guys.. here i thought we were friends ;) · 1. lower limb venous ultrasound 2. endovenous saphenous...
TRANSCRIPT
compression therapy inpost-TRAUMA INFLAMMATION & OEDEMA
Sergio Gianesini, MD, PhD, FACS
University of Ferrara (ITALY)USUHS University (BETHESDA, USA)
NO CONFLICT OF INTERESTS
…GUYS.. here I thought we were friends ;)
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AVAILABLE LITERATURE
STANDARDIZED TRAUMA
Champion HR.Major trauma in geriatric patientsAm J Public Health. 1989
LEADING CAUSE OF MORBILITY and MORTALITY
Physiological - SCORE - Anatomical
TRAUMA & INJURY Severity SCOREJavali R. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for MortalityPrediction in Elderly Trauma PatientsIndian J Critical Care Med 2019
10.5% documented LYMPHATIC lesions
23.6% consequence of DVT
65.9% edema related to INFLAMMATION.
G. Szczesny.
Post-traumatic lymphatic and venous drainage changes in persistent edema of lower extremities. Chirurgia Narzad´ow Ruchu iOrtopedia Polska,vol. 65, no. 3, pp. 315–325, 2000.
TRAUMATIC OEDEMA
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OEDEMA
Venous-lymphatictrauma component
increasedcapillary permeability
INFLAMMATION
OEDEMA
Venous-lymphatictrauma component
increasedcapillary permeability
abnormal loss ofplasma proteins
INFLAMMATION
OEDEMA
Venous-lymphatictrauma component
increasedcapillary permeability
abnormal loss ofplasma proteins
swelling
cellulitis/infection
INFLAMMATION
OEDEMA
Venous-lymphatictrauma component
increasedcapillary permeability
abnormal loss ofplasma proteins
reduced mobility
Holm B. Loss of knee-extension strength isrelated to knee swelling after total knee
arthroplasty. Arch Phys Med Rehabil. 2010;91(11):1770–6.
swelling
cellulitis/infection
INFLAMMATION
OEDEMA
Venous-lymphatictrauma component
increasedcapillary permeability
abnormal loss ofplasma proteins
reduced mobility
less lymphatic pump
Holm B. Loss of knee-extension strength isrelated to knee swelling after total knee
arthroplasty. Arch Phys Med Rehabil. 2010;91(11):1770–6.
swelling
cellulitis/infection
INFLAMMATION
OEDEMA
Venous-lymphatictrauma component
increasedcapillary permeability
abnormal loss ofplasma proteins
increasedinterstitialpressure
reduced mobility
less lymphatic pump
Holm B. Loss of knee-extension strength isrelated to knee swelling after total knee
arthroplasty. Arch Phys Med Rehabil. 2010;91(11):1770–6.
swelling
cellulitis/infection
INFLAMMATION
Eur J Trauma Emerg Surg. 2017 Aug;43(4):451-459.
Compression therapy after ankle fracture surgery: a systematic review.
Winge R
8 studies (451 patients)
Bandages, GCS, IPC:
- significant effect on EDEMA (7 studies)
- significant reduction in PAIN (2 studies)
- positive effect on ANKLE ROM (1 study)
- effect on WOUND HEALING (2 studies)
- length of stay reduction (1 study)
- reduction in time to surgery (2 studies).
8 studies (451 patients)
Bandages, GCS, IPC: from 10 mmHg to 130 mmHg.
- significant effect on EDEMA (7 studies)
- significant reduction in PAIN (2 studies)
- positive effect on ANKLE ROM (1 study)
- effect on WOUND HEALING (2 studies)
- length of stay reduction (1 study)
- reduction in time to surgery (2 studies).
*methodological limitations
Eur J Trauma Emerg Surg. 2017 Aug;43(4):451-459.
Compression therapy after ankle fracture surgery: a systematic review.
Winge R
knee length GCS20–30 mmHg
EDEMA70.00% vs. 33.33%; p.0.0045
Phlebology. 2019 Graduated compression stockingseffects on chronic venous disease
signs and symptoms duringpregnancy.
Saliba Júnior OA
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BMC Musculoskeletal Disorders (2019) 20:161.
Impact of compression stockings on leg
SWELLING after arthroscopyTischer T
CHANGE OF CICUMFERENCE KNEE
CHANGE OF CICUMFERENCE MID LEG
CHANGE OF CICUMFERENCE MIDDLE THIGH
23-32 mmHgvs
NO compression
p<.05
10 days
Munk S. Effect of compression
therapy on knee swelling and pain after total knee arthroplasty.
Knee Surg Sports Traumatol Arthrosc. 2013;21(2):388–92.
23-32 mmHgvs
NO compression
p<NS
Post-op day: 1, 2, 7, 14, 30
Munk S. Effect of compression
therapy on knee swelling and pain after total knee arthroplasty.
Knee Surg Sports Traumatol Arthrosc. 2013;21(2):388–92.
23-32 mmHgvs
NO compression
p<NS
Post-op day: 1, 2, 7, 14, 30
..but assessment at knee level and below(Tischer > edema at the thigh)
Munk S. Effect of compression
therapy on knee swelling and pain after total knee arthroplasty.
Knee Surg Sports Traumatol Arthrosc. 2013;21(2):388–92.
23-32 mmHgvs
NO compression
p<NS
Post-op day: 1, 2, 7, 14, 30
..but assessment at knee level and below(Tischer > edema at the thigh)
GCS:
- 69% increased knee stability
- 60% felt a reduction in knee swelling
- 38% reduction in knee pain
J Bone Joint Surg Am. 2014;96:1263-71Effective Treatment of Posttraumatic and
Postoperative Edema in Patients with
Ankle and Hindfoot Fractures
Rohner-Spengler M
median EDEMA:
MULTILAYER > COLD PACK > IMPULSE
0%
222%
17%
COLD PACKfoundation, ONLUS
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Ann R Coll Surg Engl 2012; 94: 463–467GCS in hip fractures
A Alsawadi
GCS, foot impulse devices or IPC should be offered to all patientsundergoing hip fracture surgery
based on individual patient factors
Venous ThromboembolismLondon: NICE
2010
The evidence supporting theserecommendations
is very limited
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Global guidelines trends & ocntroversies in
lower limb venous and lympahtic disease
Sergio Gianesini, MD, PhD, FACS
University of Ferrara (ITALY)UCES University (ARGENTINA)USUHS University, Bethesda (USA)
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SECTIONS
1. Lower limb venous ultrasound
2. Endovenous saphenous ablation
3. Bandaging, Adjustable Compression Wraps, Intermittent
Pneumatic Compression
4. Graduated Elastic Stockings
5. Sclerotherapy for varicose veins
6. Aesthetic phlebology
7. Acute and chronic deep venous disease
8. Venous Active Drugs - Ulcer management
9. Lower limb lymphedema
10. Venous thrombosis management
POST-PREOCEDURAL COMPRESSION
1B1A 1A
2B 2B2C 2C2C
1B
24 hours
3 weeks
POST-PREOCEDURAL COMPRESSION
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POST-PREOCEDURAL COMPRESSION
40 mmHg16 mmHg
*NICE, EUR and LATAM don’t specify
GLOBAL 2019: based on the physician indication
INTERMITTENT
PNEUMATIC COMPRESSION
for
reducing
TRAUMATIC OEDEMA
Caschman J, The efficacy of the A-V Impulse system in the
treatment of posttraumatic swelling following ankle fracture: a
prospective randomized controlled study. J Orthop Trauma. 2004
Oct;18(9):596-601.
Myerson MS. The use of a pneumatic intermittent impulse
compression device in the treatment of calcaneus fractures. Mil Med.
2000 Oct;165(10):721-5.
Thordarson DB. Facilitating edema resolution with a foot pump after
calcaneus fracture. J Orthop Trauma. 1999 Jan;13(1):43-6.
St¨ockle U. Fastest reduction of posttraumatic edema: continuous
cryotherapy or intermittent impulse compression? Foot Ankle Int. 1997
Jul;18(7):432-8.
Myerson MS. Clinical applications of a pneumatic intermittent
impulse compression device after trauma and major surgery to the foot
and ankle. Foot Ankle. 1993 May;14(4):198-203.
Gardner AM. Reduction of post-traumatic swelling and compartment
pressure by impulse compression of the foot. J Bone Joint Surg Br.
1990 Sep;72(5):810-5.
McMullin G. An assessment of the effect of the foot pump on venous
emptying in chronic venous insufficiency. In: Davy A, Stremmer R,
editors. Phlebologie. London: John Libbey; 1989. p 69-71.
Gardner AM. The venous pump of the human foot—preliminary report.
Bristol Med Chir J. 1983 Jul;98(367):109-12.
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Phlebology 2015
Pneumatic thigh compression reduces calf volume and augments the venous return
Lattimer C
Thigh compression Venous dilation After load microcirculation resistance
• Interface pressure in B and B1Gianesini S, Raffetto J, Mosti G et al. Graduated Compression Lower Limb Volume Control in Different Muscle Pump Activation Conditions and Related Limb ShapeImpact. J Vasc Surg VL 2019;7(2):295-296.
• Compliance assessment
• IPC proper use Only 19% of trauma patients are receiving proper IPC
Cornwell EE, 3rd, Chang D, Velmahos G, et al. Compliance with sequentialcompression deviceprophylaxis in at-risk trauma patients: a prospective analysis. Am Surg. 2002;68:470-473.
• IPC protocols
NEWS
BACKGROUNDHow do we define
a “long-haul” flight?
PROLONGED FLIGHT BRITISH JOURNAL OF HEMATOLOGY 2011:
NO indication to GCS to everybody (1C).
Patients at risk of DVT should wear GCS
if >3 hrs.
PROLONGED FLIGHT BRITISH JOURNAL OF HEMATOLOGY 2011:
NO indication to GCS to everybody (1C).
Patients at risk of DVT should wear GCS
if >3 hrs.NICE:
recommendes in all patients at risk
PROLONGED FLIGHT BRITISH JOURNAL OF HEMATOLOGY 2011:
NO indication to GCS to everybody (1C).
Patients at risk of DVT should wear GCS
if >3 hrs.
ACCP 2012:
for patients at risk, in >3 hrs, 15-30 mmHg
(GRADE 2C)
NICE:
recommendes in all patients at risk
PROLONGED FLIGHT
EUROPE 2018: in all patients at risk (2B),
but theguidelines are also recommending
GCS in healthy subjects at risk of developing edema (1B)
BRITISH JOURNAL OF HEMATOLOGY 2011:
NO indication to GCS to everybody (1C).
Patients at risk of DVT should wear GCS
if >3 hrs.
ACCP 2012:
for patients at risk, in >3 hrs, 15-30 mmHg
(GRADE 2C)
NICE:
recommendes in all patients at risk
Always report
INTERFACE PRESSUREIn
B & B1foundation, ONLUS
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Medsurg Nurs. 2013 Nov-Dec;22(6):370-4.
Incidence of incorrectly sized graduated compression stockings and
lower leg skin irregularities in postoperative orthopedic patients.
52 patients (total hip/knee arthoplasty)
Incorrectly fitting: 10%
Edema, erythema, ecchymosis,
blistering, breaks in the skin: 4%
flow velocity increase in the compressed thigh,but also in the caval vein
, J DERMATOL SURG ONCOL_1991
18-21 mmHg
APG (ns)
CIVIQ 20 (p)
VVSYMQ (p)
CIRCUMEFERENCE (p)
CUTE FASCIA US III MEDIO GAMBA E COSCIA
ROM CAVIGLIA (3 gadi)
QUESTIONARIO ORTOPEDICO (migliorato)
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PHLEB-Ortho project
J Clin Epidemiol. 2010 May;63(5):550-7. The Italian version of the lower extremity functional scale was reliable, valid, and responsive.
Cacchio A
ValidReliable
Responsive
For
musculo-skeletaldysfunctionassessment
PHLEB-Ortho STUDY(Knee arthroplasty/Hip replacement)
23-32 mmHg18-21 mmHg
30 daysCIRCUMEFERENCE
LEG VOLUMEUS subcutaneous thickness
APG
Ankle ROM
CIVIQ 20VVSYMQ
LOWER EXTREMITY FUNCTIONAL SCALE
PRELIMINARY DATA
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STUDY POPULATION14 patients
GROUP 18-21 mmHg(group A)
10 patients
GROUP 23 -32 mmHg(group B)4 patients
P*
Agemean±st. dev
69±13 71±14 67±13 0.55
M/F 2/12 1/6 1/8
BMImean±st. dev
27±3 27±3 27±3 0.67
CEAP C1 n°12C2 n°2
C1 n°4C2 n°2
C1 n°8C2 n°0
KNEE (n°) 6 4 2
HIP (n°) 8 6 2
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2241 2230 2616 2437
0
500
1000
1500
2000
2500
3000
3500
T0 T1 T0 T1
LEG VOLUME (mL)
± 327 ± 310
± 469± 457
p<0.0001p<0.4967
-179 mL (-6.8%)-11 mL (0.5%)
18-21 mmHg 23-32 mmHg
Two-tailed paired Student-T Test
PHLEB-Orthostudy
18-21 mmHg 23-32 mmHg
± 9
± 11
p<0.01p<0.1019
14° (32%)7° (16%)
± 10
42 48 4458
0
10
20
30
40
50
60
70
T0 T1 T0 T1
Flexion-extension width
± 8
Two-tailed paired Student-T Test
PHLEB-Orthostudy
1,121,07
0,68
0,50
0,00
0,20
0,40
0,60
0,80
1,00
1,20
1,40
1,60
1,80
2,00
T0 T1 T0 T1
VFI
p<0.08
p<0.8146
± 0.60± 0.71
± 0.15
± 0.24
18-21 mmHg 23-32 mmHg
Two-tailed paired Student-T Test
PHLEB-Orthostudy
0,76
0,61
0,84
0,61
0,00
0,20
0,40
0,60
0,80
1,00
1,20
1,40
T0 T1 T0 T1
Leg-Subcutaneous Thickness (cm)
18-21 mmHg 23-32 mmHgTwo-tailed paired Student-T Test
± 0.35
± 0.38
± 0.41
± 0.35
p<0.004
p<0.2418p<0.05
1,4 1,2 1,2 1,0
0,0
0,2
0,4
0,6
0,8
1,0
1,2
1,4
1,6
1,8
2,0
T0 T1 T0 T1
Thigh-SubcutanousThickness (cm)
± 0.54± 0.52
± 0.41
± 0.40
p<0.2339
p<0.05
PHLEB-Ortho study
LEFSPre-Op
LEFSPost-Op
pCIVQ-20Pre-Op
CIVQ-20Post-Op
pVVSym-Q
Pre-OpVVSym-QPost-Op
p
18-21mmHg
21.6±7.3 39.8±7.1 0.01 48.6±7.9 71.3±5.3 0.003 4.5±1.2 3.3±0.8 0.03
23-32 mmHg
25.5±7.449.1±8.3
0.003 46.8±13.3 80.1±22.9 0.005 4.3±0.7 1.75±1.9 0.008
QoL
Two-tailed paired Student-T Test
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2240
26 49
0
10
20
30
40
50
60
70
T0 T1 T0 T1
LEFS
92%p<0.0003
83%p<0.01
± 7.3
± 7.1
± 7.5
± 8.3
18-21 mmHg 23-32 mmHg
PHLEB-Orthostudy
2240
26 49
0
10
20
30
40
50
60
70
T0 T1 T0 T1
LEFS
92%p<0.0003
83%p<0.01
± 7.3
± 7.1
± 7.5
± 8.3
18-21 mmHg 23-32 mmHg
PHLEB-Orthostudy
< (p: NS)
RISK
BENEFIT
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