Evidence Based Summary

Introduction to Efficacy of Intermittent Pneumatic Compression

Surgical patients are required to have a prolonged bed rest, so as to promote the healing and attain improved healthcare outcomes from the patients. However, due to prolonged bed rest the patient might tend to develop certain bed side complications (Marušič, 2017). One of the most common form of complication observed in patients is the formation of deep vein thrombosis. Although, patients are managed with prophylactic drugs post-surgery, so as to avoid them developing the complication of vein thrombosis. However, with few patients having multiple comorbidities, the underlying harmful effect can magnify. There are multiple interventions applied for preventing the development of deep vein thrombosis in patients. Some of these common interventions include application of pressure stockings to the patients or managing them with the means of pharmacological interventions (Bui, 2019). Most common choice of drugs used in the treatment method include anticoagulant therapy. The analysis will help in providing a comparison between the effectiveness of pressure stockings and pharmacological interventions in managing and preventing the complication of deep vein thrombosis in post-surgical patients. The study will make use of various medical data bases to ponder upon peer reviewed articles pertaining to the topic considered. Main focus will be catered on the post-operative cases being managed in acute care clinical settings.

PICO question

How effective is compression stockings compared to pharmacological interventions in managing the prevalence of deep vein thrombosis in surgical patients?

P- Surgical patients

I- Compression stockings

C- Pharmacological interventions

O- Managing the prevalence of Deep Vein Thrombosis

Search Strategy

Various clinical databases were used for the research purpose. These included databases pf CINHAL, PubMed, Medline, EMBASE, Cochrane Library and so on (Bramer, 2017). All of the terms to be searched were divided into primary and secondary key words. These key words were entered separately in the desired keyword fields. The studies were searched with the help of using various operators. Truncation operators (‘*’) was added to the search strategy when multiple terms were used together at a go. This was used mainly to be used to capture the specific words that might be having a separate ending. Search strategy was also based on using multiple synonyms to be sued in the search for similar elements. For instance, patient care was also searched as patient safety and patient outcomes. The synonyms were also combined with relevant connectors such as “OR”. This was included to expand the search terms to be used and enabling us to collect the relevant and required data, by closely scrutinizing the research steps. Various Booleans operators were also used in the search strategy (Hopia, 2020). The most commonly and frequently used operator was “AND” and it also helped in narrowing down the results to precision. Connecting terms such as “healthcare professionals”, “medication management”, “clinical settings”, “intervention protocols” etc. were used in the search process. All of the articles searched were made sure to be English language. The language of preference was set primarily as “English Language”. For the research strategy articles up to last five years were taken into consideration. All relevant databases were searched for articles ranging from the year of 2015 to 2020. It was ensured that recently peer-reviewed studies were included for the analysis purpose.

Inclusion criteria- Post-surgical patient population was taken into consideration. No age limit was set for the patients considered. Interventions based on pharmacological and conventional methods of application of pressure stockings was used in the search category.

Exclusion- Studies that included any other interventions were excluded from the search. Normal patients were also excluded from the search strategy.

Results of Efficacy of Intermittent Pneumatic Compression

For the analysis purpose various medical databases were scrolled through. A total number of 100 studies were identified through the database screening. From these 100 records an additional number of 20 records were also considered from other valid and authentic scholarly resources. After carefully observing these totals of 120 records, 80 duplicate studies were removed from the selected ones. The left over 40 records were dully screened and 20 out of the same were excluded on the basis of inclusion and exclusion criteria set for the study. These twenty full-text articles were then screen for full-text requirements and were further filtered as per the authenticity standards. After excluding the left over 15 articles, 5 articles were considered for the meta-analysis. These articles were in sync with the close specifications to be considered for the study.

Evidence of Efficacy of Intermittent Pneumatic Compression

S. NO.	Author	Study Type	Study Population	Intervention	Result
1.	Shalhoub et al.	Randomized control study	Post-operative patients to be selected form seven healthcare centers across UK. The selection was done through online portal and was concluded over a time span of 18 months.	Application of graduated compression stockings with adjunction to pharmacological prophylaxis.	The statistical data was able to give an insight of a slightly significant result. The study was able to marginalize the use of both intervention in DVT prevention (Shalhoub, 2017).
2.	Milinis. et al.	Systemic review	The population was based on systemic review which was done by carrying out an extensive research through multiple databases. A total number of 1291 of studies were searched out of which 19 studies were included. Patients were selected on the basis of randomized control trial. The group included patients from both abdominal as well as orthopedic surgery.	Patients receiving an extended pharmacological intervention for more than 21 days were included in the study. The treatment was provided on a prophylaxis basis (Milinis, 2018).	There were three trials that were received by a total number of 337 patients. The group had symptomatic DVT with no reflection of presence of Pulmonary embolism. Both abdominal surgery and orthopedic surgery patients reflected on similar clinical signs.
3.	Pavon et al.	Systemic review	The main population which was taken into consideration was patients undergoing joint arthroplasty. A total number of 14 randomized control trials were taken along with three observational studies (Pavon, 2016).	Interventions included comparison of intermittent pneumatic compression application with the administration of anticoagulants, to minimize the impact and prevalence of development of underlying risk of deep vein thrombosis.	There were no significant results observed in the sub-groups. These results were on the basis of device location, mode of inflation and so on. However, the use of concurrent anticoagulant therapy along with the compression stockings, was shown to be helpful in reducing the overall risk of development of deep vein thrombosis.
4.	Hood et al.	Cohort study	Study included a total number of 41537 patients that underwent total knee arthroplasty from the time period of 2013 to 2015. These patients were monitored for 90 days post-surgery.	Most of the patients were already using pressure stockings after surgery. The research group was divided into two main categories. One of the groups was provided medical management of aspirin and the other group was not given any anti-coagulation medication (Hood, 2019).	Patients receiving the medical management of aspirin were found to have bleeding complications. Therefore, aspirin was noted as not hat beneficial for managing post-operative patients for the complication prevention of deep vein thrombosis.
5.	Feng et al.	Randomized control trial	The study was based on seven randomized control trials, involving a total number of 1001 of participants. These individuals were compared with control group that had significantly lower rates of deep vein thrombosis incidences reported (Feng, 2017).	The study used the main intervention of inclusion of intermittent pressure stockings to be used alongside graded pressure stockings. It was used to analyze the effectiveness of the same in prevention of the risk factor of deep vein thrombosis.	Intermittent pressure compressions were found to be effective method in treatment of deep vein thrombosis.

Research Gap

For the first study conducted by Shalhoub, et al., there were no significant gaps acknowledge din the process. The study formed the foundational basis for developing future intervention strategies and noting for comparatively significant results from the individuals. This will be based on linear model of distribution which will reflect upon similar results for both primary as well as secondary healthcare outcomes.
The study carried out by Milinis et al., reflected upon the insufficient evidence to recommend graduated compression stockings for patients who are already being medically managed with the help of pharmacological prophylaxis to prevent the formation of deep vein thrombosis. The study also highlighted on the gap of not evaluating the patients going for orthopedic or abdominal surgery, to be screen directly by the means of diagnostic investigations.
The main gap of the study conducted by Pavon et al., was the failure to highlight the comparison between the two interventions. There were no significant results observed in the same manner. The study also made use of a specific type of compression device, which can be observed as a limiting factor to provide analysis and comparison on a larger scale.
The main gap of the study conducted by Hood et al., is that it is based on observational demonstration and not on the basis of causative association. The conclusion of the study remains unchanged and Aspirin is still considered as an effective method of marginalizing the risk factor of deep vein thrombosis formation. The study was also limited in terms of explaining the use of aspirin in stable scenarios and not in cases where there is a dynamic rise in symptoms observed.
Feng et al. carried out a randomized control trial for acknowledging the efficacy of pneumatic pressure stockings in patients undergoing gynecologic surgery. The main research gap was the use of multiple variants to be analyzed with the primary factor. There was a limited use of research studies for this case analysis used. Which can be valid source to promote bias with the results indicated for the study.

References for Efficacy of Intermittent Pneumatic Compression

Bramer, W. M., Rethlefsen, M. L., Kleijnen, J., & Franco, O. H. (2017). Optimal database combinations for literature searches in systematic reviews: A prospective exploratory study. Systematic Reviews, 6(1), 245. https://doi.org/10.1186/s13643-017-0644-y

Bui, M. H., Hung, D. D., Vinh, P. Q., Hiep, N. H., Anh, L. L., & Dinh, T. C. (2019). Frequency and risk factor of lower-limb deep vein thrombosis after major orthopedic surgery in Vietnamese patients. Open Access Macedonian Journal of Medical Sciences, 7(24), 4250. https://dx.doi.org/10.3889%2Foamjms.2019.369

Feng, J. P., Xiong, Y. T., Fan, Z. Q., Yan, L. J., Wang, J. Y., & Gu, Z. J. (2017). Efficacy of intermittent pneumatic compression for venous thromboembolism prophylaxis in patients undergoing gynecologic surgery: A systematic review and meta-analysis. Oncotarget, 8(12), 20371. https://dx.doi.org/10.18632%2Foncotarget.13620

Hood, B. R., Cowen, M. E., Zheng, H. T., Hughes, R. E., Singal, B., & Hallstrom, B. R. (2019). Association of aspirin with prevention of venous thromboembolism in patients after total knee arthroplasty compared with other anticoagulants: A noninferiority analysis. JAMA Surgery, 154(1), 65-72. https://dx.doi.org/ 10.1001/jamasurg.2018.3858

Hopia, H., & Heikkilä, J. (2020). Nursing research priorities based on CINAHL database: A scoping review. Nursing Open, 7(2), 483-494. https://doi.org/10.1002/nop2.428

Marušič, A. P., Petrovič, D., Mrhar, A., & Locatelli, I. (2017). Polypharmacotherapy and blood products as risk factors for venous thromboembolism in postsurgical patients: A case–control study. International Journal of Clinical Pharmacy, 39(2), 416-423. https://doi.org/10.1007/s11096-017-0441-7

Milinis, K., Shalhoub, J., Coupland, A. P., Salciccioli, J. D., Thapar, A., & Davies, A. H. (2018). The effectiveness of graduated compression stockings for prevention of venous thromboembolism in orthopedic and abdominal surgery patients requiring extended pharmacologic thromboprophylaxis. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 6(6), 766-777. https://doi.org/10.1016/j.jvsv.2018.05.020

Pavon, J. M., Adam, S. S., Razouki, Z. A., McDuffie, J. R., Lachiewicz, P. F., Kosinski, A. S., ... & Williams Jr, J. W. (2016). Effectiveness of intermittent pneumatic compression devices for venous thromboembolism prophylaxis in high-risk surgical patients: A systematic review. The Journal of Arthroplasty, 31(2), 524-532. https://doi.org/10.1016/j.arth.2015.09.043

Salameh, J. P., McInnes, M. D., Moher, D., Thombs, B. D., McGrath, T. A., Frank, R., ... & Bossuyt, P. M. (2019). Completeness of reporting of systematic reviews of diagnostic test accuracy based on the PRISMA-DTA reporting guideline. Clinical Chemistry, 65(2), 291-301. https://doi.org/10.1373/clinchem.2018.292987

Shalhoub, J., Norrie, J., Baker, C., Bradbury, A. W., Dhillon, K., Everington, T., ... & Hunt, B. J. (2017). Graduated compression stockings as an adjunct to low dose low molecular weight heparin in venous thromboembolism prevention in surgery: A multicentre randomised controlled trial. European Journal of Vascular and Endovascular Surgery, 53(6), 880-885. https://doi.org/10.1016/j.ejvs.2017.02.013

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