Comparison of ... Intermittent Pneumatic Compression Devices NURS3900 Evidence-Based Practice WOHC - Brampton Civic Hospital Comparison of ... Intermittent Pneumatic Compression Devices & Anti-Embolism Stockings for the Prevention of ... Deep Vein Thrombosis & Pulmonary Embolism August 10th, 2009

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Our Topic IPC Devices vs. TED Stockings Comparison of ... Intermittent Pneumatic Compression (IPC) Devices & Thrombo-Embolic Deterrent (TED) Stockings for the Prevention of ... Deep Vein Thrombosis & Pulmonary Embolism

What is DVT? Deep Vein Thrombosis (DVT) Occurs when a blood clot forms inside a vein deep in the leg, causing leg pain and swelling because blood flow is blocked The blood clot can grow, break off, and travel to the lungs. May result in SOB or chest pain  can cause death Clots that travel to the lungs are called pulmonary emboli Many blood clots that cause DVT are small and don't produce any symptoms. Your body will usually be able to gradually break them down with no long-term effects. Larger clots can partly or completely block the blood flow in your vein and cause symptoms such as: 1.swelling of the affected leg 2.pain and tenderness in the affected leg 3. you may also find it difficult to stand properly with your full weight on the affected leg 4.a change in the colour of your skin, for example, redness skin that feels warm or hot to the touch http://www.divebytes.co.za/july_04/dvt.htm

VTE - Venous Thromboembolism Venous thromboembolism (VTE) Comprises both deep vein thrombosis (DVT)and pulmonary embolism (PE). VTE is one of the most common and preventable complications of hospitalization. The rate of hospital-acquired VTE, if not treated, is 10-40% after general surgery and 40-60% after hip surgery http://hcd2.bupa.co.uk/fact_sheets/html/pulmonary_embolism.html

Incidence of DVT in Post-op Patients General surgery, age < 40 20-40% General surgery, age > 40 for malignancy 10-20% Gynecologic surgery 20-40% Gynecologic surgery for malignancy 10-20% Urologic surgery 20-40% Urologic surgery for malignancy 15-25% Intracranial neurosurgery 40-70% Acute spinal cord injury 40-60% Orthopedic surgery, hip fracture 45-60% Orthopedic surgery, total hip arthroplasty 45-70% Orthopedic surgery, total knee arthroplasty 10-20%

Thrombo-Embolic Deterrent (TED) Stockings Prevention Measures The use of Thrombo-Embolic Deterrent (TED) Stockings vs. Intermittent Pneumatic Compression (IPC) Devices

Thrombo-Embolic Deterrent (TED) Stockings

TED Stockings Thigh-length stockings  patients in bed (Thigh or Knee Length Stockings) Thigh-length stockings  patients in bed Knee-length stockings  ambulatory patients With IPC, it saves pt the hassle of applying two types of stockings “Tourniquet Effect” – when stockings roll down and occlude blood flow in one area As such, they must be removed in preparation for surgery Stockings were tested in the laboratory to reveal insufficient elasticity to prevent the pooling of blood (Linda & Walker, 2008) -Since post-operative patients spend a lot of time sitting in chairs with their knees bent, they are at an increased risk for venostasis. This can be overcome by using well-fitted stockings. -It is recommended that thigh length stockings be used for patients who are being nursed in bed and knee length stockings are more suitable for ambulatory patients. However with the new version of the stocking- The Intermittent Pneumatic Compression (IPC), it saves patients the hassle of applying two different types of stockings -*Another issue may occur in the operating theatre as the stockings have to be removed to facilitate preparation for the operating site and can roll down causing a “tourniquet effect” -,Stockings were tested in the laboratory to reveal insufficient elasticity to prevent the pooling of blood while the patient was standing or walking around.

TED Stockings Issues: (Linda & Walker, 2008) (Thigh or Knee Length Stockings) Issues: Inappropriately-sized stockings Inadequate compression Tissue damage Pain May reverse pressure gradients ↓reduction of venous pooling Stockings may roll down the leg Causes compression bands Compromised efficiency in lower parts of the leg (Linda & Walker, 2008) Purpose: Used to prevent DVT in post-op patients

TED Stockings Problem: Application Difficulties (Thigh or Knee Length Stockings) Problem: Application Difficulties Patients with co-morbid problems may have difficulty with stocking application depending on their abilities * Antiembolic stockings are effective when the patient is confined to a bed, but does not provide adequate compression while the patient is ambulating (Coutts & Parslow, 2006) Arthritis Back problems Large abdominal girth Lack of flexibility Inability to reach the feet Weakness in the arms/hands Poor eyesight Unresolved edema Pain APPLICATION DIFFICULTIES: Patients with Co-morbid Problems: -Patients with co-morbid problems may have difficulty with stocking application depending on their abilities -Some challenges reported by patients with compression stockings are: discomfort, difficult application and removal, slippage, cost and poor aesthetics, itching, swelling etc. -Patients constantly complain that stockings are too tight, too hot, with the “toe in” are too constricting, with the “toe out” are too snug around the forefoot and uncomfortable over bunions. They “often slip, causing an indentation at the top of the calf resulting in concerns about circulation” (p. 24). -Causes leg swelling in patients and are too hot to wear in the summer -The compression stockings also are costly to purchase and have an unstylish appearance. As patients complain, they are difficult to apply and remove Conditions such as arthritis, back problems, large abdominal girth, lack of flexibility, inability to reach the feet, weakness in the arms and hands, poor eyesight, unresolved edema and pain can make the donning of stockings a challenge Antiembolic stockings are used when the patient is confined to the bed but do not provide adequate compression while the patient is ambulating

Intermittent Pneumatic Compression (IPC) Devices

What is an IPC? IPC is a safe and cost-effective alternative to the use of anticoagulant therapy to prevent deep vein thrombosis IPC helps prevent limb edema and the associated skin changes frequently seen on the legs of the immobile patient. IPC is a very effective although underused treatment modality, especially in immobile, wheelchair-bound patients Huntleigh Healthcare Ltd, 2007 (Philips et al., 2004)

IPC and Virchow’s Triad IPCs apply intermittent pressure to the lower extremities, which address all three aspects of … Virchow’s triad: Compression pushes blood form the superficial veins into the deep veins, which ↓ venous stasis Compression ↓ venous distension and ↓ the risk of damage to the endothelium Increased blood flow velocity enhances fibrinolysis *Not to be worn if pt has an active DVT* http://www.alldaymedical.com/images/prodimages/DVT10_PI.jpg (Lewis et al., 2006)

How IPC’s Work Controlled intermittent pressure to the limb Augments blood flow proximally to prevent stasis Mimics natural activity of the calf muscle increases blood flow velocity in the deep veins decreases venous hypertension flushes valve pockets Apply a shear strain on the endothelial lining of the vein/artery Biochemical mediators are released enhances fibrinolysis enhances platelet disaggregation enhances vasodilation IPC systems apply a controlled intermittent pressure to the limb, via a garment, in order to augment blood flow proximally thereby preventing stasis. On deflation of the cuff, the veins refill ready for the next cycle of pressure. This mechanism mimics the natural activity of the calf muscle pump in healthy subjects by increasing blood flow velocity in the deep veins and reducing stasis; decreasing venous hypertension; flushing valve pockets where it is thought thrombi originate and decreasing interstitial edema. The mechanical effects of increasing blood flow also apply a shear strain on the endothelial lining of the vein and artery. Biochemical mediators are released, which enhance fibrinolysis, platelet disaggregation and vasodilation. (Philips et al., 2004) http://focosi.altervista.org/EECP

Why IPC’s ? Conventional compression stockings are less efficient in supporting the deficient veno-lymphatic pump when patients are unable to move. They apply a static force to the tissues of the limb and rely on a change in the patients muscle tone to create the correct sub-bandage pressure to augment venous and lymphatic return and thus reduce swelling In immobile patients, this change in muscle tone as a result of standing or ambulation is not possible because of the inability of the patient to perform these physical movements Conventional compression stockings are less efficient in supporting the deficient veno-lymphatic pump when patients are unable to move. Conventional compression therapy (bandaging/hosiery) applies a static force to the tissues of the limb and relies on a change in the patients muscle tone to create the correct sub-bandage pressure to augment venous and lymphatic return and thus reduce swelling in immobile patients, this change in muscle tone as a result of standing or ambulation is not possible because of the inability of the patient to perform these physical movements

Statistics

Statistics: TED Stockings vs IPC Research studies have shown that more than one third (38%) of 244 patients on 22 units were wearing graduated compression stockings. Incorrect usage was found in over one quarter (28%) of these patients, due to improper application or incorrect stocking size. Thigh-length stockings were rated as even more uncomfortable (AJN, 2008)

Statistics: TED Stockings vs IPC Use of IPC in gynaecological unit caused reduction in frequency of venous thromboembolism from 7% to 1.9% Most of the patients (86%, n = 122) had other thrombo embolism prevention devices in place in addition to the stockings. Those devices included A-V Impulse System foot pumps (47%, n = 67) and the SCD Express Compression System, with both thigh- and knee-length sleeves (39%, n = 55). Kakkos SK, Caprini JA, Geroulakos G, et al. 2008

Statistics: TED Stockings vs IPC Compared to no prophylaxis, IPC devices reduce risk of DVT by 60% Compression stockings – 15% of pt developed DVT compared to no prophylaxis, (3% when stockings were combined with anticoagulation therapy) Success of either therapy is dependent on patient compliance. Maiocco, G. (2008).

Relevance to Practice

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Relevance to Practice DVT and PE affect thousands of patients and their families  prevention is critical There is a strong body of evidence supporting the use of IPCs in health care settings, and as such, it becomes relevant to nursing practice as nurses are primarily responsible for the implementation of prophylaxis (Ramzi & Leeper, 2004) Since DVT and PE affect thousands of patients and their families annually, prevention is critical for clients at risk for these disease complications. Nurses need to be able to recognize the potential for patient morbidity and mortality, such as in the case of risk assessments for DVT or PE, and advocate for the client through preventative measures in care and education. There is a strong body of evidence supporting the use of IPCs in health care settings, and as such, it becomes relevant to nursing practice as nurses are primarily responsible for the implementation of prophylaxis (Ramzi & Leeper, 2004). Evidence-based practice change can only occur when there is an acknowledgement of the issue and an appreciation for the recommended new practice. When used correctly, IPCs have the potential to decrease the risk of blood stasis when compared to other prophylaxis mechanisms.

Relevance to Practice All members of the health care team should be... Educated regarding proper assessments for risk factors Aware of the benefits of usage Attuned to protocols for use and documentation Able to provide client teaching (Cawley, 2008) Evidence-based practice change can only occur when there is an acknowledgement of the issue and an appreciation for the recommended new practice. When used correctly, IPCs have the potential to decrease the risk of blood stasis when compared to other prophylaxis mechanisms. For this reason and others, all members of the health care team should be educated regarding proper assessments for risk factors in patients, the benefits of usage, protocols for use and documentation, and client teaching (Cawley, 2008). It is recommended that health care systems design and have readily available a protocol related to when the use of IPCs, including for whom the device is indicated, compatible prophylactic therapies and troubleshooting assistance.

References Cawley, Y. (2008). Mechanical thromboprophylaxis in the perioperative setting. MEDSURG Nursing, 17 (3).   Collins, S. (2009). Deep vein thrombosis – an overview. Practice Nurse, 37 (9). Coutts, P., & Parslow, N. (2006). Compression stockings: a practical approach to common complaints. Wound Care Canada, 4 (2). Einstiein, M.H. & Hartenback, E.M. (2007). Venous thromboembolism prophylaxis: is two better than one? Gynecologic Oncology, 106. Kakkos, S.K., Caprini, J.A., Geroulakos, G., Nicolaides, A.N., Stansby G.P., & Reddy, D.J. (2008). Combined intermittent pneumatic leg compression and pharmacological prophylaxis for prevention of venous thromboembolism in high-risk patients. Cochrane Database of Systematic Reviews, 3.  Linda, W. & Walker, S. (2008). Graduated compression stockings to prevent deep vein thrombosis. Nursing Standard, 22 (40).

References Maiocco, G. (2008). DVT prevention for the obese patient: evidence-based nursing interventions. Bariatric Nursing and Surgical Patient Care, 3 (4).   Partsch, H. (2008). Intermittent pneumatic compression in immobile patients. International Wound Journal, 5 (3). Phillips, L., Macmillan, A., & Tweed, C. (2004). Review of intermittent pneumatic compression: an evidence-based therapeutic modality for the prevention of avoidable deep vein thrombosis. Journal of Integrated Care Pathways, 8 (2). Ramzi, D. & Leeper, K. (2004). DVT and pulmonary embolism: part II – treatment and prevention. American Family Physician, 69 (12), 2841-2848. Winslow, E.H. & Brosz, D.L. (2008). Graduated compression stockings in hospitalized postoperative patients: correctness of usage and size. American Journal of Nursing, 108 (9).