in combination with short stretch, multi layered, above knee bandaging resulted in very successful and timely management of patient X. Although there is a cost implication with using a large dressing, the Boot is currently £13.54 each, it has to be taken into account against the number of district nursing visits, the quality of life of the patient and patient satisfaction and consideration should be given to the large number of inappropriate other dressings that would otherwise be employed.

The Eclypse Boot with multi layered, above knee, short stretch bandaging is an excellent and effective choice for the patient with chronic oedema and lymphorrhoea.