Keywords: Anti-embolism stockings/ Nursing Practice Intermittent pneumatic compression/ Practice educator Thromboprophylaxis ●This article has been double-blind Patient safety peer reviewed Use of anti-embolism stockings and intermittent pneumatic compression is widespread but health professionals need assistance on aspects of these treatment options Best practice in the use of VTE prevention methods

Learning points... 5 practice Ten FAQs about mechanical thromboprophylaxis points The use of Assessing patients for thromboprophylaxis suitability 1anti-embolism Recommendations for use as outlined in national guidance stockings and intermittent pneumatic Authors Emma Gee is a nurse consultant existing evidence base and the experience compression in and anticoagulation; Cara and knowledge of specialist nurses. This devices is common Doyle is a venous thromboembolism information should be used alongside in acute hospital clinical nurse specialist, both at King’s local guidance to make clinical decisions settings College Hospital NHS Foundation Trust. about the use of mechanical thrombo- As health Abstract Gee E, Doyle C (2015) Best prophylaxis. 2professionals practice in mechanical thromboprophy- are often unclear laxis. Nursing Times; 111: 16, 12-14. Anti-embolism stockings about how best to Although anti-embolism stockings and Anti-embolism stockings are thigh- or use stockings and intermittent pneumatic compression are knee-length garments made from elastic IPC devices, their commonly used for mechanical thrombo- with a graduated compression profile that use varies widely prophylaxis, practice varies significantly. gently compresses the leg to aid venous Patients must This article reviews national guidance and return in non-ambulatory patients. NICE 3be assessed to research evidence on common questions (2010) recommends using stockings that ascertain whether relating to the use of these interventions to produce a calf pressure of 14-15mmHg, as stockings or IPC prevent venous thromboembolism. this profile has been shown to reduce the devices are suitable incidence of (DVT). treatment options nti-embolism stockings and The procedure for applying anti-embolism Patients intermittent pneumatic com- stockings is outlined in Box 2. 4treated using pression devices are common- stockings must Aplace in the acute hospital set- For how long should stockings be worn? have their legs ting and have been used as a mode of Amaragiri and Lees (2000) reviewed clin- checked regularly thromboprophylaxis for many years. ical trials involving anti-embolism stock- for skin damage Despite this, our experience shows dis- ings and found wide variation in the length Professionals parity in their practical use. Therefore, we of time for which they should be worn; this 5must be trained put 10 frequently asked questions relating ranged from six to 14 days. and competency to mechanical thromboprophylaxis to NICE (2010) advises that clinicians assessed to ensure venous thromboembolism clinical nurse should “encourage patients to wear their they know how to specialists from across the country. Varia- anti-embolism stockings day and night use stockings tion in the answers prompted a literature until they no longer have significantly appropriately search to see what evidence is available to reduced mobility”. Patients should be inform these clinical decisions. given both verbal and written advice when The National Institute for Health and discharged from hospital and be shown Care Excellence (2010) outlines the con- how to use stockings safely. Patients dis- traindications to anti-embolism stockings charged with stockings should know how (Box 1), but it is vital that a clinical decision to access help if they experience any issues is made in conjunction with the patient, after discharge. balancing the risk of potential harm and benefit. With this in mind, we have For how long can stockings be removed? addressed the FAQs discussed with the Although no studies have looked specifi- VTE specialists using a combination of cally at how long patients can be without Anti-embolism stockings aid venous national guidelines, information from the stockings for them to remain effective at return in non-ambulatory patients

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CONGRESS

preventing DVT, one study found that Box 1. venous distension starts to occur 30 min- Contraindications for anti-embolism utes after stockings have been removed stockings (Coleridge Smith et al, 1991). Do not offer anti-embolism stockings to patients who have: Venous distension is thought to cause ● Suspected or proven peripheral arterial disease subendothelial tears and activate clotting ● Peripheral arterial bypass grafting factors, which may lead to thrombus for- ● Peripheral neuropathy or other causes of sensory impairment mation (NICE, 2010). ● Any local conditions in which stockings may cause damage, for example fragile “tissue-paper” skin, dermatitis, gangrene or recent skin graft Do stockings cause skin damage? ● Known allergy to the material of manufacture With any compression there is a risk of ● Cardiac failure skin damage. Ulceration and damage to ● Severe leg oedema or pulmonary oedema from congestive the heel is a recognised complication of ● Unusual leg size or shape anti-embolism stockings if applied incor- ● Major limb deformity preventing correct fit rectly, especially to patients who are vul- Use caution and clinical judgement when applying anti-embolism stockings over nerable (Merrett and Hanel, 1993). NICE venous ulcers or wounds. (2010) recommends that stockings should Source: National Institute for Health and Care Excellence (2010) be removed to check for skin damage: » Up to three times daily in those most at risk of skin damage; using thigh-length stockings compared have significant VTE risk factors, (Chal- » At least once daily for all other patients. with knee-length ones. Individual patient mers et al, 2011). Skin checks should be recorded in the factors such as leg size and shape, comfort Outcome data for the paediatric popula- patient’s clinical notes along with the leg and hygiene are considerations when tion exists for prevention of DVT (Monagle measurements and size of stocking. choosing stocking length (NICE, 2010). et al, 2008) but anti-embolism stockings Stockings should be discontinued and However, the evidence supporting thigh- have never been shown to reduce the inci- the patient’s medical team informed so length stockings should be a factor in the dence of pulmonary embolism or death in that suitable alternatives can be consid- decision-making process. children. Nurses should ensure the deci- ered if there is any: sion process for whether to apply stockings » Marking; Can stockings be used with patients in children at high risk of VTE is clearly » Evidence of skin damage; who have wounds? documented. » Pain or discomfort. NICE (2010) guidance states that: “Caution Remeasuring patients’ legs, particularly and clinical judgement should be used IPC devices in the event of swelling or oedema, to when applying stockings over venous Intermittent pneumatic compression ensure their stockings are the correct size, ulcers and wounds.” devices consist of inflatable sleeves that also contributes to risk reduction. It is important to rule out arterial insuf- wrap around the legs or feet, attached with ficiency as a cause for the wound, as com- tubing to a machine that inflates the Should qualified nurses decide which pression in this instance would inhibit sleeves intermittently. This compression patients use stockings? peripheral arterial blood flow, potentially promotes blood to return to the heart from Nurses should use a VTE risk assessment resulting in ischaemia. Although there is the limb. It is thought that IPC reduces the and local thromboprophylaxis guidelines evidence that compression can aid the risk of VTE by preventing to establish whether stockings are indi- healing of venous ulcers, the effective pres- and stimulating the release of fibrinolytic cated for individual patients. They should sure profiles of compression bandages and factors in the blood (Kohro et al 2005). It then assess those patients for contraindi- stockings are different to that offered by is used in patients who cannot move. cations before proceeding. Merrett and anti-embolism stockings (Johnson, 2002). Hanel (1993) demonstrated the importance Patients with a wound need stockings to What is the right length of IPC sleeve? of applying stockings correctly to ensure be removed and the skin to be checked for Although there is evidence that thigh- they are in an optimum position to be any sign of damage or deterioration at least length sleeves offer superior haemody- effective in reducing DVT and to minimise three times a day. Careful documentation namic effects compared with knee-length the risk of skin damage. Nurses therefore of the wound size and characteristics versions (Patterson and Cardullo, 2013), require training and assessment to guar- is required to ensure deterioration convincing outcome data to prove superi- antee the stockings are used appropriately. can be identified on routine checks. ority does not yet exist. NICE (2010) states If deterioration occurs, stockings should that thigh- or knee-length sleeves can be When should thigh- or knee-length be removed immediately and other options used so nurses should use their clinical stockings be used? considered. judgement to assess factors, such as com- A recent series of clinical trials known col- fort, to select the length of sleeve most lectively as the CLOTS – Clots in Legs or From what age can stockings be worn? suitable and tolerable for the patient. Doc- sTockings after – trial (CLOTS Trial The annual incidence of VTE in children is umentation of this decision should be Collaboration, 2010) aimed to evaluate the estimated to be 0.7-1.0 per 100,000 people, recorded in the patient’s clinical notes. effectiveness of mechanical compression with a prevalence of 5.3 of 10,000 hospital in reducing VTE in patients who had admissions (Andrew et al, 1994). Mechan- Can qualified nurses decide which experienced a stroke. The second of these ical methods of thromboprophylaxis may patients use IPC? trials, CLOTS 2, demonstrated a significant be applicable in older or larger children – Nurses can use the outcome of VTE risk reduction in DVT formation in patients usually weighing more than 40kg – who assessments and local thromboprophy-

www.nursingtimes.net / Vol 111 No 16 / Nursing Times 15.04.15 13 Nursing Practice For a Nursing Times Learning unit on Practice educator venous thromboembolism, go to www.nursingtimes.net/VTE

Box 2. Using anti-embolism stockings cases, diligent monitoring is key to ensuring that mechanical thrombo- ● Identify whether anti-embolism stockings are indicated by assessing the patient’s prophylaxis does not harm patients. risk of venous thromboembolism and bleeding. The work has also highlighted that the ● Assess for contraindications to anti-embolism stockings (see Box 1) evidence base is still lacking in certain ● Decide what length of stockings to apply, taking into consideration: areas such as the optimum length of a ● Clinical judgement stocking or sleeve, the paediatric popula- ● Patient preference tion and the time a device can be safely ● Concordance removed for. More work needs to be done to ● Compliance address this. Nurses and midwives should ● Surgical/wound site have access to expert resources for help ● Gain informed patient consent for treatment with anti-embolism stockings with these more complex decisions. NT ● Measure the patient’s legs to find the correct size, noting that different sizes for References each leg may be needed; this can be done with the patient in bed or standing Amaragiri SV, Lees TA (2000) Elastic compression Thigh-length stockings stockings for the prevention of deep vein ● thrombosis. Cochrane Database of Systematic Measure the circumference of both thighs at their widest point Reviews; 3: CD001484. ● Measure the circumference of both calves at their widest point Andrew M et al (1994) Venous thromboembolic ● Measure the distance from the gluteal furrow (buttock fold) to the heel complications (VTE) in children: first analyses of the Canadian Registry of VTE. Blood; Knee-length stockings 83: 5, 1251-1257. ● Measure the circumference of both calves at their widest point Chalmers E et al (2011) Guideline on the investigation, management and prevention of ● Measure the distance from the popliteal fold (back of the knee) to the heel in children. British Journal of All stockings Haematology; 154: 2, 196-207. ● Select the correct stockings using the manufacturer’s measurement table CLOTS (Clots in Legs or sTockings after Stroke) Trial Collaboration (2010) Thigh-length versus ● Apply the stockings to the patient’s legs below-knee stockings for deep vein thrombosis ● Teach the patient how to apply and remove the stockings and ensure they prophylaxis after stroke: a randomized trial. Annals of Internal Medicine; understand that the stockings will reduce the risk of VTE 153: 9, 553-562. ● Monitor the side-effects of anti-embolism stockings Coleridge Smith PD et al (1991) Deep vein ● thrombosis: effect of graduated compression Ask the patient to report any feelings of numbness, tingling, pain or discomfort stockings on distension of the deep veins of the ● Remove stockings daily for washing and inspect skin condition, particularly calf. British Journal of Surgery; 78: 6, 724-726. over the heels and bony prominences. Patients with significantly reduced mobility, Dolibog P et al (2013) A randomized, controlled clinical pilot study comparing three types of poor skin integrity or sensory loss should have their skin checked two or three compression therapy to treat venous leg ulcers in times per day patients with superficial and/or segmental deep venous reflux. Ostomy/Wound Management; ● If there is evidence of marking, blistering or skin discolouration, or if a patient 59: 8, 22-30. experiences pain, discontinue the use of anti-embolism stockings and consider Gee E (2011) Anti-embolism stockings. Nursing Times; 107: 14, 18-19. alternative mechanical thromboprophylaxis Johnson S (2002) Compression hosiery in the ● Remeasure legs if the patient develops swelling or oedema prevention and treatment of venous leg ulcers. ● Advise the patient to wear anti-embolism stockings day and night until their Journal of Tissue Viability; 12: 2, 67, 70, 72-74. Kohro S et al (2005) Intermittent pneumatic foot mobility is no longer significantly reduced compression can activate blood fibrinolysis ● Complete documentation without changes in blood coagulability and ● platelet activation. Acta Anaesthesiologica If the patient needs stockings on discharge, provide verbal and written information Scandinavica; 49: 5, 660-664. as per the manufacturer’s instructions on caring for the stockings and checking the Merrett ND, Hanel KC (1993) Ischaemic patient’s skin complications of graduated compression stockings in the treatment of deep venous thrombosis. Source: Gee (2011) Postgraduate Medical Journal; 69: 232-234. Monagle P et al (2008) Antithrombotic therapy in children: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest; laxis policies to inform whether IPC is laxis as long as the aetiology of the ulcer 133: 6 Suppl, 887S-968S. National Institute for Health and Care Excellence indicated in individual patients. Nurses has been confirmed as venous and not arte- (2010) Venous Thromboembolism: Reducing the who have received training on the use of rial (Nelson et al 2014; Dolibog at el, 2013), Risk: Reducing the Risk of Venous IPC devices are well placed to assess patient unless otherwise specified by the manu- Thromboembolism (Deep Vein Thrombosis and Pulmonary Embolism) in Patients Admitted suitability. Training should include assess- facturer. This is important as any sort of to Hospital. ment of contraindications to IPC. An compression in the presence of arterial nice.org.uk/CG92 Nelson EA et al (2014) Intermittent pneumatic important contraindication is clinical sus- disease could cause further restriction to compression for treating venous leg ulcers. picion of VTE due to the perceived peripheral blood flow. It may be necessary Cochrane Database of Systematic Reviews; 5: increased risk of embolisation from the to consider using a pressure-relieving heel CD001899. Patterson RB, Cardullo P (2013) Superior compression device. Nurses must ensure product in combination with the IPC. haemodynamic performance of a thigh-length they have assessed patients for signs and versus knee-length intermittent pneumatic compression device. Journal of Vascular Surgery: symptoms of VTE before applying IPC. Conclusion Venous and Lymphatic Disorders; 1, 3:276-279 Our work has highlighted the need for Can IPC be used instead of stockings in standardisation in the use of anti-embo- For more on this topic go online... the presence of heel ulcers? lism stockings and IPC as well as empow- Anti-embolism stockings There is evidence suggesting that IPC has a ering nurses to make clinical decisions on Bit.ly/NTAntiEmbolism positive impact on venous ulcers so an IPC an individual basis by giving them the nec- Stockings device could be used as thromboprophy- essary skills and knowledge. In many

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