Brandy Mckeown, OTR/L, CLT-LANA, CLWT In this interview, WoundCon speaker Brandy Mckeown shares her insights on new innovations and practical knowledge regarding the treatment of lymphedema and lipedema.

Lymphedema and Lipedema: Different Conditions With Similar Obstacles from HMP on Vimeo.

Transcript

1. What inspired you to create and present this session?

I have been a occupational therapist certified in lymphedema treatment for almost 22 years. And so in that process of being a therapist and building clinics and seeing all of these amazing lymphedema patients, we have also run into a large population of lipedema patients in our office. And I think that one of the biggest problems that we have is that practitioners in general have a really difficult time determining between what is a lymphedema patient and what is a lipedema patient? What does that lymphedema patient look like? What are those stages? What does that lipedema patient look like, and what are those stages? Just trying to help others try to navigate through that process of determining which of those patients that is, or maybe it’s a mixed disease and we need to know a little bit more about that as well. Definitely the love of the disease process and being able to help other individuals and then practitioners as well.

2. What do you feel are the leading innovations in the field regarding lymphedema and lipedema treatments?

Over the last few years, in the lymphedema world, we had a huge change with what we thought was the processes for the reabsorption of fluid in the tissues of the body. And so we say that it’s now a Starlings Revision, which is the endothelial glycocalyx layer. And we’ve learned so much about this amazing layer of the body and how that layer does not reabsorb any of the fluid back into the veins to be able to reabsorb that fluid. The lymphatic system does all of that now. With that, and then Dr. Hiroo Suami also made a new complete lymphosomal map. He started all of that research back in 2015-16. Started publishing more about that in 2018-2019. And so that lymphosomal map, along with the endothelial glycocalyx layer has led to some wonderful innovations in the world of manual lymphatic drainage and where do we drain this fluid to as lymphoedema therapists. That process has been quite amazing. And then we’ve got ICG fluoroscopy that is also in development, primarily in the European countries, however we’re starting to see more and more of it in the US as well, where we can actually see where that fluid is moving. And so, us, as practitioners, it would be fabulous if we could actually see that fluid moving and help with diagnosis processes for lymphedema and lipedema patients, really. In the lipedema world, we are seeing more and more research based off of inflammatory processes, so inflammation. Lipedema patients typically are extremely painful, very lumpy adipose tissue, limits mobility, limits function. And what we’re finding is that the inflammatory processes with that have a lot to do with it. How do we help with those inflammatory processes as well? And then definitely a lot of those patients also have what we call a lymphedema overload, or they have a lipo-lymphedema, which is where they’ve got mixed disease, so they have a lipedema, but then ended up with some lymphedema as well. There again, that ICG fluoroscopy would be amazing in order to be able to visualize that fluid moving through those tissues on that lipedema patient as well as that lymphedema patient. We’re hoping to see much, much more of those processes in the US in the next few years. It’s very exciting work, and I love the fact that we’re on this groundbreaking adventure with these new techniques.

3. What do you think is the future of lymphedema and lipedema management strategies?

I definitely think that our techniques are going to be improved as lymphedema therapist. As practitioners that are treating lymphedema patients, treating lipedema patients, I think that all of that is going to be improved by ICG fluoroscopy. There’s also new ultrasound techniques that are coming out that are going to help us to be able to visualize the fluid in those tissues. I see all of those techniques just magnifying what we do in the clinics to be able to route this fluid and manage this fluid. I think that we’re going to be able to utilize better compression garments based off of these devices as well, and being able to use that research and that mapping with those devices to be able to create the best plans for the drainage for these patients. The other thing is that there’s wonderful new surgical techniques that have been out over the last several years, but they’re definitely getting better and better and better so we’re still seeing some of the lymphovenous anastomosis with these lymphedema patients and vascularized lymph node transfers. With these lipedema patients we’re seeing some amazing liposuction techniques, some water assisted liposuction that is really able to pull out a lot of those tissues that are so incredibly painful for those patients. We’re seeing those techniques as well get more and more research with those techniques, and then those techniques continue to improve and improve and improve over the years for the betterment of these patients. And a lot of these with more severe disease, obviously when we start to talk about the surgical techniques, but we’re also starting to see some surgical techniques that are meant for those patients that we know they’re at risk and we know that maybe they have a little bit of the beginning of lymphedema, but maybe we can do some surgical techniques to make sure that it never exacerbates to a point where they would ever need full lymphoedema treatment, or even to the point of needing full-time compression garments or anything along those lines. Very exciting work out as well with that. I’ve seen a piece out by Dr. Wei Chen, who has done some amazing work with those patients in those early out type protocols. Really neat with those as well.

4. What one thing do you think wound care clinicians can apply to their practice to manage these disorders?

I think, first of all, is being able to clinically say, okay, this patient, that’s lymphedema, this is lipedema. Lipedema is maybe not as much going to have an effect on our wound healing processes, but very possibly could as well, because we have inflammatory processes that happen with these lipedema patients, we have a likelihood of developing the lipo-lymphedema, which means we have the lymphedema as well, which we know definitely slows down the healing process when we don’t have that fluid management control as well as our wonderful wound management. What we really have to figure out is if a patient does have lymphedema, then we’ve got to be able to control that. Knowing what it looks like, knowing what the stages of it are, knowing what the presentations are for that lymphedema is going to be able to help us better as wound care clinicians to be able to know when we need even more compression, when we need some manual lymphatic drainage. We need all of those things in order to get a wound to even remotely start to heal. Because what we know about the lymphatic system is that not only does it take 100% of the fluid out of your body, but it’s a huge component in that healing process. That’s what sends all those antibodies down to heal things. I always say the lymph nodes are like those little garbage cans, but they got some sensors in there, too. It tells the body when our body needs antibodies in a certain area. When the lymphatic system isn’t moving, not only do we not have good return of the fluid out of the interstitium, so out of the tissues, however, we also have a significant delay with the body’s immune response to those wounds. As soon as we can the lymphatic system to start flowing more properly and to start really absorbing that fluid back into the lymphatic system, the lymphatic system then can tell the body, hey, we need some antibodies down here to heal things. Then the healing process for those wounds, no matter how wonderful your techniques are with wound management and how wonderful your products are for exudate management and anything else associated with that wound, until we get the edema under control that is surrounding that wound, still going to be a rough road to trying to get that healed and a very slow process.

5. Ultimately, what do you hope readers/clinicians will take away from this session?

I hope, out of everything that they can take away from this session is that they’ll have a better idea of what lymphedema looks like, what lipedema looks like, what the difference between the two of them is, and then knowing that there’s also that combined disease that we see with those patients. I think if they can identify those patients, then they’re going to be able to identify that maybe we’re going to have to add a little bit of something to this treatment in order to get this wound to heal.

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About Brandy Mckeown, OTR/L, CLT-LANA, CLWT Brandy Mckeown is a occupational therapists with 20+years of hands on experience as a lymphedema practitioner. She is director of multiple outpatient clinics in South Georgia that specialize in lymphedema therapy and wound healing. Brandy is also the CEO of International Lymphedema and Wound Training Institute. She is nationally recognized as an expert in the field of lymphedema, leader and board member of several industry organizations, and regularly requested to speak at regional and national conventions. In addition to treating patients, she has a wealth of knowledge and track record building successful lymphedema clinics and works to consult OT/PTs and vein/wound clinics to start up lymphedema programs and expand their practices profitably. The views and opinions expressed in this vlog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

Introduction

As the body’s largest organ, skin has multiple functions, causes, and manifestations of failure at end of life.1 The concept of skin failure was first proposed in 1991 and continues to impact how injuries at end of life are understood.2-5

Skin failure is often discussed alongside mention of unavoidable pressure injuries, which develop despite implementation of prevention measures, best practices, and monitoring.3 For patients who are critically ill, these pressure injuries may be categorized as acute skin failure depending on the pathophysiological factors that led to their development.4 Wound care professionals may find categorizing these injuries, and other injuries concurrent with skin failure, challenging.

WoundSource had a chance to interview Dr. Barbara Delmore and Dr. Jill Cox, thought leaders who have published extensive research on acute skin failure and pressure injuries. Their WoundCon Spring session, “Skin Failure: Will You Know It If You See It?” examined factors that differentiate these injuries. Dr. Delmore and Dr. Cox discuss their motivations for presenting this session and their hopes for future research in the field.

What inspired you to participate in the creation and presentation of this session?

As researchers and wound care experts, our clinical experience was an important driver for this session. We have many years of experience in wound care in the acute setting and had similar experiences with regard to what we were seeing in our critically ill patients. Patients were developing wounds, particularly in the sacral region, that appeared as rapid onset deep tissue pressure injuries. However, we asked, “Are these really pressure-related wounds based on the patient presentation?” Looking at the literature, we found minimal research in this area that would help us explain or confirm our similar anecdotal experiences. That lack of data led us to initially conduct a primary, multisite investigation into the factors associated with acute skin failure, published in 2015. We subsequently conducted a second study using a larger, more diverse dataset to validate our previous findings. This study was published in 2020.

What do you feel are the leading innovations in the field regarding skin failure?

Skin failure and its subtype, acute skin failure, have been conceptually defined for some time in the literature. Currently, the issue is two-fold. First, there are no technologies deemed capable of differentiating skin failure from other wound types. Second, there are no diagnostic criteria established to validate this concept as a true condition. Innovation in this area will occur when either or both above are definitively established and available in everyday clinical practice.

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What one thing do you feel clinicians can do tomorrow to improve how they assess skin for failure or pressure injury?

Clinicians can improve assessment by identifying the risk factors that the patient possesses, in addition to what they are visually and tactilely assessing on the skin. The risk factors can help the clinician determine if factors, such as other organ failures, might be occurring simultaneously. This finding might lead the clinician to suspect that pressure may not be the most significant etiologic cause in the wound they are visualizing.

Ultimately, what do you hope readers/clinicians will take away from this session?

We hope that participants will come away with a better understanding of risk factors that may predict skin failure and its subtypes. We also hope this presentation will spark future researchers to clarify this concept further.

Conclusion

Investigation into the prevalence of acute skin failure continues. Experts have found that patients with severe COVID-19 are at risk for acute skin failure. In a 2023 article, it was reported that one patient repositioned every 2 hours still developed a butterfly-shaped injury in the gluteal area.5 Although, in the case of this patient, the ulceration was relatively healed after around 4 months of treatment with best practices, diagnosis of acute skin failure is essential.5 Underdiagnosis of acute skin failure impacts management, healing trajectory, and litigation regarding current and future patients, further complicating care in a time where the health care system is strained.5

References

Levine JM, Delmore B, Cox J. Skin Failure: Concept Review and Proposed Model. Adv Skin Wound Care.2022;35(3):139-148. doi:10.1097/01.ASW.0000818572.31307.7b
Irvine C. ‘Skin failure’ – a real entity: discussion paper. J R Soc Med. 1991;84:412-413. https://journals.sagepub.com/doi/pdf/10.1177/014107689108400711
Pittman J, Beeson T, Dillon J, et al. Hospital-Acquired Pressure Injuries and Acute Skin Failure in Critical Care: A Case-Control Study. J Wound Ostomy Continence Nurs. 2021;48(1):20-30. Accessed March 3, 2023. doi:10.1097/WON.0000000000000734
Delmore B, Cox J, Rolnitzky L, et al. Differentiating a Pressure Ulcer from Acute Skin Failure in the Adult Critical Care Patient. Adv Skin Wound Care. 2015;28(11):514-524. doi: 10.1097/01.ASW.0000471876.11836.dc
Panahi A, Couch K, White P, et al. Acute Skin Failure Associated with Severe COVID-19. Plast Reconst. 2023;151(1):185-186. doi:10.1097/PRS.0000000000009748

Introduction

As clinicians know, wound healing is a complex biological process that involves the migration and proliferation of cells along with other molecular events like extracellular matrix deposition.1 Regardless of the process for healing a wound at the cellular level, a patient’s ability to get adequate nutrition can also play a role in this healing process.2 It has been shown that malnutrition can cause increased levels of infection, along with a decrease in tensile strength.

As a result, the lack of nutritious foods further delays the wound healing process, potentially putting a patient at risk of developing a non-healing wound.2 As simple as it may sound for clinicians to recommend their patients eat more nutritious foods, they need to understand that many other factors go into a patient’s ability to purchase these nutritious foods. Factors like inflation or job/income loss can decrease a patient’s ability to purchase the foods necessary for optimal healing.

WoundSource had the opportunity to talk with Dr. Nancy Collins, PhD, RDN, LD, NWCC, FAND, about her presentation, “Meeting Nutritional Needs for Wound Healing During Inflationary Times,” for WoundCon Spring 2023. In her session, she shared how clinicians can help their patients get the nutrition they need despite the increased cost of food.

What are you hoping to cover in this session?

This session will address how the recent price increases for groceries, utilities, gasoline, and housing have forced many wound care patients to sacrifice their nutritional needs in order to make ends meet. I will offer ideas on how to get patients adequate protein and nutrition to help wounds heal while still allowing them to stick to a budget, whether in the inpatient or outpatient setting.

What inspired you to create and present on this topic?

I love nutrition science, and I most often talk about that, but I also think it is important to talk about real-life concerns. Lately, all I hear from family, friends, and patients is how much they spent at the grocery store, the gas pump, and big box stores. You can’t watch the news without seeing something about the high cost of living and the financial concerns facing almost everyone. It is a timely and important topic that we can’t ignore because the very best wound care will not heal wounds if there isn’t adequate nutritional substrate from which to build new tissue.

Why do you feel like it is a crucial topic for clinicians?

During this period of high inflation, wound care clinicians can help their patients by listening, answering questions, and providing helpful suggestions for eating well on a limited budget. Wound care patients need adequate calories and protein, but recently, even formerly inexpensive sources of protein, such as eggs, have risen in price. Clinicians can help by offering suggestions to their patients, so they can afford the nutrition they need to heal. I am well aware that this circumstance is beyond the typical duties and scope of practice for most of us; we are not trained financial advisors. That said, we just can’t ignore this financial reality and look away when a patient says they are having a tough time. Many patients simply need common sense advice, reassurance, and empathy. Inadequate nutrition and protein affect the body’s ability to build new tissue. If patients have concerns about how they can manage to get protein and adequate nutrition, clinicians can offer helpful advice and suggestions about getting more for their dollar. Community and government programs are options for some, as well as learning how to plan menus, shop wisely, and look for coupons and sales.

What do you feel are the leading innovations in the field regarding wound care, healing, and nutrition?

Medical nutrition therapy products continue to evolve just like traditional medications such as insulins, and antibiotics have advanced. For example, there are new medical nutrition products containing citrulline, which is a different way for the body to produce arginine endogenously. In addition, efficacious products are now available in a 2-fl-oz serving vs multiple 8-fl-oz servings, which is the typical serving size. Less to drink translates to more adherence and better healing. It is cash in the trash if your patient doesn’t consume his or her nutrition supplement, and it ends up down the drain. That obviously does nothing for healing.

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What are some common roadblocks that you’ve seen when it comes to a patient’s ability to meet their nutritional needs, and how can clinicians address them? What are some common roadblocks for clinicians?

The common roadblock for clinicians is not being prepared to have this type of discussion. It is not something we are used to doing. During these high inflation times, clinicians need to prepare for difficult conversations that patients may raise about how they can possibly afford the nutrition and protein they need to heal their wounds. Practitioners should provide patients with information about foods that are high in protein and lower cost and even suggest some less expensive meatless options, such as peanut butter, Greek yogurt, black beans, and edamame. They also must know what community resources are available, and for those working in the inpatient setting, perhaps now is the time to reevaluate the formulary to see if the current nutrition products are truly consumed and working well or try some of the newer products.

What one thing do you feel clinicians can do tomorrow to improve their understanding of nutritional practices when it comes to wound healing?

Listening to patients is key. Outpatient clinicians need to answer their patient’s concerns with useful suggestions to promote wound healing—everything from shopping tips to meal planning and even to help them meet their nutritional needs through budgeting and smart shopping. Inpatient clinicians should evaluate their nutrition programs, speak to product representatives about what is new, conduct waste studies, and make any necessary changes to their formularies and/or vendors.

What do you hope clinicians will take away from this session?

I hope clinicians come away with some new ideas and the confidence to deal with this issue if it is brought up. Sometimes all a patient or their family needs is someone to listen and understand. Wound care is also people care.

Conclusion

Adequate nutrition plays a large role in helping patients heal. In her session at WoundCon, Dr. Collins gave clinicians the tools they need to encourage their patients to come up with strategies for ensuring their nutritional needs are met.

References

Barchitta M, Maugeri A, Favara G, et al. Nutrition and Wound Healing: An Overview Focusing on the Beneficial Effects of Curcumin. Int J Mol Sci. 2019;20(5):1119. Published March 5, 2019. doi:10.3390/ijms20051119
Stechmiller JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25(1):61-68. doi:10.1177/0884533609358997

Author Disclosures Consultant Abbott Nutrition and Medtrition, Inc. Speakers Bureau Abbott Nutrition, Medtrition, Inc., and Nutricia. The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.

Introduction

Surgical site infections (SSIs) are just one of the many complications that may follow a surgical procedure. A study conducted from 2019-2020 found the rate of SSIs in Medicare and Premier populations to be 2%, with the rate of SSIs in patients who received abdominal surgery at approximately 5%. The cost of these infections was estimated to be over $18,000 incrementally.1 In addition to SSIs, other postoperative complications may include the following2:

Deep vein thrombosis or pulmonary embolism
Shock or hemorrhage
Reactions to anesthesia
Pulmonary complications and difficulty breathing
Temporary problems with urine retention

Because of the many risks surgery poses, patients and non-surgeon clinicians tend to be apprehensive when assessing treatment options. In addition, patients may harbor concerns about the severity of postoperative pain.3 However, even procedures such as reconstructive plastic surgery can be integral for achieving best outcomes, including restoring functionality in those with congenital disabilities or deformities.4 For these reasons, many surgeons are adopting the practice of prehabilitation to minimize risk and ensure a patient’s ability to recover from a procedure.

According to the American College of Surgeons, prehabilitation is the practice of “improving the functional capability of a patient prior to a surgical procedure so the patient can withstand any postoperative inactivity and associated decline.”5

Our team had the chance to interview Dr. Lisa Gould about her WoundCon session, “Prehabilitation – What Should I Do Before My Patient Undergoes Reconstructive Plastic Surgery?” Dr. Gould discusses the wide variety of patients she sees as a wound surgeon and how she applies prehabilitation to wound care patients.

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What are you hoping to cover in this session?

My goal for this session is to emphasize that it requires a team effort to get patients with wounds ready for major surgeries. I intend to highlight how the principles of prehabilitation, usually used for elective general surgery patients, can be adapted to improve outcomes for even our most complex wound patients.

What inspired you to create and present on this topic?

The American College of Surgeons has really been pushing “prehab,” which evolved into Enhanced Recovery After Surgery (ERAS). I am the wound surgeon for my hospital and treat a wide variety of patients and problems, including older adults who are often frail and have multiple medical problems, younger patients with severe infections, diabetics with chronic infections, and people with spinal cord injury/disease who have non-healing pressure-related wounds. I wanted to see if that program is applicable to the patients I treat.

Why do you feel like Prehabilitation is a crucial topic for clinicians?

There is a lot of misunderstanding about surgery. I have heard wound clinicians and non-surgical clinicians discouraging patients from having surgery. Patients, especially our older adults, tend to be afraid of surgery, especially anesthesia. This is a team sport. Therefore, it is important for all clinicians to understand when surgery is appropriate and how to prepare the patient medically to have a safe surgery.

What do you feel are the leading innovations in the field regarding prehabilitation?

I think prehab itself is still considered an innovation. Most recently, the concept has entered the field of cancer care and cancer surgery. New literature supports that even a short period of prehab, including in-patient prehab, may be beneficial. For patients at home, the implementation of digital support that includes customizable and personalized care pathways, remote monitoring, and decision support can increase access, help personalize the program, improve adherence, and increase collaboration between caregivers.

What are some common roadblocks that you’ve seen when it comes to a successful outcome for patients? What are some common roadblocks for clinicians?

Patients with wounds do not fit the mold of the typical prehab program. Many cannot ambulate or do prescribed exercises, which negates one key component of the usual approach. Physical Therapy/ Occupational Therapy (PT/OT) is overlooked for these patients because people forget that being bed or chair bound does not mean that these patients cannot be active. I try to emphasize to my older or spinal cord-injured patients that they can do things, such as upper extremity exercises and leg lifts in bed. These improve their strength and will increase their heart rate. Also, the emphasis on emotional support and stress reduction, which includes caregivers, is an area that clinicians tend to overlook. It can help with the surgery itself and definitely helps when post-op care is prolonged and difficult. Nutrition is also a major component of prehab, and nutritional supplements are expensive, rarely covered by insurance, and sometimes not very palatable. We need to teach patients that food is medicine and will go a long way toward improving their recovery and healing.

What one thing do you feel clinicians can do tomorrow to improve their understanding of these practices when it comes to prehabilitation?

Increased awareness of the concept of prehab will go a long way toward acceptance. Although there are 4 basic parameters—nutritional supplementation, smoking cessation, physical and cognitive exercise, and stress reduction—it’s important to understand that the overarching goal of prehab is to improve the patient’s functional capacity for a surgical procedure. Therefore, these 4 parameters can be (and need to be) adapted to fit the patient.

What do you hope clinicians will take away from this session?

I hope they will examine their practices and identify at least a few patients who would benefit from prehab with an emphasis on nutrition, edema control in preparation for surgery, and stress reduction. See how it goes and talk to your surgeons, emphasizing that the goal is to achieve better outcomes. That is pretty hard to resist.

Conclusion

Prehabilitation prepares patients for operations and requires the aid of a multidisciplinary team.6 It mitigates risk factors before the procedure rather than peri- or postoperatively. Dr. Gould uses the lens of reconstructive plastic surgery to explore this innovation’s uses across broader patient populations.

References

Hou Y, Collinsworth A, Hasa F, et al. Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures. Surgery Open Science. 2023;11:1-18.https://doi.org/10.1016/j.sopen.2022.10.004
WoundSource Practice Accelerator. Preventing Postoperative Complications. WoundSource. Published September 30, 2020. Accessed January 26, 2023. https://www.woundsource.com/blog/preventing-post-operative-complications
Blondeel P. The perpetual changing paradigm in reconstructive surgery: Developing a vision for the future. J Surg Reconstruction. October 17, 2022; 77:179-189. https://doi.org/10.1016/j.bjps.2022.10.038
Ustunel F, Erden S. Evaluation of Fear of Pain Among Surgical Patients in the Preoperative Period. J PeriAnesthesia Nurs. 2022;37(2):188-193. https://doi.org/10.1016/j.jopan.2021.02.003
Strong for Surgery: Prehabilitation. ACS. Accessed January 25, 2023. https://www.facs.org/for-patients/strong-for-surgery/prehabilitation/
Durrand J, Singh SJ, Danjoux G. Prehabilitation. Clin Med (Lond). 2019;19(6):458-464. doi:10.7861/clinmed.2019-0257