NURS 3900 Evidence-Based Practice WOHC

NURS 3900 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 10 th, 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 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: //hcd 2. bupa. co. uk/fact_sheets/html/pulmonary_embolism. html

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

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 § Knee-length stockings (Thigh or Knee Length Stockings) patients in bed 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)

TED Stockings (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)

TED Stockings (Thigh or Knee Length Stockings) Problem: Application Difficulties Patients with co-morbid problems may have difficulty with stocking application depending on their abilities § Arthritis § Back problems § Large abdominal girth § Lack of flexibility § Inability to reach the feet § Weakness in the arms/hands § Poor eyesight § Unresolved edema § Pain * 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)

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, wheelchairbound 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: 1. Compression pushes blood form the superficial veins into the deep veins, which ↓ venous stasis 2. Compression ↓ venous distension and ↓ the risk of damage to the endothelium 3. Increased blood flow velocity enhances fibrinolysis *Not to be worn if pt has an active DVT* http: //www. alldaymedical. com/images/prodimages/DVT 10_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 (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

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 eitherapy 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)

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)

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).

NURS 3900 Evidence-Based Practice WOHC — Brampton Civic