Pneumatic compression devices

Important for preventing deep venous thromboses in critically ill patients and is a mainstay of patient care in intensive care units.

Risk factors for venous thromboembolism (VTE) include advanced age, surgery, trauma, hospital or nursing home confinement, malignant neoplasm, central venous catheter/pacemaker placement, acute infectious disease, neurologic disease with extremity paresis, and history of VTE. (Hall, Arch Intern Med 2000; Alikhan, Arch Intern Med 2004)

The Joint Commission’s current performance measure addressing VTE prophylaxis for medical and surgical patients (VTE 1) assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission.

VTE 2 assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission, or transfer, to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission or transfer.

At-risk individuals are eligible for VTE prophylaxis using anticoagulants and mechanical compression devices.

Current evidence supports use of pharmacologic anticoagulants as primary VTE prophylaxis.

Mechanical compression devices are not recommended as primary prophylaxis unless pharmacologic agents are contraindicated or the likelihood of significant bleeding poses an unacceptable risk.

It is recommended for patients with a contraindication to pharmacologic thromboprophylaxis.

Mechanical pneumatic compression decreases lower limb venous stasis by displacing blood from the superficial to the deep venous system.

The incidence of deep vein thrombosis is lower with mechanical thromboprophylaxis with intermittent pneumatic compression than with no thromboprophylaxis, but the efficacy of intermittent intermittent pneumatic compression may be lower than that of pharmacologic thrombosis prophylaxis.

Mechanical methods, including graduated compression stockings and intermittent compression (IPC) devices can reduce risk of VTE but are less effective than anticoagulants.

Anticoagulants and mechanical methods used in combination are more effective than either measure alone (DVT incidence pharm v. combined 4.21% to 0.65%; DVT IPC v. combined 4% to 1%) Cochrane Database Syst Rev. 2008.

In a randomized trial involving hospitalized patients with stroke, among 24% receiving thrombolysis or a prophylactic or therapeutic anticoagulation, the incidence of the deep vein thrombosis was approximately 30% lower with intermittent pneumatic compression than without it.

Among critical ill patients receiving pharmacologic thromboprophylaxis, adjunctive intermittent pneumatic compression did not result in a significant lower incidence of proximal lower deep vein thrombosis than pharmacologic thromboprophylaxis alone (Arabi YM.)

In the PREVENT trial combined thromboprophylaxis of anticoagulants and pneumatic compression did not result in significant lower incidence of proximal lower-limb deep-vein thrombosis, pulmonary embolism, or other clinical outcomes than pharmacologic thromboprophylaxis alone.

IPC devices are used widely for thromboprophylaxis, particularly in critical illness, surgery, and trauma.

IPC devices are designed to reduce VTE by decreasing stasis in leg veins and by enhancing fibrinolysis.

To augment venous blood volume and flow, IPC devices rely on a pump periodically inflating and deflating air bladders within sleeves wrapped around the legs.

Devices differ in terms of sleeve coverage, extent of air bladders, inflation patterns (uniform versus sequential), and pressures achieved.

Evidence is insufficient to recommend parameters that demonstrate a clear efficacy benefit.

Enhanced IPC-associated fibrinolysis has been observed in normal individuals (Morris. J Vasc Surg, 2006) but not in those undergoing abdominal surgery (Killewich. J Vasc Surg, 2002).

Complications of IPC device applications are reported rarely and include local tissue injury, peroneal nerve injury, bleeding, compartment syndrome, and PE in instances of DVT.

Application of IPC devices has been shown to be suboptimal, consistently demonstrating that IPC therapy is delivered substantially less than ordered/expected.

Lapses in delivery range from complete absence of therapy to device misapplications.

Lapses in IPC use may be related to device design, nursing workload, lack of evidence of efficacy, inadequate patient and staff education, unfamiliarity with devices, patient discomfort.

Systematic efforts to improve IPC use have yielded inconsistent results.

Based on reports of quality assurance efforts, passsive dissemination of guidelines, educational programs, and inclusion in daily rounding checklists will likely not result in improvements.

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