3M Coban 2 Layer
Compression System
™
™
in clinical practice
Jan Rice and Bill McGuiness are the co-conveners of
the World of Wounds (WoW) located within the Division
of Nursing and Midwifery at La Trobe University. WoW
is aimed at facilitating wound care knowledge through
education, supported research, and the provision of clinical
consultation and wound care resources.
The following case studies were collected from two Wound
Management Clinics, the Alfred Vascular Dressing Clinic
and the Ashwood Medical Centre Wound Care Clinic.
Introduction
The new 3M Coban 2 Layer Compression System was
evaluated in the Wound Care Clinics to gain an understanding
of its effectiveness in terms of clinical and patient outcomes.
This paper comprises four case studies where Coban 2 Layer
Compression System was used and concludes with an overall
discussion. All names used in these case studies are fictitious
to maintain confidentiality.
Case Study One
Joe, a 48 year old school teacher had been suffering from
the symptoms of chronic venous insufficiency for the last
five years, principally leg swelling, itch and restless legs.
He weighed 132kg. His ulcer had developed from minor
trauma suffered when he “knocked his leg on a door”. Initial
management from his local General Practitioner (GP) failed
to reduce the ulcers over a 6 week period and he was referred
to the Alfred Vascular Dressing Clinic.
On presentation at the clinic, Joe had a left lower leg ulcer
with moderate serous exudate, dry surrounding skin and
marked lower leg oedema. The ulcer was located on the
medial aspects of his calf and measured 6.4cm 2 (See Figure
1). His pain was 3 out of 10 and his APBI (Ankle Brachial
Pressure Index) 0.92. His local GP had instigated moist
wound healing management without compression.
Figure 1: Ulcer on initial presentation
Diagnosis was left venous leg ulceration related to an
underlying chronic venous disease.
Bill McGuiness & Jan Rice
Co-Convenors
WoW – “World of Wounds”
Division of Nursing and Midwifery
La Trobe University Melbourne, Victoria.
Having concluded that his ulcer was a venous insufficiency
in origin it was decided to instigate a triple layer compression
system using topical zinc (Viscopaste™), undercast
padding (Softban™) and a low stretch compression bandage
(Comprilan™). This was then covered with straight
elasticated tubular bandage size E to help prevent slippage.
Topical zinc was used as a primary dressing in order to
improve the condition of the surrounding skin and aid
collagen deposition. Joe was instructed to undertake calf
pump exercises four to five times a day and to keep his leg
elevated where possible. Further information about reduction
diet options was provided to help reduce his obesity.
The triple layer compression regime was continued with
weekly changes for three weeks resulting in significant
reduction in oedema and modest reduction in the size of the
ulcer 5.7cm 2 (See Figure 2). Pain level remained between
2 and 3 and exudate was reduced to minimal serous loss.
Slippage of the compression bandage was encountered in
the first three weeks due to reduced leg circumference as the
oedema was reduced.
In an effort to improve the healing rate of the ulcer
the management regime was changed to an alternative
compression system (Coban 2 Layer Compression System) on
Week Three.
Figure 2: Ulcer at the commencement of the Coban 2 Layer
Compression System application
On the following weekly review the patient indicated a much
greater degree of comfort with pain levels down to 0. A small
degree of slippage had occurred and some ridging of the leg
was evident (See Figure 3) when the bandage was removed.
Case Study Two
Figure 3: Ulcer after one week of Coban 2 Layer Compression
System application.
Note: ridging above the ulcer.
The size of the ulcer had reduced substantially in comparison
to previous reductions. In one week of Coban 2 Layer
Compression System the ulcer had reduced from 5.7cm 2 to
3.6cm2. In an attempt to help reduce the ridging of the patients
leg additional under cast padding (Softban™) was introduced in
Week Two. This reduced the ridging of the patients leg but led
to increased slippage of the bandage over the week. (See Figure 4).
Julie, aged 62 years had been suffering from the symptoms
of chronic venous insufficiency for the last fifteen years,
principally leg swelling, itch and restless legs. She weighed
96kg. Her ulcer had developed from minor trauma suffered
when she “knocked her leg in the garden”. Initial management
from her local GP failed to reduce the ulcers over a 5 month
period and she was referred to the Wound Clinic.
On presentation, Julie had a left lower lateral leg ulcer with
heavy serous exudate, dry surrounding skin and marked
bilateral lower leg oedema. The ulcer was located on the lateral
aspects of her calf and measured 1.7cm 2 (See Figure 1). Her
pain was 6 out of 10 and her ABPI 0.87. Surrounding skin was
indicative of stasis dermatitis. Her local GP had been using dry
dressings as management without compression.
Figure 1: Initial presentation
Figure 4: Slippage after one week of wear following application
of the Coban 2 Layer Compression System with the addition of
an undercast padding to help reduce ridging.
Softban™ was ceased at the next application and care was
taken to ensure even bandage distribution of Coban 2 Layer
Compression System.
Coban 2 Layer Compression System was continued for a further
three weeks resulting in complete healing of the ulcer.
(See Figure 5).
Figure 5: Ulcer healed following four weekly applications
of Coban 2 Layer Compression System
Summary
Diagnosis was left lateral venous leg ulceration related to an
underlying chronic venous disease.
Having concluded that her ulcer was a venous insufficiency
in origin it was decided to instigate a triple layer compression
system using topical zinc (Viscopaste™), under cast
padding (Softban™) and a low stretch compression bandage
(Comprilan™). This was then covered with straight elasticated
tubular bandage size E to help prevent slippage. Topical
zinc was used as a primary dressing in order to improve the
condition of the surrounding skin as well as aid collagen
deposition. Topical steroid was used for the first week to help
reduce the dermatitis. Julie was instructed to undertake calf
pump exercises four to five times a day and to keep her leg
elevated when possible.
The triple layer compression regime was continued with weekly
changes for eleven weeks resulting in a reduction in oedema
and an increase in the size of the ulcer to 3.1cm 2 (See Figure
2). Despite non-narcotic analgesic and anti-inflammatory
medication, her pain level remained 3 to 5. The wound exudate
remained at moderate levels of serous fluid. A punch biopsy
was taken in week seven to exclude pyoderma gangrenosum
and skin tumours. Return findings were compatible with venous
disease only.
Coban 2 Layer Compression System resulted in a healed venous
leg ulcer within a four week period and a substantial increase in
patient comfort. Careful application ensuring even distribution
of the two layers is needed to ensure the higher ambulatory
pressures achieved with this system does not result in ridging
and potential pressure injury.
Figure 2: Prior to the commencement of Coban 2 Layer
Compression System
9/10/08
25/9/08
11/9/08
28/8/08
14/8/08
31/7/08
17/7/08
3/7/08
19/6/08
5/6/08
22/5/08
8/5/08
24/4/08
10/4/08
In an effort to improve the healing rate of the ulcer
the management regime was changed to an alternative
compression regime (Coban 2 Layer Compression System)
on Week 12. On the following weekly review the patient
indicated a much greater degree of comfort with pain levels
down to 0. The bandage had remained intact throughout
the week (See Figure 3) and when removed the visual
presentation of the patients leg indicated that an even pressure
had been applied over the entire leg with minimal ridging
evident.
Table 1: Reduction in ulcer surface area from commencement
of Coban 2 Layer Compression System on the 11/9/08
Case Study Three
Figure 3: Bandage after one week of wear
The size of the ulcer had reduced substantially from 3.1cm to
2.5cm 2, which reduced to 1.9 cm 2 by the second week.
(See Figure 4).
2
Figure 4: Ulcer after two weekly applications of Coban 2
Layer Compression System
The Coban 2 Layer Compression System was continued for a
further three weeks resulting in complete healing of the ulcer
(see Figure 5).
Figure 5: Ulcer healed following four weekly applications of
Coban 2 Layer Compression System
Summary
For this patient Coban 2 Layer Compression System resulted
in a healed venous leg ulcer within a four week period with
substantial increase in patient comfort. The reduction of ulcer
size is demonstrated in Table 1.
Joy, aged 76 years had been cleaning about the house and
slipped off a ladder. The initial trauma was to the (L)
anterior shin. Three months later she tripped in the street
and injured the anterior (R) shin. Her past history included
temporary colostomy 5 years earlier for removal of polyps
and puncturing of the colon during surgery. She also suffered
from myaglia and recently had developed an abdominal
hernia at the old colostomy site. She was a healthy weight and
nutrition appeared very good.
Joy was otherwise very active and had many interests
including attending art classes. She had been visiting her GP
for the past eight months and her history was one of healing
then sudden deterioration of the wounds for no apparent
reason.
Joy had been having calcium alginate dressings, Melolin™,
and crepe bandages twice weekly. Other products used
included Silvazine™ Cream, Iodosorb™, Duoderm™ CGF
and Solosite™.
Joy presented at the leg ulcer clinic eight months after
the initial injury and was fed up as the ulcers were really
beginning to impact on her quality of life. On assessment
of the wound bed, red granulation was evident however
the exudate was thick, tenacious and slightly green. There
was also evidence of foliculitis and pitting oedema. Joy
acknowledged that her legs would swell and she was aware
she had varicose veins but as she was active they had not
bothered her. The discomfort of the ulcers was slowing
her down so she admitted she may not have been as active
as normal over the past 3 months. ABPI was 0.89 and the
diagnosis was believed to be of venous origin.
A silver alginate was applied to the wounds, covered with
absorbent pads and inelastic compression was commenced.
Three weeks later Joy was almost healed. Joy requested
stockings as she had a special event to attend and so she
was measured and fitted with elastic stockings providing
15-20mmHg compression.
Unfortunately, the wounds did not recover well however the
bandage performed exceptionally well. After three weeks
despite excellent bandage performance there was still no
improvement and so the patient was referred back to her GP
with a request to consider that the underlying diagnosis may
be vasculitis or at least an inflammatory ulcer. Three weeks
later the wounds were healed.
Initial management was to apply compression to only one leg
using Coban 2 Layer Compression System, so it would not
stress her circulatory system or overwhelm her generally. One
week later the leg oedema was considerably reduced and there
had been no adverse side effects. The patient was amazed as
to how lighter her leg now felt and she intended to continue
with the bandage system until she could be measured for short
stretch hosiery to maintain her limbs oedema free. She was
investigated to ascertain why she had this amount of oedema
and thus far all that has been found was a small 3cm suprarenal tumour.
Summary
The patient comfort and performance of the product was
exceptional.
However, the next visit the wounds had deteriorated from
slippage caused by the hoisery. Coban 2 Layer Compression
System was commenced.
The purpose of this case study was not to demonstrate the
healing outcome using Coban 2 Layer Compression System
but rather to show that it remained in place and addressed
the slippage that was caused by the hosiery. The patient
satisfaction with Coban 2 Layer Compression System was
overwhelming and she stated that there was no discomfort at
night as she had previously experienced with other bandages.
Joy said she had spent the entire weekend gardening after the
first Coban 2 Layer Compression System was applied because
she was so comfortable.
Summary
In this particular case study, Coban 2 Layer Compression
System was not used for an active venous leg ulcer but to
help reduce oedema in order for the patient to be fitted into
compression hosiery. The outcome was very successful in
terms of clinical outcome as well as comfortable and well
tolerated by the patient.
Overall Summary
Case Study Four
Angelina, aged 82 years presented at the leg ulcer clinic with
bilateral pitting oedema to the top of her thighs. There were
no wounds but severe discomfort as she had little strength to
lift her legs to walk. It appeared that the osteoporosis caused
her severe back pain and this limited her normal active lifestyle
where she would walk up to 5kms per day. Angelina was a thin
woman but not severely underweight, as she had always been of
slight build.
Relevant history included severe osteoporosis, otherwise there was
no significant past medical history. The current diagnosis was
bilateral lower leg oedema of unknown origin. ABPI was 0.9.
Obtaining the required level of compression is an essential
element for the timely healing of venous leg ulcers. For
some clients the mechanisms used to achieve this aim
are uncomfortable and in a number of instances can be
intolerable. The increased ambulatory pressures achieved by
Coban 2 Layer Compression System provides the clinician
with an alternative form of effective compression that in our
experience is easily tolerated by the patient. Care is required
to ensure the first padded layer is applied evenly to prevent any
“ridging” and subsequent ulceration. Consideration could be
given to additional under cast padding to help eliminate this
problem. However, this may contribute to additional slippage
of the bandage as the contact of the system with the skin of the
patient is reduced.
Overall we believe the achievement of comfortable resting
pressures and effective working pressures along with increased
patient comfort makes Coban 2 Layer Compression System
a very effective form of compression that addresses the real
challenges that clinicians and patients currently face.
3M Medical
3M Australia Pty Ltd
950 Pacific Highway
Pymble NSW, 2073
Phone: 1300 363 878
Web: www.3m.com.au/healthcare
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www.worldofwounds.com.
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