Running head: SYNTHESIS PAPER
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Synthesis Paper
Kristen Shiver
University of South Florida
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SYNTHESIS PAPER
Abstract
Deep vein thrombosis (DVT) is a serious complication that many hospitalized
patients who are immobile are at risk for. Lung transplant patients are at high risk
for deep vein thrombosis complications due to the postoperative immobile period
and sensitivity of the new organ. The objective of this paper is to determine if the
use of a sequential compression device during admission will reduce the risk of
deep vein thrombosis and related complications in postoperative lung transplant
patients. By using Google Scholar, PubMed, and CINAHL, three randomized
controlled trials were found with the keywords of DVT prophylaxis, intermittent
pneumatic compression, and DVT prophylaxis postoperatively. By utilizing the
Agency for Healthcare Research and Quality one clinical practice guideline was
found. All the studies evaluated showed positive outcomes for patients using some
form of intermittent compression device. Each study displayed strong evidence that
mechanical compression was both effective and perhaps safer than strictly
pharmacological methods. The clinical practice guideline states that venous
thromboembolism prophylaxis includes pneumatic compression devices placed
before surgery and continued until patient is fully ambulatory as well anticoagulant
therapy after surgery until discharge (ACOG, 2007).
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SYNTHESIS PAPER
Sequential Compression Device Use on DVT Prevention
In the hospital, all non-ambulatory patients are a greater risk of developing
deep vein thrombosis and subsequent complications, such as pulmonary embolism.
According to an article by the CLOTS Trials Collaboration (2013), venous
thromboembolism is one of the most important, potentially preventable, causes of
death and morbidity in patients in hospital. To prevent deep vein thrombosis (DVT)
complications, it is imperative to include some form of prophylaxis in the patient
care plan. Sobiera-Teague et al. (2011) states that in patients not receiving
thromboprophylaxis, the reported frequency of any venous thrombotic embolism
(VTE) has ranged from 29% to 60%.
In postoperative lung transplant patients, DVT prophylaxis is especially
important because these patients are at an even greater risk of complications
resulting from DVT, mainly pulmonary embolism, not just due to immobility but to
the sensitivity of the transplanted organ and immunosuppression. Approximately
90% of symptomatic pulmonary emboli result from lower extremity deep vein
thrombosis, thus demonstrating the critical use of prophylaxis for lung transplant
patients (Colwell et al., 2005). To evaluate the prevention of DVT in this patient
population a PICOT question was formed. In lung transplant patients, how does
sequential compression device use compared to no sequential compression device
use affect the development of deep vein thrombosis during current admission?
Literature Search
To conduct the search for appropriate evidence based literature, Google
Scholar, PubMed, and CINHAL were used. Three randomized controlled trials were
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SYNTHESIS PAPER
found using the key words deep vein thrombosis, DVT prophylaxis, intermittent
pneumatic compression, and DVT prophylaxis postoperatively. One clinical practice
guideline was found using the Agency for Healthcare Research and Quality
(AHRQ)(Table 1).
Literature Review
The guideline from the American College of Obstetricians and Gynecologist
(ACOG) for prevention of DVT discussed the evidence-based recommendations for
preventing DVT in surgical gynecological patients (2007). The guideline used
various databases to conduct a literature search for relevant articles discussing the
topic, and was reaffirmed in 2012 by utilizing a similar literature search for more
current articles. The recommendations made by the guideline for moderate to highrisk patients include: Pneumatic compression devices placed before initiation of
surgery and continued until the patient is fully ambulatory, unfractionated heparin
(5,000 units) administered subcutaneously 2 hours before surgery and every 8
hours postoperatively and continued until discharge, and Low molecular weight
heparin (dalteparin 5,000 antifactor-Xa units or enoxaparin 40 mg) administered
subcutaneously, 12 hours before surgery and once daily postoperatively until
discharge(ACOG, 2007). Though this guideline is referring to surgical gynecological
patients specifically, it is relevant to the postoperative lung transplant patient
population because both are surgical populations utilizing DVT prophylaxis.
Sobiera-Teague et al. (2011) performed a randomized controlled trial about
the use of a specific portable compression device called Venowave for prevention of
SYNTHESIS PAPER
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DVT in neurosurgical patients. The article discussed the process of randomly
assigning 75 patients to receive Venowave devices and 75 patients to the control
group. All were neurosurgical patients 18 or older and all standard measures taken
to prevent DVT regardless. The outcome of the study was measured by confirming
DVT presence or absence with venography and compression ultrasound. The results
of the study showed a significant decrease in the incidence of DVT formation for the
group of patients who received the Venowave device, for patients with the
Venowave device the rate of VTE was 4.0% compared to 18.7% in the control group
(P=0.008). The strengths of this source are that is a randomized controlled trial,
displaying the highest level of evidence, and that the study uses both post surgical
patients and non-surgical patients. A weakness of the article is that all patients
received some form of prophylaxis, therefore there could be other factors
influencing the success of the device.
Colwell et al. (2005) conducted a randomized controlled trial about the use
of mechanical compression device compared to low molecular weight heparin in the
prevention of bleeding events and DVT. Patients who had a total hip arthroplasty
were randomized to receive prophylaxis with a mobile compression device or low
molecular weight heparin for ten days. The study consisted of 410 patients with
205 patients in the compression group and 209 in the heparin group. All patients
were over 18 years of age and were scheduled for the procedure and had no history
of venous thromboembolism or coagulation disorder. Definitions for major bleeding
events and methods used to confirm these events and DVT events were discussed.
The study showed a significantly higher instance of bleeding in the heparin group.
SYNTHESIS PAPER
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The rate of major bleeding events was 0% in the compression device group and 6%
in the heparin group and the difference as significant (p=0.0004). There was no
measurable difference between the two groups with regard to DVT prevalence. The
study supported the use of mechanical compression versus heparin therapy as a
form of prophylaxis in this patient population. A strength of the article is that is
studying a specific post surgical patient population and is a randomized controlled
trial. A weakness of the article is that there was little evidence specifically about
DVT events versus bleeding events and that the mechanical compression group
received a low dose aspirin as well.
The final study conducted by the CLOTS Trials Collaboration (2013),
assessed the effectiveness of intermittent pneumatic compression (IPC) to reduce
the risk of DVT in patients who have had a stroke. This was a randomized controlled
trial, taking place in hospitals where patients were randomized to either receive IPC
or not on the day of admission. A technician who was masked to treatment
allocation did a compression duplex ultrasound (CDU) of both legs at 7–10 days and,
wherever practical, at 25–30 days after enrollment. The sample consisted of 2876
patients enrolled in 94 centers in the UK. The included patients were broadly
representative of immobile stroke patients admitted to hospital and had a median
age of 76 years. The results of the study supported the use of IPC by showing that
the difference in the number of patients developing a DVT was 8.5% for patients
receiving the ICP and 12.1% for patients who did not receive IPC with a significant
difference of p=0.001. A strength of this article is that is a randomized controlled
trial and discusses a immobile patient population. A weakness of this article is that
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SYNTHESIS PAPER
is not explicitly looking at the population under question and that medication use
was not thoroughly discussed.
Synthesis
All of the research reviewed supports the use of intermittent pneumatic
compression devices for the prevention of DVT and relating complications in
postoperative patients (ACOG, 2007; CLOTS, 2013; Colwell et al., 2010; SobieraTeague et al., 2011). One study found that with the use of a portable pneumatic
compression device the risk of venous thrombotic events were reduced by 79%
when compared with no pneumatic compression device (Sobiera-Teague et al.,
2011). Colwell et al. (2005) found that mechanical compression proved to be safer
than heparin therapy in regards to major bleeding events after surgery. Finally the
study conducted by the CLOTS Trials Collaboration (2013), further proves that
universally intermittent pneumatic compression significantly decreases the
incidence of DVT of hospitalized patients across healthcare systems by analyzing
patients at multiple hospital locations and using the largest sample group.
While the research does strongly support the use of intermittent
compression devices, there are gaps in the research. For instance, assessing the use
of mechanical compression solely, without any outside factors, is nearly impossible
due to the nature of care in the hospital and multi-disciplinary approaches to care.
Another area that was not discussed thoroughly in the literature was the effect of
patient and provider compliance on DVT prevention outcomes. Both mechanical and
pharmacological methods of prophylaxis success are dependent on patient
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SYNTHESIS PAPER
compliance and knowledge of treatment and all members of the care team correctly
and consistently applying methods.
Clinical Recommendations
Venous thrombosis prophylaxis is a widely accepted and commonly
implemented measure taken for many hospitalized patients, however there is not
always a set policy to ensure that all necessary measures are taken. In order to
ensure success consistent with the evidence based research, policies, procedures,
and education need to be in place for all members of the healthcare team as well as
patients. In relation to lung transplant patients, there should be a specific policy
regarding the continued use of intermittent pneumatic compression devices, even
with the use of pharmacological agents as well. The policy should specify that at all
times the patient is not ambulating; intermittent pneumatic compression devices
should be on the patient. Clinicians and managers will be responsible for educating
members of their team about policies and correct use of the devices. Nurses will also
need to include in their care plans use of the device as well as patient education
about the device, the importance of use, and consistent monitoring of compliance.
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SYNTHESIS PAPER
References
American College of Obstetricians and Gynecologists (ACOG). (2007). Prevention of
deep vein thrombosis and pulmonary embolism. ACOG Practice Bulletin, 84.
Retrieved from www.guideline.gov
CLOTS (Clots in Legs Or Stockings after Stroke) Trials Collaboration. (2013).
Effectiveness of intermittent pneumatic compression in reduction of risk of
deep vein thrombosis in patients who have had a stroke (CLOTS 3): A
multicentre randomised controlled trial. The Lancet, 382(9891), 516-524.
doi: 10.1016/S0140-6736(13)61050-8
Colwell, C.W., Froimson, M. I., Mont, M.A., Ritter, M.A., Trousdale, R.T., Buehler, K.C.,
…Padgett, D.E. (2010). Thrombosis prevention after total hip arthroplasty: A
prospective, randomized trial comparing a mobile compression device with
low-molecular-weight heparin. The Journal of Bone and Joint Surgery, 92, 527535. doi: 10.2106/JBJS.I.0047
Sobiera-Teague, M., Hirsh, J., Yip, G., Gastaldo, F., Stokes, T., Sloane, D., …Eikelbloom,
W. (2011). Randomized controlled trial of a new portable calf compression
device (Venowave) for prevention of venous thrombosis in high-risk
neurosurgical patients. Journal of Thrombosis and Haemostasis, 10, 229-235.
doi: 10.1111/j.1538-7836.2011.04598.x
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SYNTHESIS PAPER
Table 1
Literature Review
Reference
Aims
Sobiera-Teague,
M., Hirsh, J., Yip,
G., Gastaldo, F.,
Stokes, T.,
Sloane, D.,
…Eikelbloom, W.
(2011).
Randomized
controlled trial of
a new portable
calf compression
device
(Venowave) for
prevention of
venous
thrombosis in
high-risk
neurosurgical
patients. Journal
of Thrombosis
and Haemostasis,
10, 229-235. doi:
10.1111/j.15387836.2011.04598.
x
Colwell, C.W.,
Froimson, M. I.,
Mont, M.A.,
Ritter, M.A.,
Trousdale, R.T.,
Buehler, K.C.,
…Padgett, D.E.
(2010).
Thrombosis
prevention after
total hip
arthroplasty: A
prospective,
randomized trial
comparing a
mobile
Sample
To assess efficacy
and tolerability of
a portable
intermittent
compression
device
(Venowave) for
the prevention of
VTE in
neurosurgical
patients.
Design
and
Measures
A RCT
comparing
a specific
IPC device
with the
control.
Primary
outcome
was no
DVT
detected.
To compare a new
mobile
compression
device with low
molecular weight
heparin with
regard to their
safety and
effectiveness fro
the prevention of
venous
thromboembolic
disease.
A RCT
with
patients
randomize
d to
receive
either
prophylaxi
s or
mobile
compressi
on for 10
days.
410 patients
with 205 in
compressio
n group and
209 in
heparin
group.
Outcomes /
statistics
150
For patients with
Neurosurgic the Venowave
al patients.
device the rate of
VTE was 4.0%
compared to
18.7% in the
control group
(P=0.008)
The rate of major
bleeding events
was 0% in the
compression
device group and
6% in the heparin
group and the
difference as
significant
(p=0.0004). There
was no measurable
difference between
the two groups
with regard to
DVT prevalence.
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SYNTHESIS PAPER
compression
device with lowmolecular-weight
heparin. The
Journal of Bone
and Joint
Surgery, 92, 527535. doi:
10.2106/JBJS.I.00
47
CLOTS (Clots in
Legs Or
Stockings after
Stroke) Trials
Collaboration.
(2013).
Effectiveness of
intermittent
pneumatic
compression in
reduction of risk
of deep vein
thrombosis in
patients who have
had a stroke
(CLOTS 3): A
multicentre
randomised
controlled trial.
The Lancet,
382(9891), 516524. doi:
10.1016/S01406736(13)61050-8
American College
of Obstetricians
and
Gynecologists
(ACOG). (2007).
Prevention of
deep vein
thrombosis and
pulmonary
embolism. ACOG
Practice Bulletin,
To assess the
effectiveness of
IPC to reduce the
risk of DVT in
patients who
have had a stroke.
A RCT
where
patients
were
randomize
d to either
receive
IPC or not
on day of
admission.
2876
immobile
stroke
patients
were
enrolled in
94 centers.
The difference in
the number of
patients
developing a DVT
was 8.5% for
patients receiving
the ICP and 12.1%
for patients who
did not receive IPC
with a significant
difference of
p=0.001.
To aid
practitioners in
making decisions
about
appropriate
obstetric and
gynecologic care.
To review the
current literature
on the use of
thromboprophyla
Handsearches
of
Published
Literature
(Primary
Sources)
Handsearches
of
Published
Women
undergoing
gynecologi
c surgery
Effectiveness of
thromboprophyla
xis for preventing
venous
thromboembolis
m
Prophylacticrelated morbidity
and mortality
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SYNTHESIS PAPER
84. Retrieved
from
www.guideline.g
ov
xis in gynecology
patients and to
provide evidencebased
recommendations
to guide clinical
decision making.
Literature
(Secondar
y Sources)
Searches
of
Electronic
Databases