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Compartment syndrome

Q - Is there an association between use of intermittent pneumatic compression and patients developing
A - Compartment syndrome (CS) is most commonly associated with trauma or surgery to the limbs, although the actual incidence is relatively low (Raza 2004). Rare anecdotal reports have postulated, in the absence of evidence, that intermittent pneumatic compression (IPC) may have been one contributory factor to the development of CS. However, Gilbart et al (1995) demonstrated that the periods of pressure elevation produced by IPC were insufficiently long to produce any adverse effects. Where CS has occurred, it has been in association with prolonged lithotomy or Lloyd Davies positions and multiple risk factors, hence the causative factors are difficult to determine.

Pfeffer et al (2001) looked at the effects of IPC on directly measured intracompartmental pressure in the lower limb in 25 healthy volunteers with the leg in 3 different lithotomy positions. The findings suggested that support near the ankle resulted in lower compartment pressures while the application of IPC in this study was associated with a general decrease in intracompartmental pressures. The FLOWTRON® system does not apply high enough pressures to cause damage to the muscle, tissue or vasculature within the limb and evidence of any association between IPC and CS is lacking.

However, as a precautionary measure and part of good practice, we recommend regular repositioning of a limb when using IPC in the lithotomy position or modifying the position to extend the limb laterally. Use of a foot garment may be an alternative solution particularly for prolonged procedures in those patients with a large body mass index.

History of PE

Q - Can the FLOWTRON® system be used on patients with a history of previous PE?
A - Yes, as long as there is no suspicion of acute PE. Having had one episode of venous thromboembolism, the patient is at increased risk of another, therefore it is important to risk assess and where necessary implement prophylaxis as soon as possible.

Large limbs

Q - What should I do where standard sized garments do not fit the patient who has a large limb? Is it OK to fasten two together to make a single large garment?
A - FLOWTRON® DVT prophylaxis garments are designed, licensed and sold to be used where one garment is applied on each leg. Garment design (be it foot, calf or calf and thigh) is based upon the principle of applying pressure to a specific part of the lower limb to augment blood flow, enhance anti-thrombotic and pro- fibrinolytic effects, preventing DVT formation. This is achieved using a specifically shaped single piece of specialist fabric in the garment construction that has been quality assessed for durability and safety as well as undergoing vigorous testing in the clinical setting.
For patients with a large limb size, either a foot garment or bariatric sized garment should be utilised.
Anecdotally there have been reports of clinicians using two calf garments fastened together for patients with a large limb size. This cannot be recommended or endorsed. The outcomes of this practice are unknown and there is potential risk of an adverse event.

Use after previous DVT

Q - After a previous DVT, how soon can the FLOWTRON® system be used?
A - Deep Vein Thromboses resolve by local infiltration of the thrombus by white blood cells, retraction and recanalisation of the vein. Once diagnosed, patients are given anticoagulants (such as LMWH, heparin, warfarin etc) to prevent build up of any further thrombus formation and, after a few days, will begin to mobilise.

The action of the calf and foot muscle pumps is similar to that of the FLOWTRON garments. Thus if a patient is mobile with a DVT they will be using the natural foot and calf pumps – use of FLOWTRON merely mimics these effects so is unlikely to be detrimental.
For non-mobile patients with acute DVT the use of Intermittent Pneumatic Compression (IPC) is not recommended, however it can be used once the acute symptoms of DVT have resolved i.e. reduction of swelling, redness, pain etc.

In the post-DVT phase IPC is an efficient way of reducing oedema, stimulating blood flow and is indicated in post-phlebitic syndrome.

Re-starting therapy

Q - After a period of non-use, can the FLOWTRON® garments be re-applied and therapy re-started without
A - The FLOWTRON DVT system can only prevent stasis when it is applied and working on the leg / foot. Although there are longer term haematological changes, which persist when the therapy is paused, it is unpredictable for individual patients and depends on multiple factors (Morris and Woodcock 2004, 2006). The general advice is that the FLOWTRON DVT system should only be stopped if the patient is mobilising, or for short periods of time. If a longer time period occurs, then FLOWTRON DVT prophylaxis should only be recommenced if there are no clinical signs/symptoms of DVT (redness, swelling, pain etc). In the event of possible clinical signs/symptoms, screening for DVT using Duplex ultrasound should be performed.

Given the wide variation in individual risk factors and co-morbidities, it is not possible to indicate a ‘safe’ period within which therapy can be restarted.

Seated position

Q - When using the FLOWTRON® system, does the seated position adversely affect venous return?
A - No. We undertake testing of the FLOWTRON system with all our associated garments, in subjects with limbs elevated, as well as dependent and both positions demonstrate significant venous augmentation. However having the legs elevated does enhance venous return.

Skin grafts

Q - Can the FLOWTRON® system be used over skin grafts?
A - Yes but with caution. This will be dependent upon location of the graft, the securing dressing and the view of the surgeon in charge of the patient.

Using calf garments

Q - Does using the calf garment leave the patient at risk of DVT distal to this i.e. ankle/foot area?
A - Isolated foot DVT is not something that's routinely found. By removing blood from the calf, fluid is encouraged to move from the foot to the space created in the calf vessels. There is only relative stasis in the foot during the compression; therefore intermittent pneumatic compression is unlikely to pose a risk.

Varicose veins

Q - Can the FLOWTRON® system be used on patients with varicose veins?
A - Yes. Use of the FLOWTRON system enhances venous blood flow.

Venous access and blood pressure monitoring

Q - Can I use other medical devices beneath a Flowtron® intermittent compression garment?
A - All intermittent compression (IPC) devices are designed to alter the blood flow in the limb during both the compressive and refill phases of the cycle; this will have an effect on any other medical equipment used on the same limb. As a result, the use of monitoring equipment (such as oximetry, venous access lines, blood pressure cuffs and arterial lines) or drug delivery/infusion lines beneath a compression garment should be avoided where possible.

Fluid and drug administration:
If fluids or drugs are being administered as a continuous infusion or via a pump, the use of IPC may intermittently interrupt the therapy regimen; whether this will have a marginal or detrimental effect on the treatment will depend both upon the patient’s condition and the drug being administered. In addition, intermittent compression may cause repeated infusion pump alarms, while localised movement over the vascular access site may cause irritation, leakage or line displacement.
If IPC is considered essential, then the use of a foot garment on the affected limb will reduce side effects by eliminating the direct irritation. However, the pulsatile effect on blood flow (arising from plantar plexus compression) may still influence drug delivery.

Blood pressure and vital signs monitoring equipment:
If blood pressure, or other monitoring equipment, is placed beneath the compression garment the readings are likely to be unreliable if recorded during, or immediately after, the compressive phase: the exact effect cannot be determined, as it will vary between patients. Similarly, readings taken from arterial lines may be unreliable and may cause ‘false low pressure’ alarms from monitoring equipment.
We recommend that monitoring equipment is not placed beneath garments but, if there is no alternative, readings need to be supervised to ensure the results are not coincidental with, and thus confounded by, the inflation cycle.

General advice:
Where any device is placed beneath a compression garment, the skin and surrounding tissue should be regularly assessed for sign of irritation or damage. If IPC therapy is interrupted it is important to restart the therapy as soon as the monitoring is complete: no longer than a few minutes. As the range of individual circumstances is wide, the final decision must rest with the treating physician and be based upon the risk and benefit associated with complex cases.


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