BELLARMINE UNIVERSITY, LOUISVILLE, KY Compression Devices and Incidence of Deep Vein Thrombosis in Post Operative Patients By: Erik Rice, Kevin Mooney, Nick Pucillo and AJ Walsh

BELLARMINE UNIVERSITY, LOUISVILLE, KY Deep Vein Thrombosis (DVT) Frequent cause of complications in the hospital setting –  incidence of hospitalization due to reoccurrence –Average 1 week longer stay –Cost hospital ≈$3000 per patient (Byrne, 2001)

BELLARMINE UNIVERSITY, LOUISVILLE, KY DVT Treatment Options Pharmacological –Low Molecular Weight Heparin –Warfarin –Aspirin –Lovenox Graduated Compression Stockings –TED hose thigh length vs. knee length Mechanical Compression –Intermittent Pneumatic Compression Devices (IPC) (Lieberman, 2013)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Why use Compression Devices IPC’s = intermittent pressure Graduated Compression = constant pressure Both increase venous velocity Decrease clot risks. Image from biohorizonmedical.com g (Colwell, 2010)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Compression Device Comparison Mechanical Compression Incidence of DVT was 4.8% in Mechanical Compression. (Arabi, 2013) Graduated Compression Incidence of DVT was 10% in Graduated Compression. (Arabi, 2013)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Incidence of Deep Vein Thrombosis with compression vs. no compression IPC vs No Compression –DVT risk reduced 60% (Urbankova, 2005) –Incidence Decreased from 16.7% to 7.3% (Ho, 2013)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Pharmacological Interaction with IPC Compared to Pharmacological intervention –IPC’s = Pharmacological interventions –IPC’s show decreased bleeding –(Ho, 2013; Colwell, 2010) Combining IPC’s with Pharmacologic Interventions –IPC + Pharm shows lesser DVT incidence than Pharm alone –(Kakkos, 2012, Ho, 2013)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Research Summary StudyCompression Incidence Non-Compression IncidenceDescription of comparison Kakkos (2012)3.70%18.70%Anticouagulant + IPC vs Anticouagulant alone Arabi (2013)IPC 4.8 %, GCS 10%7.20%IPC and GCS vs No Compression Colwell (2010)5% Mobile Compression Device vs Low- Molecular-Weight-Hearpin UrbanKova (2005)11.30%27.50%IPC vs No IPC

BELLARMINE UNIVERSITY, LOUISVILLE, KY Knee Length vs. Thigh Length Compression Stocking Length –No effect on incidence of DVT Benefits of below knee compression include –Equal effectiveness –Increased compliance –Cost effective –Easier to put on correctly for patient and nurse (Byrne, 2001)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Compression Length Summary Study TitleStudy OutcomeStudy Limitations Williams JT, No difference in efficiency between the lengths of stockings. Absence of a power analysis. McNally MA, Graduated stockings increase blood flow significantly No difference in stocking length Small number of participants may mean this study was not suitably powered to find difference. Hui AC, No difference in DVT and stocking length. Higher incidence of proximal thrombosis with compression Joint replacement patients differ from other surgical patients; therefore it is questionable whether these results can apply to general surgical patients. Porteous MJ, Below-knee stockings are equally or even more efficient in postoperative DVT prophylaxis. Small number of patients participating reduces statistical significance of results.

BELLARMINE UNIVERSITY, LOUISVILLE, KY Other Benefits of Compression Enhance healing of venous ulcers (Comerota, 2011) Decrease mRNA concentrations. (Sheldon, 2012)

BELLARMINE UNIVERSITY, LOUISVILLE, KY Clinical Implications Compression decreases DVT incidence. Length of compression devices seem to have no effect on DVT incidence. Compression + Pharmacological interventions seem to have greatest reduction in DVT incidence.

BELLARMINE UNIVERSITY, LOUISVILLE, KY Further Research More studies comparing compression devices combined with pharmacological interventions. Also in various medical conditions –Diabetes –PAD –PVD –Status Post op

BELLARMINE UNIVERSITY, LOUISVILLE, KY References Arabi YM, Khedr M, Dara SI, et al. Use of intermittent pneumatic compression and not graduated compression stockings is associated with lower incident VTE in critically ill patients: a multiple propensity scores adjusted analysis. Chest. 2013;144(1): Byrne B. Deep vein thrombosis prophylaxis: the effectiveness and implications of using below-knee or thigh-length graduated compression stockings. Heart Lung. 2001;30(4): Colwell CW, Froimson MI, Mont MA, et al. Thrombosis prevention after total hip arthroplasty: a prospective, randomized trial comparing a mobile compression device with low-molecular-weight heparin. J Bone Joint Surg Am. 2010;92(3): Comerota AJ. Intermittent pneumatic compression: physiologic and clinical basis to improve management of venous leg ulcers. J Vasc Surg. 2011;53(4): Ho KM, Tan JA. Stratified meta-analysis of intermittent pneumatic compression of the lower limbs to prevent venous thromboembolism in hospitalized patients. Circulation. 2013;128(9): Hui AC, Heras-palou C, Dunn I, et al. Graded compression stockings for prevention of deep-vein thrombosis after hip and knee replacement. J Bone Joint Surg Br. 1996;78(4): Kakkos SK, Warwick D, Nicolaides AN, Stansby GP, Tsolakis IA. Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery. J Bone Joint Surg Br. 2012;94(6): Lieberman JR, Hsu WK. Prevention of venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2005;87(9): McNally MA, Cooke EA, O’Connell BM, Mollan RAB. Thigh versus knee length compression stockings in the prevention of venous stasis. J Bone Joint Surg 1995;77-B(1):11. Porteous MJ, Nicholson EA, Morris LT, James R, Negus D. Thigh length versus knee length stockings in the prevention of deep vein thrombosis. Br J Surg. 1989;76(3): Sheldon RD, Roseguini BT, Thyfault JP, Crist BD, Laughlin MH, Newcomer SC. Acute impact of intermittent pneumatic leg compression frequency on limb hemodynamics, vascular function, and skeletal muscle gene expression in humans. J Appl Physiol. 2012;112(12): Urbankova J, Quiroz R, Kucher N, Goldhaber SZ. Intermittent pneumatic compression and deep vein thrombosis prevention. A meta-analysis in postoperative patients. Thromb Haemost. 2005;94(6): Williams AM, Davies PR, Sweetnam DIS, Harper G, Pusey R, Lightowler CDR. Knee ‐ length versus thigh ‐ length graduated compression stockings in the prevention of deep vein thrombosis. British Journal of Surgery. 83(11):1553.