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PubMed2001

Ultrasound assessment of scald scars in Asian children receiving pressure garment therapy.

BACKGROUND/PURPOSE: Scar formation after scald injury in children is managed commonly by application of pressure garment. The duration of the treatment depends on clinical assessment. The objective of the study was to evaluate the efficacy of the pressure garment therapy and to correlate the clinical assessment scar thickness with ultrasound measurement. METHODS: Prospective study of children with hypertrophic scars receiving pressure garment therapy was carried out between 1993 and 1998. The scars were mapped with paper cutting. Representative scar sites were scored clinically according to Vancouver General Hospital Burn Assessment Scale (pigmentation, vascularity, pliability, height, pain, itchiness). Blind to the clinical results, 2 radiologists measured the scar thickness of the same sites with ultrasonography (5 to 10 MHz transducer, General Electric LOGIQ 500). The correlation between the clinical scores and ultrasound measurement of scar thickness were analysed using analysis of variance (ANOVA). RESULTS: The median age of 58 children with scald injury (M:F = 36:22) was 2.8 years (0.5 to 15.8 years). The mean percentage of scald was 8.8% (24% had scald area >10%). In addition, there were 5 children with burn from naked flame and 9 children with keloid secondary to surgical incisions. With pressure garment therapy, the scar thickness reached a plateau 1 (1/2) years after the injury and began to decline gradually thereafter. The clinical estimation of scar thickness correlated well with the ultrasound measurement (ANOVA, P =.003, Adjusted R square = 0.99). The accuracy rate of clinical thickness estimation was 67%. Overestimation and underestimation accounted for 15% and 18%, respectively. There also was good correlation between total clinical score and the ultrasound measurement (ANOVA, P <.001). CONCLUSIONS: In children with scald injury, the pressure garment needs to be continued for a minimum of 1 year. Ultrasound measurement correlates well with overall score of the Vancouver General Hospital Burn Assessment Scale but not individual components of the scoring system except wound height.

Adolescent↗
PubMed2001

Unanticipated variations between expected and delivered pneumatic compression therapy after elective hip surgery: a possible source of variation in reported patient outcomes.

The differences between the pneumatic compression thromboprophylaxis delivered after elective total hip arthroplasties and that was expected were quantified before (49 patients) and after a concerted nursing education program (30 patients) that was designed to ensure maximum compliance and to verify the correct application of the devices. The expected therapy was not delivered to any of the patients monitored. Therapy was delivered only an average of 77.8% of the time during the expected treatment periods. During 99.9% of the expected therapy times, values of key outcomes-related parameters of the therapy delivered to the patients varied by >10% from expected values. These variations were not reduced significantly by medical and nursing education. This variation may be a significant confounding factor in comparatively evaluating thromboembolic disease outcome reports.

Adult↗
PubMed1993

A preliminary study of cardiopulmonary resuscitation by circumferential compression of the chest with use of a pneumatic vest.

BACKGROUND: More than 300,000 people die each year of cardiac arrest. Studies have shown that raising vascular pressures during cardiopulmonary resuscitation (CPR) can improve survival and that vascular pressures can be raised by increasing intrathoracic pressure. METHODS: To produce periodic increases in intrathoracic pressure, we developed a pneumatically cycled circumferential thoracic vest system and compared the results of the use of this system in CPR (vest CPR) with those of manual CPR. In phase 1 of the study, aortic and right-atrial pressures were measured during both vest CPR (60 inflations per minute) and manual CPR in 15 patients in whom a mean (+/- SD) of 42 +/- 16 minutes of initial manual CPR had been unsuccessful. Vest CPR was also carried out on 14 other patients in whom pressure measurements were not made. In phase 2 of the study, short-term survival was assessed in 34 additional patients randomly assigned to undergo vest CPR (17 patients) or continued manual CPR (17 patients) after initial manual CPR (duration, 11 +/- 4 minutes) had been unsuccessful. RESULTS: In phase 1 of the study, vest CPR increased the peak aortic pressure from 78 +/- 26 mm Hg to 138 +/- 28 mm Hg (P < 0.001) and the coronary perfusion pressure from 15 +/- 8 mm Hg to 23 +/- 11 mm Hg (P < 0.003). Despite prolonged unsuccessful manual CPR, spontaneous circulation returned with vest CPR in 4 of the 29 patients. In phase 2 of the study, spontaneous circulation returned in 8 of the 17 patients who underwent vest CPR as compared with only 3 of the 17 patients who received continued manual CPR (P = 0.14). More patients in the vest-CPR group than in the manual-CPR group were alive 6 hours after attempted resuscitation (6 of 17 vs. 1 of 17) and 24 hours after attempted resuscitation (3 of 17 vs. 1 of 17), but none survived to leave the hospital. CONCLUSIONS: In this preliminary study, vest CPR, despite its late application, successfully increased aortic pressure and coronary perfusion pressure, and there was an insignificant trend toward a greater likelihood of the return of spontaneous circulation with vest CPR than with continued manual CPR. The effect of vest CPR on survival, however, is currently unknown and will require further study.

Aorta↗
PubMed2000

Predictors of rehospitalization for symptomatic venous thromboembolism after total hip arthroplasty.

BACKGROUND: Recent studies have shown that symptomatic venous thromboembolism after total hip arthroplasty most commonly develops after the patient is discharged from the hospital. Risk factors associated with these symptomatic thromboembolic events are not well defined. METHODS: Using administrative data from the California Medicare records for 1993 through 1996, we identified 297 patients 65 years of age or older who were rehospitalized for thromboembolism within three months after total hip arthroplasty. We compared demographic, surgical, and medical variables potentially associated with the development of thromboembolism in these patients and 592 unmatched controls. RESULTS: A total of 89.6 percent of patients with thromboembolism and 93.8 percent of control patients were treated with pneumatic compression, warfarin, enoxaparin, or unfractionated heparin, alone or in combination. In addition, 22.2 percent and 29.7 percent, respectively, received warfarin after discharge. A body-mass index (the weight in kilograms divided by the square of the height in meters) of 25 or greater was associated with rehospitalization for thromboembolism, with an odds ratio of 2.5 (95 percent confidence interval, 1.8 to 3.4). In a multivariate model, the only prophylactic regimens associated with a reduced risk of thromboembolism were pneumatic compression in patients with body-mass indexes of less than 25 (odds ratio, 0.3; 95 percent confidence interval, 0.2 to 0.6) and warfarin treatment after discharge (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 1.0). CONCLUSIONS: In patients who underwent total hip arthroplasty, a body-mass index of 25 or greater was associated with subsequent hospitalization for thromboembolism. Pneumatic compression in patients with a body-mass index of less than 25 and prophylaxis with warfarin after discharge were independently protective against thromboembolism.

Aged↗
PubMed1987

Air-plethysmography and the effect of elastic compression on venous hemodynamics of the leg.

Leg volume changes during exercise have been measured in absolute units (milliliters) by means of a new method of air-plethysmography. Venous volume (VV), venous filling time, and venous filling index on standing from the recumbent position, ejected volume (EV) and ejection fraction (EF = EV x 100/VV) with one tiptoe movement, and residual volume (RV) and residual volume fraction (RVF = RV x 100/VV) after 10 tiptoe movements were measured in normal limbs, limbs with superficial venous incompetence, and limbs with deep venous disease. The same measurements were repeated with a graduated medium compression stocking in limbs with SVI and graduated high compression stockings in limbs with DVD. Ambulatory venous pressure was measured at the same time, with a needle in a vein in the foot. The results indicate that this method of air-plethysmography is not only of diagnostic value but offers a new and unique technique to assess and study the hemodynamic effects of different forms of elastic compression. The lower ambulatory venous pressure, produced by the elastic compression, was the result of a reduction in reflux and an improvement in the calf muscle ejecting ability during rhythmic exercise.

Adult↗
PubMed2000

External pneumatic compression and fibrinolysis in abdominal surgery.

INTRODUCTION: External pneumatic compression (EPC) devices prevent lower extremity deep venous thrombosis by increasing venous flow and thereby reducing stasis. Early studies suggested that they also enhance systemic fibrinolytic activity and thus prevent thrombus formation; more recent studies have been conflicting. The hypothesis of this study was that EPC devices enhance systemic fibrinolysis or reduce postoperative fibrinolytic impairment in patients undergoing abdominal surgical procedures. METHODS: Each of 48 patients (98% male; mean age, 67 years) undergoing major intra-abdominal surgical procedures (36 bowel procedures, 12 aortic reconstructions) was prospectively randomized to one of three treatments for deep venous thrombosis prophylaxis: subcutaneous heparin injections (HEP group), use of a thigh-length sequential EPC device (EPC group), or both (HEP + EPC group). Antecubital venous samples were collected for measurement of systemic fibrinolytic activity on the day before surgery, after induction of anesthesia but before prophylaxis was initiated, and on postoperative days 1, 3, and 5. Fibrinolysis was assessed through measurement of the activities of the rate limiting fibrinolytic activator, tissue plasminogen activator, and its inhibitor plasminogen activator inhibitor-1 with amidolytic methods. RESULTS: On the day before surgery, plasminogen activator inhibitor-1 activity was elevated in all groups in comparison with that in age-matched and sex-matched controls (20.3 +/- 0.6 AU/mL). In the HEP group, plasminogen activator inhibitor-1 activity was further elevated above the value for the day before surgery on postoperative day 1 (28.5 +/- 4.3 AU/mL; P =.04) and postoperative day 3 (25.1 +/- 1.9 AU/mL; P =.07). No significant decrease in plasminogen activator inhibitor-1 activity occurred in either group treated with EPC devices in comparison with the HEP group at any time. There were no changes in tissue plasminogen activator activity postoperatively in the HEP group and no significant increases in either EPC group at any point. CONCLUSIONS: Reduced systemic fibrinolytic activity ("fibrinolytic shutdown") occurred in these patients after abdominal surgery; it was manifested as increased plasminogen activator inhibitor-1 activity. EPC devices did not enhance systemic fibrinolysis or prevent postoperative shutdown either by decreasing plasminogen activator inhibitor-1 activity or by increasing tissue plasminogen activator activity. These data suggest that EPC devices do not prevent deep venous thrombosis by fibrinolytic enhancement; effective prophylaxis is achieved only when the devices are used in a manner that reduces lower extremity venous stasis.

Aged↗
PubMed2001

Controlled ischemia for complex venous surgery: the technique of choice.

Surgery under controlled ischemia has been extensively practiced by cardiac, plastic, orthopedic, vascular, and general surgeons. During the past 20 years, we have routinely used this technique to operate on a clean, bloodless field in complex cases of congenital vascular malformations. Based on our favorable experience, we have extended the use of the pneumatic tourniquet to complex cases of primary varicose veins. The use of the tourniquet has dramatically decreased the blood loss and operating time in complex venous surgery without complications secondary to its use. This technique represents a welcome alternative to the bloody, tedious, and time-consuming traditional varicose vein surgery of the past. Complex venous surgery for extensive varicose veins of the extremities can be safely and expeditiously performed under controlled ischemia. It should be the technique of choice.

Gravity Suits↗
PubMed2001

Improved hemodynamic effectiveness and associated clinical correlations of a new intermittent pneumatic compression system in patients with chronic venous insufficiency.

PURPOSE: A new intermittent pneumatic compression device (SCD Response System) has recently been shown in healthy volunteers to have the ability to detect the postcompression refilling of the calf veins and to respond by initiating the subsequent cycle when these veins are full. This has proven to be more effective in expelling blood proximally than the conventional intermittent pneumatic compression device (SCD Sequel System). The aim of this study was to test the influence of venous disease on the postcompression refill time detected by means of the SCD Response and the effectiveness of the new system in expelling blood in patients who have venous reflux caused by post-thrombotic syndrome or varicose veins. METHODS: This open, controlled trial was conducted in an academic vascular unit with 10 patients who had post-thrombotic syndrome and 10 patients who had varicose veins. The new SCD Response System was tested against the existing SCD Sequel System in both legs in the supine, semirecumbent, and sitting positions. The refilling time sensed by means of the device was correlated with the venous filling index by using air plethysmography. The total volume of blood expelled per hour during compression was compared with that expelled by the SCD Sequel System in the same volunteers and in the same positions. RESULTS: An inverse association was found between the mean postcompression refilling time in the sitting position and the venous filling index of the apparently healthy or less severely affected leg (r = -0.52, P =.019), the refill time being significantly shorter in patients with advanced venous disease. The SCD Response System increased the volume expelled per hour in the post-thrombotic leg, when compared with the SCD Sequel System, by 109.9% (P =.005) in the supine position, by 85.1% (P =.009) in the semirecumbent position, and by 40.2% (P =.005) in the sitting position. The corresponding results in the more severely affected leg in patients with varicose veins were 71.9% (P =.005) in the supine position, 77.9% (P =.005) in the semirecumbent position, and 55.7% (P =.013) in the sitting position. Similar improved results were also found in the contralateral leg in both groups. CONCLUSIONS: The deflation settings of the new SCD Response System are able to be adjusted selectively, correlating with the physiological severity of chronic venous insufficiency. By achieving more frequent compression cycles, the new system is more effective than the current one in expelling blood proximally, confirming our earlier findings in healthy volunteers. Further studies testing a possible improved efficacy in preventing deep venous thrombosis in this high-risk group are justified.

Blood Flow Velocity↗
PubMed2001

Home use of impulse compression of the foot and compression stockings in the treatment of chronic venous insufficiency.

PURPOSE: The use of intermittent pneumatic compression, in addition to elastic bandages or stockings, accelerates the healing of leg ulcers in patients with severe chronic venous insufficiency (CVI). There is recent evidence that impulse compression of the plantar venous plexus reduces post-traumatic ankle swelling and prevents postoperative venous thromboembolism. The purpose of this study was to evaluate the clinical and hemodynamic responses after home use of impulse foot compression for 3 months in patients already using therapeutic compression stockings for the management of CVI. METHODS: Twelve extremities from 9 patients with documented CVI, class 4 to 5 according to the Clinical, Etiology, Anatomy, Pathophysiology classification system, were included in this prospective cohort study. All patients were instructed to use a foot pump device at home for 2 hours a day for 3 months in addition to therapeutic compression stockings (30-40 mm Hg) worn during the day. The device was set to three cycles (3 seconds) of compression (120 mm Hg) per minute. A clinical scoring system was completed before foot compression and 1, 2, and 3 months thereafter. In addition, all patients underwent air plethysmography studies at the same time intervals, including venous volume, venous filling index, ejection fraction, and residual volume fraction. RESULTS: Patients reported significant improvement in their scores for swelling (P <.05) and pain (P <.04). Air plethysmography showed a reduction in venous volume and venous filling index, although these differences were not significant. Ejection fraction remained unchanged and residual volume fraction was significantly reduced (P <.05) compared with baseline. The foot compression devices were well tolerated by all the patients in the study. CONCLUSIONS: The use of home foot impulse compression plus elastic stockings significantly reduced the residual volume fraction as measured by air-plethysmography in a group of patients with severe CVI. This favorable hemodynamic response could, in part, explain the clinical improvement achieved by this combined treatment. However, this represents a preliminary pilot study that needs to be confirmed in future randomized controlled studies with more patients included.

Bandages↗
PubMed2002

Does thigh compression improve venous hemodynamics in chronic venous insufficiency?

OBJECTIVE: The aim of this study was to investigate the hemodynamic effects of thigh compression in patients with deep venous incompetence. PATIENTS AND METHODS: This diagnostic test study was set in a municipal general hospital. Twelve patients with venous leg ulcers (CEAP classification, C6 Es Ad Pr; four men and eight women), with a mean age of 56.5 +/- 16.8 years, with popliteal venous reflux of more than 1 second detected with duplex scan, underwent investigation with the following methods: 1, the pressure exerted under thigh-length compression stockings class II and short-stretch adhesive compression bandages was measured with an MST tester (Salzmann, Switzerland) and a CCS 1000 device (Juzo, Germany), respectively; 2, the great saphenous vein and the femoral vein on the thigh were compressed with a pneumatic cuff (0, 20, 40, and 60 mm Hg) containing a window through which the diameters of these veins could be measured with duplex ultrasonography; and 3, with the same thigh-cuff occlusion procedure, the venous filling index (VFI) for each experiment was measured with air plethysmography. These values reflected the presence and extent of venous reflux in each experiment depending on the degree of venous narrowing. RESULTS: The mean pressure of a class II compression stocking was about 15 mm Hg at the thigh level, and adhesive bandages achieved a pressure of more than 40 mm Hg in the same location. A statistically significant reduction of the diameters of the great saphenous vein and the femoral vein could be obtained only when the cuff pressure on the thigh was equal to or higher than 40 mm Hg (P <.001). A reduction of the venous reflux (VFI) was achieved only with a thigh pressure of 60 mm Hg (P <.001). No significant reduction was seen of VFI with a thigh pressure in the range of the class II stockings. Previous investigations have shown that, in patients with deep venous incompetence, a pressure cuff on the thigh with 60 to 80 mm Hg is able to reduce ambulatory venous hypertension. CONCLUSION: Thigh compression as exerted with class II thigh-length compression stockings is not able to significantly reduce venous diameter or venous reflux. However, with a pressure of 40 to 60 mm Hg on the thigh that can be achieved with strongly applied short-stretch bandages, considerable hemodynamic improvement, including reduced venous reflux, can be obtained in patients with severe stages of chronic venous insufficiency from deep vein incompetence. The practical value of these preliminary findings should be investigated with further clinical trials.

Bandages↗
PubMed2002

The effect of external pneumatic compression on regional fibrinolysis in a prospective randomized trial.

INTRODUCTION: External pneumatic compression devices (EPC) prevent deep venous thrombosis (DVT) by reducing lower extremity venous stasis. Early studies suggested they also enhance fibrinolytic activity; however, in a recent study, EPC had no effect on systemic fibrinolysis in patients undergoing abdominal surgery. The hypothesis of this study was that EPCs enhance regional fibrinolysis in these subjects. METHODS: Forty-five patients (44 male, one female; mean age, 67 years) undergoing major abdominal surgery (35 bowel procedures, 10 aortic reconstructions) were prospectively randomized to one of three groups for DVT prophylaxis: subcutaneous heparin injections (HEP), thigh-length sequential EPC devices (EPC), or both (HEP+EPC). Prophylaxis was begun immediately before surgical incision and continued until postoperative day 5 or patient discharge. Venous blood samples were collected from the common femoral vein for measurement of regional fibrinolysis after induction of anesthesia but before initiation of prophylaxis, and on postoperative days 1, 3, and 5. A baseline sample was collected the day before surgery. Fibrinolysis was quantified with measurement of the activities of tissue plasminogen activator (tPA; the activator of fibrinolysis) and its inhibitor plasminogen activator inhibitor-1 (PAI-1) with amidolytic technique. RESULTS: tPA activity in all groups was normal at baseline; baseline PAI-1 activity was elevated. Within each prophylaxis group, no significant changes occurred in either tPA or PAI-1 activities after induction of anesthesia or after surgery compared with before surgery (P >.05, analysis of variance with repeated measures). No changes occurred between postoperative samples and after anesthesia within each group. No significant enhancement of fibrinolysis, manifested as either increased tPA activity or decreased PAI-1 activity, occurred in either EPC group compared with the HEP group at any time point (P >.05, analysis of variance with repeated measures). No differences were noted when surgery was performed for malignant disease versus nonmalignant disease. CONCLUSION: In this study, enhanced regional fibrinolysis in the lower extremities could not be detected with the use of EPCs, as measured with tPA and PAI-1 activity in common femoral venous blood samples. EPC devices do not appear to prevent DVT with fibrinolytic enhancement; effective and safe prophylaxis is provided only when the devices are used in a manner that reduces lower extremity venous stasis.

Abdomen↗
PubMed2002

External pneumatic compression does not increase urokinase plasminogen activator after abdominal surgery.

External pneumatic compression (EPC) devices prevent lower extremity deep venous thrombosis (DVT) by reducing stasis. There is a widely held belief that they also enhance endogenous fibrinolysis; however, recent studies of tissue plasminogen activator (the primary activator of fibrinolysis) and plasminogen activator inhibitor-1 (the primary inhibitor of fibrinolysis) failed to confirm this. The hypothesis of this study was that EPC devices increase the level of urokinase plasminogen activator (uPA), a second activator of fibrinolysis. This was a prospective trial in which 44 subjects who underwent major abdominal surgery were randomized to receive unfractionated heparin injections, thigh-length sequential EPC devices, or both for DVT prophylaxis. Prophylaxis was begun immediately before surgical incision and continued until postoperative day 5 or discharge. Venous blood samples were collected from an antecubital vein for measurement of systemic uPA levels and from the common femoral vein for measurement of regional uPA levels. Samples were collected the day before surgery, after induction of anesthesia but before surgical incision, and on postoperative days 1, 3, and 5. uPA levels (ng/mL) were measured with an enzyme-linked immunoassay. Baseline uPA levels (0.41 to 0.56 ng/mL; P >.05, analysis of variance with repeated measures) were similar among the three groups. uPA levels did not change after surgery in systemic or regional blood samples in any group. There were no significant differences in systemic or regional uPA levels in the groups treated with EPC devices relative to those treated with heparin at any time point (P >.05, analysis of variance with repeated measures). Enhancement of fibrinolysis with EPC devices remains unproven; the findings reported here suggest that effective DVT prophylaxis can only be assured when the devices are used in a manner that reduces venous stasis.

Abdomen↗
PubMed2003

Hemodynamic effect of intermittent pneumatic compression and the position of the body.

PURPOSE: The purpose of this study was to investigate the three likely mechanisms of intermittent pneumatic compression (IPC) in deep vein thrombosis prophylaxis (increased volume flow, increased flow velocity, and acceleration of flow) and to do this in a variety of positions, in different venous segments, and with the stimulus of three different compression garments. METHODS: In 12 healthy volunteers, three types of compression cuffs were used: foot, calf, and calf + thigh. The foot was compressed with 80 mm Hg, and the calf and thigh with 40 mm Hg. Duplex ultrasound scan was performed before and during the compression in the horizontal, 15-degree head-down, and 15-degree head-up positions. The common femoral, greater saphenous, profunda femoral, superficial femoral, and popliteal veins were examined. RESULTS: In comparison with the horizontal position, the 15-degree head-down position was associated with an increase of volume flow and velocities and the head-up position was associated with decreased flow and velocities in the deep veins. The application of IPC caused significant increases in velocities and volume flow in all venous segments. The lowest increase in velocities and volume flow in the deep veins was observed with the subjects in the head-down position, and in the two other positions, the increases were greater and similar to each other. IPC caused a much more prominent increase in flow velocities and volume flow in deep veins compared with simple elevation of the legs. CONCLUSION: IPC produces significant increases of venous flow volume and flow velocity and acceleration of flow. This is true whether the limbs are elevated, horizontal, or dependent. Segmental flow changes vary with the position of the patient and the compression garment used. Foot compression increases volume flow and velocity primarily in the popliteal vein. Calf compression provides maximal increases of volume flow and flow velocity through the deep veins.

Adult↗
PubMed2003

A systematic review of pneumatic compression for treatment of chronic venous insufficiency and venous ulcers.

INTRODUCTION: As part of a reconsideration of coverage policy, the Centers for Medicare and Medicaid Services requested a systematic review of the evidence on the use of pneumatic compression devices in the home environment for treatment of chronic venous insufficiency (CVI) and venous ulcers. METHODS: Articles were found with a systematic literature search of MEDLINE, EMBASE, and AMED (Allied and Complementary Medicine) databases, hand searches of reference lists, and suggestions of experts. RESULTS: Eight trials that met the inclusion criteria, including several randomized control trials, were found. Most studies were small and may have been underpowered. However, several were well-designed randomized controlled trials. Three studies showed that the devices could alleviate symptoms of CVI. No studies directly measured whether the devices could prevent the occurrence of venous ulcers. Some studies on the treatment of venous ulcers did not show a benefit for pneumatic compression, but other studies showed a benefit for the devices in healing long-standing chronic ulcers that had not healed with other methods. No studies directly compared single-chamber and multiple-chamber devices or studied whether the effectiveness of the pump was dependent on types of treatment used concurrently with the pump. Few adverse events were reported in the trials. Patients generally expressed satisfaction with the pneumatic compression devices, and several studies reported higher compliance than with other compression methods. CONCLUSION: The available data cannot be relied on to inform the optimal choice of compression therapy or optimal protocol for patients with CVI or venous ulcers. Methodologically rigorous research designed to answer these questions would be useful for treatment decisions. The Centers for Medicare and Medicaid Services considered the results of this study and issued a decision that pneumatic compression will only be covered for patients with refractory edema with significant ulceration of the lower extremities after a 6-month trial of standard therapies, such as compression stockings, has failed.

Chronic Disease↗