What follow-up advice should be given to a 66-year-old male patient with a pressure ulcer (pressure sore) on his left lower calf, a history of Deep Vein Thrombosis (DVT) in the popliteal (pop) vein, and hypertension, who is currently taking warfarin (Coumadin) 5 mg daily?

From the Guidelines

The patient should continue his warfarin 5 mg daily without interruption, with weekly INR monitoring to maintain a therapeutic range of 2.0-3.0, as this approach is supported by the most recent and highest quality study 1.

Wound Management

For the pressure ulcer on his left lower calf, daily wound care is essential, including:

• Gentle cleansing with saline solution
• Application of appropriate dressings based on wound characteristics
• Regular dressing changes every 1-3 days depending on drainage Pressure relief is critical, and the patient should:
• Avoid prolonged pressure on the affected area
• Change positions at least every two hours
• Use specialized cushioning or mattresses

Compression Therapy

Compression therapy should be approached cautiously given his DVT history - if prescribed, graduated compression stockings (15-20 mmHg) should only be used after consultation with his vascular specialist.

Nutritional Support

Nutritional support with adequate protein intake (1.2-1.5 g/kg/day) and sufficient hydration will promote wound healing.

Monitoring and Follow-up

The patient should monitor for signs of infection (increased pain, redness, warmth, purulent drainage, fever) or DVT recurrence (increased leg swelling, pain, warmth) and seek immediate medical attention if these occur. Regular follow-up appointments should be scheduled weekly until improvement is noted, then biweekly until resolved, as recommended by guidelines on anticoagulant therapy 1.

Anticoagulation Management

The patient's warfarin therapy should be managed carefully, with consideration of potential interactions with other medications and nutrients, as well as the risk of bleeding complications, particularly in patients with a history of DVT 1.

From the FDA Drug Label

The dosage and administration of warfarin sodium tablets must be individualized for each patient according to the particular patient’s PT/INR response to the drug. The risk-benefit should be reassessed periodically in patients who receive indefinite anticoagulant treatment.

The patient should be advised to follow up regularly to monitor their PT/INR levels and adjust their warfarin dosage as needed. The patient should also be educated on the importance of regular monitoring to minimize the risk of bleeding or thromboembolic events. It is recommended that the patient's INR levels be maintained within the target range of 2.0 to 3.0. The patient should be advised to report any changes in their condition or any signs of bleeding or thrombosis to their healthcare provider promptly. 2 2

From the Research

Follow-up Advice for a 66-year-old Male Patient with a Pressure Ulcer

The patient has a pressure ulcer on his left lower calf, a history of Deep Vein Thrombosis (DVT) in the popliteal vein, and hypertension, and is currently taking warfarin 5 mg daily.

• Wound Care: The patient should be advised to follow a wound care plan that includes regular dressing changes, debridement, and off-loading of pressure to promote healing 3.
• Pain Management: Pain management is crucial in the treatment of chronic wounds. The patient's pain should be assessed and managed accordingly, using a multimodal approach that includes oral and parenteral medications, nerve blocks, and implantable devices 3.
• Hyperbaric Oxygen Therapy: Hyperbaric oxygen therapy (HBOT) may be beneficial in promoting wound healing, particularly in diabetic foot ulcers. However, its effectiveness in pressure ulcers is unclear, and further research is needed to determine its benefits 4.
• Anticoagulation Therapy: The patient is currently taking warfarin 5 mg daily. The international normalized ratio (INR) should be monitored regularly to ensure it remains within the therapeutic range of 2.0-3.0 5.
• Follow-up Appointments: The patient should be advised to attend regular follow-up appointments with his healthcare provider to monitor the progress of his wound, adjust his treatment plan as needed, and prevent complications such as infection or further DVT 6.
• Lifestyle Modifications: The patient should be advised to make lifestyle modifications to reduce his risk of further DVT, such as staying hydrated, avoiding long periods of immobility, and maintaining a healthy weight 7, 6.

It is essential to note that the patient's individual needs and medical history should be taken into account when providing follow-up advice. Regular communication with his healthcare provider is crucial to ensure the best possible outcomes.