Pressure differences of elastic compression stockings at the ankle region

'Well-leg' compartment syndrome associated with gynaecological surgery: a perioperative risk-reduction protocol and checklist

'Well-leg' compartment syndrome (WLCS) is an uncommon, but potentially devastating, complication associated with prolonged patient positioning for abdomino-pelvic surgery. Gynaecologists, anaesthetists and the wider theatre team share a responsibility to minimise the risk of this highly morbid, and even fatal, postoperative complication. This article provides an overview of WLCS related to gynaecological surgery - raising awareness amongst gynaecologists and highlighting the time-critical nature of diagnosis and management. Given the potential litiginous nature of this complication, we also present a perioperative checklist and risk-reduction protocol to suggest a standardised approach to prevention and relevant documentation. TWEETABLE ABSTRACT: Gynaecologists share a responsibility to minimise the risk of postoperative 'well-leg' compartment syndrome.

Use of Sponge-Foam Inserts in Compression Bandaging of Non-Healing Venous Leg Ulcers

Objective: Venous leg ulcers (VLUs) caused by chronic venous insufficiency are difficult to treat. Outcomes after compression therapy and the current standard of care often used in conjunction with other options vary widely. We examined the effects of foam inserts on sub-bandage pressures in patients with VLUs and compared use of foam inserts in elastic and inelastic compression bandaging. Methods: Six patients (≥20 years old) with VLUs and skin perfusion pressure >40 mmHg were included. Each patient underwent weekly treatment regimens of debridement, dressing changes, and dual sponge-insert application followed by elastic (n=3) or inelastic (n=3) compression bandaging. The median resting sub-bandage pressures of the ulcer beds, wound sizes, and healing percentages were recorded. Wound beds were biopsied before and after treatment for histological assessment. Nine healthy volunteers served as controls during preliminary testing. Results: With proper sub-bandage pressures (>35 mmHg), the average healing time was 88.0±66 days, which was shorter than anticipated (i.e., ≥6 months). Combining large and local sponge-foam inserts increased sub-bandage pressures regardless of the compression bandage selected, with marked improvements seen in deeper wounds. Conclusion: Layering one or two sponge-foam inserts beneath compression bandages facilitates uniform and optimal wound-bed pressure, which accelerates the healing of VLUs.

Well leg compartment syndrome following robot-assisted radical cystectomy in the lithotomy position: a case report

Background

The indications for robot-assisted urologic surgeries have expanded due to their low invasiveness. However, complicated surgical procedures lead to prolonged surgical duration, requiring patients to remain in the lithotomy position for an extended time. Well leg compartment syndrome (WLCS) is a known severe postoperative complication related to the lithotomy position.

Case presentation

We report a case of WLCS after robot-assisted radical cystectomy (RARC), in which the patient recovered without neurological sequelae. A 55-year-old, obese male who underwent RARC complained of right leg pain and paresthesia 3 h after the surgery that lasted for 481 min. Emergency evaluation revealed unilateral WLCS in the anterior and lateral compartments. Urgent fasciotomy was performed 4 h after symptom onset. He thereafter recovered completely and was discharged without any neuromuscular dysfunction.

Conclusions

Early detection of WLCS, surgical treatment, and additional measures are crucial to prevent its life-threatening and/or disabling outcomes.

Avoiding, diagnosing and treating well leg compartment syndrome after pelvic surgery

Background

Patients undergoing prolonged pelvic surgery may develop compartment syndrome of one or both lower limbs in the absence of direct trauma or pre‐existing vascular disease (well leg compartment syndrome). This condition may have devastating consequences for postoperative recovery, including loss of life or limb, and irreversible disability.

Methods

These guidelines represent the collaboration of a multidisciplinary group of colorectal, vascular and orthopaedic surgeons, acting on behalf of their specialty associations in the UK and Ireland. A systematic analysis of the available peer‐reviewed literature was undertaken to provide an evidence base from which these guidelines were developed.

Results

These guidelines encompass the risk factors (both patient‐ and procedure‐related), diagnosis and management of the condition. Key recommendations for the adoption of perioperative strategies to facilitate prevention and effective treatment of well leg compartment syndrome are presented.

Conclusion

All surgeons who carry out abdominopelvic surgical procedures should be aware of well leg compartment syndrome, and instigate policies within their own institution to reduce the risk of this potentially life‐changing complication.

The Haemodynamic Efficacy of Six Different Compression Stockings from Compression Class 2 in Patients Suffering from Chronic Venous Insufficiency

Objective:

To describe the efficacy of six different compression stockings from compression class 2 on venous haemodynamics in patients with chronic venous insufficiency (CVI).

Design:

An open, randomised, prospective study.

Setting:

University Department of Dermatology, Tübigen, Germany.

Patients:

Twenty-two patients (11 women, 11 men; mean age 55.1 years, SD 10.3 years) suffering from chronic venous insufficiency (CVI) at clinical stages C14EpAs, A14, Ap, PR.

Interventions:

The acute effect of six different compresion stockings from compression class 2 (CEN) on venous haemodynamics were measured using dynamic mercury strain gauge plethysmography. At the same time as venous function, the pressure exerted by the compression hosiery was determined under resting conditions and during exercise.

Main outcome measures:

Resting pressure exerted in the supine position was equivalent in all compression hosiery to the data defined in textile technology for compression class 2 (25–35 mmHg at the ankle). Compression hosiery produced a statistically significant improvement in venous refilling time t 0. The differing improvement in venous function could be explained by the quotient for maximum active pressure/resting pressure on standing (r = 0.98, p <0.01).

Conclusion:

Compression stockings from the same compression class possess differing acute effects on venous haemodynamics. The efficacy of the various compression devices derives to an exceptional degree from the elasticity of the material, and can be characterised in vivo by the ratio between maximum pressure exerted during exercise and the resting pressure on standing.

Practical limitations of two devices used for the measurement of sub-bandage pressure: implications for clinical practice

OBJECTIVE

This study was undertaken to examine the accuracy of two hand-held devices commonly used to measure the pressures produced by extensible bandages.

METHOD

The performance of the pneumatic sensors of two devices, the Kikuhime and Picopress instruments was first examined in air in a compression chamber, then subsequently beneath multiple layers of bandages applied to standard cylinders with predetermined levels of tension.

RESULTS

In the compression chamber, both instruments provided readings that were typically within 1 mmHg of the reference value, but on curved formers in free air or beneath bandages the accuracy of both sensors was greatly reduced, influenced both by the curvature of the cylinders and the volume of air contained in the sensor capsule. The Picopress instrument recorded pressures up to 70% higher than predicted, particularly on the smaller cylinders and at the lower end of the pressure range (circa 20mmHg). At 40mmHg measured pressure were around 40% higher than predicted values in some instances. The accuracy of the Kikuhime was greatly influenced by the calibration technique but percentage deviations as high as 150% were recorded in some tests.

CONCLUSION

Pneumatic pressure sensors used to record the pressures developed beneath compression bandages are much less accurate than is commonly believed. Calibration studies using air chambers or water tanks have no relevance to the normal clinical use of these devices. These limitations should be considered by clinicians when making judgments about the performance of other medical devices such as bandages or stockings. They also call into question the validity of many published studies which rely upon such measurements.

DECLARATION OF INTEREST

This project was generously supported by 3M Healthcare who provided a small research grant to assist with the costs associated with the construction of the test equipment.

The influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy

BACKGROUND

Venous leg ulcers (VLU) have a huge social and economic impact. An estimated 1.5% of European adults will suffer a venous ulcer at some point in their lives. Despite the widespread use of bandaging with high pressure in the treatment of this condition, recurrence rates range between 25% to 70%. Numerous studies have suggested that the compression system should provide sub-bandage pressure values in the range from 35 mm Hg to 45 mm Hg in order to achieve the best possible healing results.

METHODS

An open, randomized, prospective, single-center study was performed in order to determine the healing rates of VLU when treated with different compression systems and different sub-bandage pressure values. One hundred thirty-one patients (72 women, 59 men; mean age, 59-years-old) with VLU (ulcer surface >3 cm(2); duration >3 months) were randomized into three groups: group A - 42 patients who were treated using an open-toed, elastic, class III compression device knitted in tubular form (Tubulcus, Laboratoires Innothera, Arcueil, France); group B - 46 patients treated with the multi-component bandaging system comprised of Tubulcus and one elastic bandage (15 cm wide and 5 cm long with 200% stretch, Niva, Novi Sad, Serbia); and group C - forty-three patients treated with the multi-component bandaging system comprised of Tubulcus and two elastic bandages. Pressure measurements were taken with the Kikuhime device (TT MediTrade, Soro, Denmark) at the B1 measuring point in the supine, sitting, and standing positions under the three different compression systems.

RESULTS

The median resting values in the supine and standing positions in examined study groups were as follows: group A - 36.2 mm Hg and 43.9 mm Hg; group B - 53.9 mm Hg and 68.2 mm Hg; group C - 74.0 mm Hg and 87.4 mm Hg. The healing rate during the 26-week treatment period was 25% (13/42) in group A, 67.4% (31/46) in group B, and 74.4% (32/43) in group C. The success of compression treatment in group A was strongly associated with the small ulcer surface (<5 cm(2)) and smaller calf circumference (CC; <38 cm). On the other hand, compliance in group A was good. In groups B and C, compliance was poor in patients with small CC, but the healing rate was high, especially in patients with large ulcers and a large CC (>43 cm).

CONCLUSION

The results obtained in this study indicate that better healing results are achieved with two or multi-component compression systems than with single-component compression systems and that a compression system should be individually determined for each patient according to individual characteristics of the leg and CC. Target sub-bandage pressure value (B1 measuring point in the sitting position) of the compression system needed for the ulcer healing could be determined according to a simple formula, CC + CC/2.

A systematic review of compression hosiery for uncomplicated varicose veins

OBJECTIVE

Compression hosiery is widely used in the prevention and management of symptoms related to varicose veins. However, there are still gaps and questions in relation to its benefit. This review seeks to examine the current evidence regarding the effectiveness of compression hosiery in the treatment of varicose veins.

METHOD

Prospective, randomized controlled trials (RCTs) evaluating compression hosiery in the treatment of varicose veins were sought. Where RCTs were unavailable other evidence was included. Studies were included if they evaluated the application of compression to patients with a diagnosis of varicose veins. Twelve electronic bibliographic databases and 18 internet-based research resources were searched. Inclusion or exclusion of trials was decided by two reviewers acting independently.

RESULTS

The search strategy identified 25 studies. Eleven were RCTs or systematic reviews, 12 non-randomized studies and two guidelines. No consensus was found regarding the class of compression needed for the effective management of varicose veins. Wearing compression improved symptom management, but could be confounded by the exclusion of high number of non-compliant patients within the trials. Wearing compression to slow the progression, or prevent the reoccurrence of varicose veins could not be supported by the current published evidence.

CONCLUSION

The evidence for the benefit of compression hosiery for varicose veins was equivocal. The published literature was often contradictory and had methodological flaws.

Systematic review of topic treatment for venous ulcers

Venous ulcer patients can experience this situation for several years without achieving healing if treatment is inadequate. Evidence-based professional practice generates effective results for patients and services. This research aimed to carry out a systematic review to assess the most effective method to improve venous return and the best topic treatment for these ulcers. Studies were collected in eight databases, using the following descriptors: leg ulcer, venous ulcer and similar terms. The sample consisted of 33 primary studies and two Meta-analyses. A wide range of treatments was identified, grouped in compression therapy (54.3%) and topical treatment (45.7%). It was evidenced that compression therapy increases ulcer healing rates and should be used in patients with intact arteries. There is no consensus about the best topical treatment, although different options should be associated with compression therapy.

Human muscle fatigue and elastic compressive stockings

The present study was performed to test if elastic compressive stockings (ECSs) increase muscle fatigability during sustained muscle contraction or if it improves the recovery after fatigue. Surface electromyograms (EMGs) were recorded on 4 leg and thigh muscles, and static ankle dorsal flexion force levels were measured in the right limb of 15 healthy subjects. The subjects maintained a 50% maximum ankle dorsal flexion force (MVF) for as long as possible without and, after a 30 min rest, with a European class I ECS. Finally, after another 30 mn rest, the pressure exerted by the ECS on the skin was measured at standard points on the limb, using a Salzmann apparatus. During the first 10 min of both rest periods, the subjects performed brief static maximum ankle dorsal flexions every 30 s. ECS exerted a 14.3 mm Hg mean pressure at tibial level C. Linear relationships, whose slopes were not influenced by ECS, existed between the maintenance time and both the mean power frequency and the logarithm of the total power of the tibialis anterior and gastrocnemius lateralis EMGs. The endurance times, the force recovery times after fatigue and the linear relationships between the logarithm of the time elapsing after exhaustion and the MVF reached during the recovery period were also independent of ECS. The results show that class I ECSs are not responsible for greater muscle fatigability; but they do not improve force recovery during rest following static fatiguing voluntary contractions.

Objective Evaluation of Skin Pressure Distribution of Graduated Elastic Compression Stockings

BACKGROUND

The beneficial effects of graduated elastic compression stockings (GCSs) have been demonstrated. However, their pressure performances are variable and unstable in practical applications owing to many influencing factors. Comprehensive assessment of skin pressure profiles may help elucidate the mechanisms of action of compression stockings.

OBJECTIVE

The objective of this study was to quantify and objectively evaluate the magnitude and distribution of skin pressure applied by different GCSs and to analyze the possible reasons influencing the stocking pressure performances.

METHODS

Six healthy females were required to wear eight kinds of GCSs with different pressure levels while standing upright. The skin pressures of 16 different positions located in four heights and four directions of the lower limb were measured and recorded by FlexiForce interface pressure sensors (Tekscan, Inc., Boston, MA, USA) and a multichannel measuring system.

RESULTS

The pressure gradients, pressure levels, and testing locations significantly influenced skin pressure (p < .001). All tested GCSs exerted the highest pressure at the ankle region, and the pressure gradually decreased toward the thigh, which follows the gradient design of GCSs. However, many of them failed to produce the perfect pressure gradients from the ankle region to the calf region. Obviously, reversed pressure gradients occurred in the medial side of the leg, where the pressure at the ankle region was lower than that on the prominent part of the calf by 36% on average. GCSs with higher pressure levels applied higher skin pressure on the lower limb. The pressure at the anterior side was far higher than that in the medial and lateral directions. The distribution patterns of skin pressure at transverse sections were similar to the anatomic outlines of cross sections of the leg. The measured average ankle pressure of all tested GCSs did not reach the pressures specified by the manufacturers.

CONCLUSION

Skin pressure distributions and magnitudes applied by GCSs were significantly influenced by the locations of testing points in terms of height and direction, which are determined by the specific anatomic structure and body shape of individual human legs and potentially influenced by the pressure sensor and testing methods.

Measurement of Lower Leg Compression In Vivo: Recommendations for the Performance of Measurements of Interface Pressure and Stiffness

BACKGROUND

Interface pressure and stiffness characterizing the elastic properties of the material are the parameters determining the dosage of compression treatment and should therefore be measured in future clinical trials.

OBJECTIVE

To provide some recommendations regarding the use of suitable methods for this indication.

METHOD

This article was formulated based on the results of an international consensus meeting between a group of medical experts and representatives from the industry held in January 2005 in Vienna, Austria.

RESULTS

Proposals are made concerning methods for measuring the interface pressure and for assessing the stiffness of a compression device in an individual patient.

CONCLUSIONS

In vivo measurement of interface pressure is encouraged when clinical and experimental outcomes of compression treatment are to be evaluated.

Health-related quality of life tools for venous-ulcerated patients

Healthcare manufacturing companies have developed many new and novel materials for wound care. They claim that the dressing materials will improve the healing progress of the wound or have a therapeutic value and have sought to assess their efficacy and effectiveness in clinical trials. These claims should be clearly supported by the perspectives of those who actually use the devices. Compression therapy, which is regarded as an effective treatment for venous leg ulcers, is far from ideal owing to a number of limitations that it possesses, such as patient discomfort, difficulty experienced in applying correct compression on the limbs, choosing a correct dressing for the wound or finding differences between the performance of various devices. It is necessary to investigate the patient's views and perspectives while randomized controlled clinical trials are conducted. In this review the concept of quality of life (QoL) and the tools used to measure QoL and studies that were conducted with patients suffering from chronic venous leg ulcers and undergoing therapy are considered, along with contributory factors to the healing process. In addition, a questionnaire modified from the original format is recommended as the suitable tool for assessing the QoL of patients suffering from venous leg ulcers while participating in clinical trials.

Effect of Posture on the Pressure Exerted by Below-Knee Class II Compression Stockings on Normal Subjects

Background:

Below-knee elastic compression stockings are widely used for the treatment of chronic venous insufficiency. The exact amount of pressure exerted by these stockings on different parts of leg and in different postures remains controversial.

Objective:

To examine the pressure exerted by correctly fitted class II below knee compression stockings at different levels and postures in normal subjects.

Methods:

Seven healthy human volunteers (mean age 38 years) were fitted with CEN class II below-knee compression stockings. Interface pressure measurements were recorded at 4 cm intervals from the malleolus to the top of the stocking on the medial and lateral aspects of the leg in supine, sitting and standing postures.

Results:

The interface pressure at 4 cm and 32 cm above the medial malleolus was not significantly different from the recommended values for class II socks and did not change significantly with posture. In the supine position the pressure at the mid-calf (12 cm) was greater than at the ankle (p < 0.05), creating a reverse pressure gradient, which increased further on standing (p < 0.05).

Conclusion:

The pressure profile under correctly fitted class II socks varies with posture due to the change in shape of the leg. The resulting profile deviates from the theoretical ideal of a graduated pressure gradient that adapts with posture. The clinical significance of this effect is not known.

Venous haemodynamics and the effects of compression stockings

Over the years, graduated compression stockings exerting varying ankle pressures have been used with differing degrees of effectiveness in the prevention of deep venous thrombosis and ulcer recurrence, and the treatment of venous ulceration (Stemmer et al, 1980; Partsch and Horakova, 1994; Veraart et al, 1997). Whether in the hospital or community setting, nurses often have the responsibility of measuring the limb and fitting the compression stocking on the patient and it is he/she who often influences the patient on the type of stocking and level of compression required. Understanding the influence of graduated compression on the venous haemodynamics of the lower limb and having a good working knowledge of the claims of the manufacturers as to expected levels of compression from each garment will aid the nurse and patient in decision making. An awareness of the hazards of inappropriate use of compression therapy should ensure that the nurse is a safe practitioner.

Movement-related variation in forces under compression stockings

OBJECTIVES

Compression therapy is widely used in the treatment of venous leg ulcers, but the efficacy of this treatment is variable. Assessment of variation in compression forces associated with movement may help to elucidate the mechanism of action of compression therapy. The aim of this study was to develop and apply a system to investigate forces under compression stockings during movement.

METHOD

Three sensors were placed on the medial aspect of the left leg on six healthy volunteers to monitor forces under class 2 (Continental European classification) compression stockings. Data were recorded during dorsiflexion and plantar flexion of the left foot and also during short periods of walking.

RESULTS

Changes in pressure were observed, associated with dorsiflexion and plantar flexion of the foot. These changes were dependent on sensor position. Changes in pressure during walking were also position-dependent and of variable duration.

CONCLUSIONS

The system enables forces associated with compression therapy to be examined during movement and may thus be of value in further understanding its mechanism of action. Foot movement can be associated with clear changes in pressure under compression stockings and rapid changes in pressure may occur during walking.

Muller's ambulatory phlebectomy and compression

BACKGROUND

Compression therapy will relieve patients of symptoms of venous disease, if not prevent the occurrence of complications, and is used either alone or in combination with other treatment options.

OBJECTIVE

To describe the use of compression in the two main therapy modalities: sclerocompression and ambulatory phlebectomy.

METHODS

Aim and mechanism of compression therapy are analyzed and clinical implications are discussed.

RESULTS

A modification of compression therapy after ambulatory phlebectomy is suggested based on empirical evidence.

CONCLUSIONS

The use of broad compression pads after ambulatory phlebectomy reduces hemorrhage and enhances resorption.