Vascular Assessment

Vascular Assessment 

Vascular assessment as performed in lab includes palpating and grading pulses, calculating ankle brachial index, performing and evaluating capillary refill, and performing and evaluating venous refill.  Vascular assessment is particularly important for patients with peripheral arterial disease and for patients receiving wound care.  The initial evaluation of the wound care patient should always contain a thorough vascular assessment.  

Supporting Articles: 

The first article supports the use of ABI for evaluating peripheral vascular disease (PVD).  The second article supports the use of photolpethysmography (PPG) for assessing venous insufficiency.  The third article supports the use of strain gauge plethysmography (SGP) for assessing venous incompetence.   

Ikem et. al evaluated the occurrence of peripheral vascular disease (PVD) using ankle-brachial index (ABI) in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcers (DFU).  Seventy-four patients were recruited with 42 males and 32 females.  Forty-six had foot ulcers while twenty-eight were without.  Thirty-one patients with DFU were diagnosed with PVD (based on ABI <.9) while ten patients without DFU were diagnosed with PVD.  The researchers also looked at the occurrence of PVD determined by the absence of more than 2 pulses and found that assessment by palpation is subjective while the use of ABI is quantitative and more reliable.  The study also showed that patients with DFU and PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure.  The results of this study showed that the use of ABI with a hand held Doppler will help with early diagnosis of PVD and help prevent and reduce the high rate of limb loss in these types of patients. 

  

Kelechi et. al proposed a screening procedure to assess venous insufficiency with a hand-held photoplethysmography (PPG) instrument in a clinical setting (Kelechi & Bonham, 2008).  PPG is a noninvasive technology that is used for venous assessment in the lower extremities.  Although duplex ultrasound is the gold standard for assessment, there are many instances where access or expertise is not available.  PPG is underused in clinical settings, but it has great potential since it can be used outside of laboratory settings.  In laboratory settings, PPG has demonstrated high validity and reliability in identifying the presence of chronic venous disorders (CVD).  If PPG is used in a variety of clinical settings, the ultimate goal of early diagnosis and prompt therapeutic interventions for patients with CVD can be achieved that might otherwise go unrecognized.  

Skeik et. al used strain gauge plethysmography (SGP) with and without tourniquet application to distinguish between the superficial and deep components of venous incompetence (Skeik, Kalsi, Wysokinski, Heaser, & Wennberg, 2012).  SGP with tourniquet application was found to be a simple and fast technique that could identify patients with superficial venous incompetence. This can be easier than ultrasound technique which uses time consuming methods that are operator dependent and unable to provide overall haemodynamic assessment of the venous system.  In addition, the ultrasound technique does not globally assess the component of superficial and deep venous insufficiency.  

Refuting Articles:  

The first article discusses the limitation of using ABI to diagnose peripheral vascular disease (PVD).  The second and third articles discuss the limitations of using the capillary refill test.  

Premalatha et. al compared colour duplex ultrasound (CDU) and ankle-brachial pressure index (ABI) measurements in patients with peripheral vascular disease (PVD).  The aim of their study was to compare the specificity and sensitivity of ABI and CDU for the diagnosis of PVD.  Their study involved 100 type 2 diabetic patients who were admitted to a diabetic center with foot lesions.  These patients underwent both CDU and ABI measurements.  A diagnosis of PVD was given if the individual had a haemodynamically significant obstruction on the CDU or if the ABI was <.9.  CDU was the gold standard they used to find the sensitivity and specificity of ABI.  Twenty subjects that were diagnosed with PVD by the CDU were not diagnosed with PVD by the ABI.  Three subjects classified with PVD by the ABI had normal arteries on the CDU scanning.  These results indicated that ABI has a low sensitivity but a high specificity.  Based on this, the researchers believe that ABI is a good initial screening tool but patients with PVD will be missed if ABI is used alone in the diagnosis of PVD.  

In the article by Gorelick et. al., they tested the affects of ambient room temperature on the results of capillary refill test in healthy children. In this study, they tested 32 well hydrated children who presented in an urban emergency room for minor illnesses or injuries. The children were otherwise healthy with normal circulation. The subjects were randomly assigned to a cold waiting room and a warm waiting room where they stayed for 15 minutes prior to seeing the physician at which time capillary refill test was performed. The results of this study found that the average capillary refill time in the warm waiting room was 0.85 +/- 0.45 seconds and in the cold waiting room was 2.39 +/- 0.76 seconds. It is important to remember that a capillary refill time of >2 seconds is considered a positive finding for vascular impairment. Ultimately this study showed that a decrease in ambient room temperature can significantly lengthen capillary refill time thus suggesting that it is not a reliable test for vascular impairment.

In the article by McGee et al., they sought to find which components of a physical exam truly and accurately assist in determining the presence and location of peripheral arterial disease. In this study, the authors analyzed 17 different relevant studies to determine the level of evidence for each. After the levels of evidence were found, the authors determined that the 4 aspects of the physical exam that are positive diagnostic findings for the presence of PAD are abnormal pedal pulses, a unilaterally cool extremity, extended venous filling time, and femoral bruits. Other examination findings including warm knees, the Buerger test, various lower extremity bruits, and an abnormal femoral pulse were found to assist in deciding the extent and location of the present PAD. However, the capillary refill test foot discoloration, atrophic skin, and loss of hair on the extremities were not considered useful for diagnosing PAD.   Ultimately this study showed that many of the vascular assessment tools are useful in diagnosing PAD, however, capillary refill and skin changes of the extremity are not reliable diagnostic findings.

Ann Bonsignore, Mallory Mahoney, Laura Sweeney, Brandon Walker 

 

Works Cited

Ikem, R., Ikem, I., Adebayo, O., & Soyoye, D. (2010). An assessment of peripheral vascular disease in patients with diabetic foot ulcer. Foot (Edinburgh, Scotland), 20(4), 114-7. doi:10.1016/j.foot.2010.09.002

Kelechi, T. J., & Bonham, P. A. (2008). Measuring venous insufficiency objectively in the clinical setting. Journal of Vascular Nursing , 26 (3), 67-73.

Skeik, N., Kalsi, H., Wysokinski, W. E., Heaser, T. V., & Wennberg, P. W. (2012). Predicting superficial venous incompetence with strain gauge plethysmography. Phlebology , 27 (3), 135-140.

Premalatha, G., Ravikumar, R., Sanjay, R., Deepa, R., & Mohan, V. (2002). Comparison of colour duplex ultrasound and ankle-brachial pressure index measurements in peripheral vascular disease in type 2 diabetic patients with foot infections. The Journal of the Association of Physicians of India, 50, 1240-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12568206

Gorelick, M. H., Shaw, K. N., & Baker, M. D. (1993). Effect of ambient temperature on capillary refill in healthy children. Pediatrics, 92(5), 699-702. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/8414858

McGee, S. R., & Boyko, E. J. (1998). Physical examination and chronic lower-extremity ischemia: a critical review. Archives of internal medicine, 158(12), 1357-64. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/9645831

Sussman, C., & Bates-Jensen, B. (2007). Wound Care: A Collaborative Practice Manual for Health Professions. Baltimore, Maryland, United States of America: Lippincott Williams & Wilkins.