1	Anti-Embolism Stocking Educational Programme
2	Aims of the Programme To understand: The clinical profile of DVT The process of DVT diagnosis Prevention of DVT Potential long-term complications Simple methods of assessment and measurement of hosiery Research of hosiery in prevention of DVT
3	IMPORTANT How to use this CD You may select the area you are most interested in and start there by clicking on the appropriate button on the contents page For this you will need to use the mouse button Or You may read the contents as they are set out For this you will need to use the arrows on the key board Short films are ended by pressing the arrow on the key board
4	Contents The clinical profile of DVT Specific factors in DVT Long term effect of DVT Diagnostic methods of DVT Prevention of DVT Treatment of DVT Research on anti-embolic stockings Measuring and applying History of Carolon
5	The Clinical Profile of Deep Vein Thrombosis
6	Clinical Profile of DVT Awareness of risk factors relative to the development of deep vein thrombosis and pulmonary embolism is important for the practitioner Understanding the pathophysiology can help guide prophylaxis and treatment plans (Ecklund 1995)
7	Clinical Profile of DVT Deep vein thrombosis (DVT) is a common condition Most cases arise as complications during the peri-operative period (Tyrrell et al. 1995)
8	Clinical Profile of DVT Lower-limb DVT affects between 1% to 2% of hospitalized patients (Line 2001)
9	Clinical Profile of DVT As many as 41.7% patients can develop asymptomatic calf vein thrombosis (Lee et al. 2001)
10	Clinical Profile of DVT DVT can have serious long-term consequences and can result in fatal complications (Bonner 2004)
11	Clinical Profile of DVT The principal complications of DVT are: Pulmonary embolism, which may be fatal Development of a post-phlebitic leg (Tyrrell et al. 1995)
12	Clinical Profile of DVT The causes of thrombosis include vessel wall damage, stasis or low flow, and hypercoagulability This is known as Virchow’s triad (Line 2001)
13	Virchow’s Triad Some 150 years ago, Virchow recognized the three-fold origin of thrombosis
14	Virchow’ Triad The functional trias concerned in the pathogenesis of thrombosis are changes in the: Vessel wall Pattern of blood flow (flow volume) Constituents of blood (hypercoagulability)
15	Virchow’s Triad Simply put this means: Damage to the veins Venous stasis Blood clots easily These three elements need to be present for DVT to form
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18	Pulmonary Embolism
19	Pulmonary Embolism DVT is of clinical importance and carries the short-term risk of pulmonary embolism (Haas 2000)
20	Pulmonary Embolism A thrombus may form in any vein of both lower limbs, not only in the veins of the operated leg The forming of blood clots in veins of the limbs is not life threatening in itself
21	Pulmonary Embolism If the thrombus grows large and then breaks free it can travel through veins and eventually reach the lungs The thrombus can then block the lung vessels, a serious, and potentially fatal condition, called pulmonary embolism
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23	Pulmonary Embolism A thrombus is a soft and round - jelly-like formation, which partially or totally fills the vein It can be only millimetres in size or several centimetres long
24	Pulmonary Embolism More than 90% of pulmonary emboli originate from a thrombus in the deep veins of the legs (Matzdorff and Green 1992)
25	Pulmonary Embolism As many as 40% of patients over the age of 40 operated on for more than an hour will develop a deep venous thrombosis The risk of fatal pulmonary embolus then becomes 37% (Seiden and Pensak 1986)
26	Clinical Profile of DVT Among the 30% who have venous thrombosis, about 85% have proximal vein thrombosis The remainder have thrombosis confined to the calf (Line 2001)
27	Clinical Profile of DVT Patients with proximal vein thrombosis who are inadequately treated have a 47% frequency of recurrent venous thromboembolism over 3 months (Line 2001)
28	Clinical Profile of DVT Calf veins are one of the most common sites for DVT (O'Shaughnessy and Fitzgerald 1997)
29	Clinical Profile of DVT The possibility of pulmonary embolism is not only life-threatening but the costs associated with DVT are also enormous (Turkoski 2000)
30	Clinical Profile of DVT The emotional consequences of pain, extended isolation, and impaired social interaction impact every aspect of the lives of patients with DVT (Turkoski 2000)
31	Clinical Profile of DVT Many patients are at increased risk of DVT Knowledge of common risk factors and awareness of appropriate prophylactic measures can help prevent DVT occurrence (Bonner 2004)
32	Clinical Profile of DVT Symptoms and clinical signs suggestive of DVT are common and have numerous possible causes Studies have shown that symptoms and clinical signs in themselves are inaccurate for the diagnosis of DVT (Kahn 1998)
33	Clinical Profile of DVT Less than 50% of patients with DVT manifest the classical symptoms and signs of DVT (Bjorgell et al. 2001)
34	Clinical Profile of DVT When the signs and symptoms of DVT are nonspecific - treatment may be delayed until complications arise Prophylactic prevention of DVT is often the chosen route of post-surgical care (Turkoski 2000)
35	Clinical Profile of DVT Symptoms and clinical signs, when combined with other patient information such as the presence or absence of known risk factors for DVT, can improve clinical prediction considerably (Kahn 1998)
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37	Specific Factors that Enhance Risk of DVT
38	Specific Factors that Enhance Risk of DVT Obesity Limb weakness Heart failure Lower extremity trauma (Swann and Black 1984) Previous DVT Surgery Immobilization Advanced age
39	Specific Factors (references) DVT is a known common cause of perioperative death (Capper 1998)
40	Specific Factors (references) Only old age and smoking were identified as being associated with a higher incidence of DVT (Lee et al. 2001)
41	Specific Factors (references) Patients undergoing orthopaedic surgery are at particular risk of DVT (Haas 2000)
42	Specific Factors (references) DVT is a particularly serious and complicated aspect of orthopaedic surgery, especially in surgery that involves hip and knees (Turkoski 2000)
43	Specific Factors (references) DVT is particularly prevalent in patients undergoing total knee and hip arthroplasty, occurring at a rate of 50 to 60% (Rice and Walsh 2001)
44	Specific Factors(references) DVT remains a leading cause of postoperative morbidity and mortality in patients who undergo total knee arthroplasty (Yang et al. 2002)
45	Specific Factors (references) 2% of orthopaedic patients receiving pharmacologic prophylaxis still develop PE (Rice and Walsh 2001)
46	Specific Factors (references) Approximately 60% of trauma patients developed DVT within the first 2 weeks of admission (Attia et al. 2001)
47	Specific Factors (references) DVT and subsequent pulmonary embolism (PE) is a major source of mortality and morbidity in stroke patients (Pambianco et al. 1995)
48	Specific Factors (references) The development of DVT in conjunction with a gynaecologic malignancy connotes a poor prognosis, especially in patients with cervical cancer (Morgan et la. 2002)
49	Specific Factors (references) It is possible that the poor prognosis is related to the pathophysiology that results in venous thrombosis and not just the presence of cancer (Morgan et la. 2002)
50	Specific Factors (references) Morbidly obese patients undergoing bariatric surgery have commonly been concluded to be at high risk for the development of peri-operative venous thromboembolism (Wu and Barba 2000)
51	Specific Factors (references) Statistically DVT in HIV/AIDS is approximately 10 times greater than in the general population (Saber et al. 2001)
52	Specific Factors (references) DVT detected by fibrinogen scanning in neurosurgical patients to be 29% to 43% (Swann Black 1984)
53	Specific Factors (references) DVT was more common in the Chinese than the other races and more common in females (Ng 1994)
54	Specific Factors (references) Critically ill patients commonly develop DVT, with rates that vary from 22% to almost 80% (Attia et al. 2001)
55	"Moreover" Moreover, with increasing age there is an increased incidence of comorbid conditions, which may, in themselves, be associated with an increased risk for the development of thrombosis (Nurmohamed et al. 1994)
56	Specific Factors (references) The incidence of thrombosis in the calf veins or muscular veins in long-haul flight passengers range between 0% and 10% (Ferrari and Morgan 2004)
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58	Long-Term Effect
59	Long-Term Effect DVT may also lead to: long-term venous insufficiency disabling symptoms of swelling, chronic pain, and skin ulceration substantial health-care costs (Haas 2000)
60	Long-Term Effect Approximately 25% of DVT patients remain asymptomatic in the long term but severe signs of post-thrombotic syndrome (ulceration) are observed in 2-10% of patients 10 years after DVT (Leizorovicz 1998)
61	Long-Term Effect Surveys suggest that post-thrombotic syndrome is present in 30%-70% of patients, 5 years after an initial symptomatic or asymptomatic, proximal or distal DVT (Haas 2000)
62	Long-Term Effect One in every three patients with DVT will develop post-thrombotic complications within five years (Kolbach et al. 2004)
63	Long-Term Effect 30% of patients diagnosed with deep vein thrombosis will experience at least one recurrence of symptoms (Launius and Graham 1998)
64	Long-Term Effect It is known that DVT of the ilio-femoro-popliteal axis is frequently associated with irreversible damage to valvular competence of the veins consequently there are varying degrees of chronic venous insufficiency (Ganger et al.1989)
65	Long-Term Effect Venous ulcers can result from damage caused to the lining of the veins due to the DVT (Vogeley and Coeling 2000) Damage to the vessel wall or valves can be found in 44% of patients post DVT (Caprini et al. 1995)
66	Long-Term Effect Development of varicosities These symptoms are a precursor to formation of the chronic venous ulcer. (Vogeley and Coeling 2000) May include: High pressure in the damaged venous system Swelling Haemosiderin staining around the ankle area
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69	Long-Term Effect After adjustment for age, sex, and other potential confounding factors, people who had a diagnosed thromboembolism were at almost three times higher risk of having a leg ulcer (Walker et al. 2003)
70	Long-Term Effect In the sole randomized study available, daily use of elastic compression stockings after proximal DVT reduced the incidence of postphlebitic syndrome by 50% (Kahn et al. 2000)
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72	Diagnosis of DVT
73	Diagnosis of DVT About 70% of patients referred for clinically suspected venous thrombosis do not have the diagnosis confirmed by objective testing (Line 2001)
74	Clinical Signs / Symptoms of DVT Any of these signs and symptoms may be present: Oedema Tenderness Inflammation Erythema
75	Diagnosis of DVT Aetiopathogenesis of true DVT is determined by Virchov's triad (Maksimovic et al. 2001)
76	Diagnosis of DVT Accurate diagnostic techniques and strategies for treatment and prevention of DVT should be mandatory in order to prevent potentially fatal complications such as pulmonary embolism (Prandoni and Bernardi 1999)
77	Diagnosis of DVT Although principles of treatment have changed relatively little during the past 20 years, significant advances have been made in the diagnosis of DVT (Peterson 1986)
78	Diagnosis of DVT Controversy exists as to whether patients suspected of having DVT can be studied safely without venography, with its attendant expense, inconvenience, and potential risk (Wheeler et al. 1982)
79	Diagnostic Methods of DVT Although practice varies between countries, venography, once the only reliable diagnostic technique, has been largely replaced by non-invasive tests
80	Diagnostic Methods of DVT Fibrinogen-uptake test Phleborheography (Peterson 1986) D-dimer test Impedance plethysmography Duplex ultrasound
81	D-dimer Test When the coagulation cascade is activated (as in DVT) fibrin protein is produced and then degraded as the clot breaks down into fibrin degradation products (FDP) One of these FDPs is D-dimer, which consists of variously sized pieces of cross-linked fibrin
82	D-dimer Test Normally, D-dimer is undetectable in the blood and is produced only after a clot has formed and is in the process of being broken down This can be measured and is an accurate test of DVT
83	Impedance Plethysmography Impedance plethysmography (IPG) is an accurate non-invasive method to test for proximal vein thrombosis and is: a test to evaluate blood flow through the leg insensitive to calf-vein thrombi (Hull et al 1985)
84	Impedance Plethysmography IPG is based on the principle that volume changes of the leg lead to changes in electrical resistance (impedance) Temporary venous occlusion is produced by an inflatable thigh cuff, and venous volume response in the calf is measured during inflation and for seconds following release
85	Impedance Plethysmography Normally, there is a progressive increase in blood volume of the calf following inflation, followed by a rapid runoff when the cuff is released When a DVT is present, the runoff is notably impaired
86	Impedance Plethysmography IPG can be falsely normal An elevated central venous pressure or venous compression by mass or haematoma can produce a false positive result Clear demarcation exists between symptomatic patients and asymptomatic high-risk patients who are screened for DVT
87	Duplex Ultrasound Doppler ultrasound is a painless, fast, and easy method of "seeing" inside the human body through the use of high-frequency sound waves A transducer, a wand-like device, is used to send sound waves into the leg
88	Duplex Ultrasound The waves travel through the leg tissue and reflect back A computer then transforms the waves into a moving image that reveals the presence of a clot
89	Fibrinogen Uptake Test Uses an isotope which, when injected, is taken up by thrombi This technique is sensitive for distal venous thrombosis but is less specific for DVT in proximal veins
90	Phleborheography This technique is used to measure venous volume changes in response to respiration and to compression of the foot or calf It employs a plethysmograph with cuffs applied to the abdomen, thigh, upper, mid, and lower calf, and foot
91	Diagnosis of DVT Non-invasive testing for the diagnosis of DVT is generally less accurate in asymptomatic patients than in those with symptoms This is because asymptomatic DVT is often confined to distal veins (Kearon 2001)
92	Diagnosis of DVT When DVT involves the proximal veins, the thrombi are usually smaller than in symptomatic patients with proximal thrombosis (Kearon 2001)
93	Diagnosis of DVT Initially true DVT may be asymptomatic in 35-70% of patients and detection may depend on the diagnosis methods used (Maksimovic et al. 2001)
94	Diagnosis of DVT Some veins are especially hard to display on phlebography or colour Doppler ultra-sonography These include the veins of the planta pedis, the deep muscle veins of the calf and thigh and the deep internal iliac vein (Bjorgell et al. 2001)
95	Diagnosis of DVT The ideal diagnostic method must display the whole venous system from the planta pedis to the caval vein (Bjorgell et al. 2001)
96	Diagnosis of DVT Upper extremity DVT has recently been recognized as being a more common and less benign disease than previously reported It arises generally in the presence of recognizable risk factors, such as central venous catheters and cancer (Prandoni and Bernardi 1999)
97	Diagnosis of DVT Upper extremity deep-vein thrombosis is at least as serious a disease entity as deep-vein thrombosis of the lower extremities (Prandoni and Bernardi 1999)
98	Diagnosis of DVT Considerable emphasis has been placed on the cost-effectiveness of implementing prophylactic measures in patients who are at high risk for developing DVT (Melamed and Suarez 1988)
99	Diagnosis of DVT Fibrinogen uptake test was the most sensitive test in detecting DVT and had an accuracy of 97 per cent (Borow and Goldson 1983)
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101	Prevention of DVT
102	Prevention of DVT Anti-thrombotic treatments have been proven effective in preventing recurrence of DVT but carry the risk of major bleeding (Leizorovicz 1998)
103	Prevention of DVT The use of below-knee graduated compression stockings appears to be highly effective in prevention of travel- associated-DVT (Ferrari and Morgan 2004)
104	Prevention of DVT Combining compression hosiery and one pharmacologic agent (e.g. Heparin, Warfarin) greatly reduces the incidence of lower extremity thrombi (Borow and Goldson 1983)
105	Prevention of DVT Use of unfractionated heparin appears to decrease the incidence of DVT by only 20% low-molecular-weight heparin decreases the incidence by a further 30% (Attia et al. 2001)
106	Prevention of DVT Although subcutaneous heparin has emerged as a major deterrent worldwide for thrombosis prevention it is also associated with the potential risk of bleeding and cannot be used in certain situations (Caprini et al. 1988)
107	Prevention of DVT The responsibility for DVT prophylaxis, patient assessment and the monitoring of the effectiveness of the prophylactic therapy lies with the nursing staff (Capper 1998)
108	Prevention of DVT The risk of venous thromboembolism increases with age This increasing risk is associated with a concurrent enhancement of coagulation activation and gradual development of a 'prethrombotic state’ (Nurmohamed et al. 1994)
109	Prevention of DVT This is reflected by increased levels of coagulation activation peptides in the elderly and a decreased activity of the fibrinolytic system (Nurmohamed et al. 1994)
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111	Treatment of DVT
112	Treatment of DVT Treatment goals for DVT include: Dissolving the clot (clot lysis) Preventing: the recurrence of thrombus The occurrence of pulmonary embolism The development of pulmonary hypertension
113	Treatment of DVT Post-treatment therapy usually consists of warfarin therapy and venous compression stockings for at least 3 to 6 months (Semba ET AL 2004)
114	Treatment of DVT Clot lysis can take place as early as 35 hours after starting heparin but vessel changes remain for at least 11 weeks (Ng 1994)
115	Treatment of DVT Low dose heparin administered every 8 hours appears to be more effective in reducing DVT than Low dose heparin administered every 12 hours (Clagett and Reisch 1988)
116	Treatment of DVT Mobile patients with acute proximal DVT treated with low molecular weight heparin should be encouraged to walk with compression stockings (Partsch and Blattler 2000)
117	Treatment of DVT Despite plenty of surgical options, conservative treatment is preferable because half of the patients improve or remain stable during follow-up, provided they wear elastic stockings (Bernardi et al. 2001)
118	Treatment of DVT Leg compression (stockings) combined with walking is the better alternative to bed rest for the treatment of symptomatic outpatients with proximal DVT (Blattler and Partsch 2003)
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122	Research on Anti-Embolic Stockings
123	Compression Hosiery Research There is substantial evidence that elastic compression stockings reduce the occurrence of post-thrombotic syndrome after DVT (Kolbach et al. 2004)
124	Compression Hosiery Research Graduated compression stockings can effectively reduce postoperative DVT and their use is recommended by expert committees (Meyer et al. 2004)
125	Compression Hosiery Research Graduated compression stockings are effective in diminishing the risk of DVT in hospitalised patients (Amarigiri and Lees 2000)
126	Compression Hosiery Research Turner et al. (1984) found that none of 104 patients who wore compression stockings developed a DVT Four of the 92 control patients who did not wear the stockings had DVT This difference between the two groups was statistically significant
127	Compression Hosiery Research The application of graded pressure stockings and the avoidance of unnecessary peri-operative blood transfusion are worth while in the management of total hip arthroplasty (Ishak and Morley 1981)
128	Compression Hosiery Research Patients with DVT are willing to comply with graduated compression stocking therapy and most find them to be helpful (Kahn et al. 2003)
129	Compression Hosiery Research Early application of pharmacological plus mechanical treatment for DVT prevention: Produces a marked reduction in complications Reduces morbidity and mortality risks Reduces hospitalization costs during early periods of rehabilitation (Aito ey al. 2002)
130	Compression Hosiery Research Early use of external compression in DVT & pharmacological therapy can result in: reduction of the growth of the thrombus reduction of pulmonary embolism ratio prevention of post-thrombotic syndrome Indirect improvement of quality of life
131	Compression Hosiery Research The effect of stockings is enhanced by combination with pharmacological agents such as heparin The combination is recommended in patients at moderate or high risk of DVT (Agu et al. 1999)
132	Compression Hosiery Research The effect of four DVT-prophylaxis-stockings was examined by computer-aided-video-plethysmography An increase of venous outflow was observed under the influence of all elastic stockings (Schmitt and Wienert 1990)
133	Compression Hosiery Research Graduated compression stockings alone or in combination with IPC are effective methods of preventing DVT in neurosurgical patients (Turpie et al. 1989)
134	Compression Hosiery Research Complications of anti-embolic hosiery are rare and avoidable (Agu et al. 1999)
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136	Measuring and Applying Carolon Anti-Embolism Stockings
137	Anti-Embolism Stockings Carolon Anti-Embolism Stockings are Available in Three Styles
138	Measuring Proper measuring is critical to insure ease of application and comfort and performance For ease of measuring, a measuring tape is enclosed with each pair of stockings The most accurate fit will be accomplished utilizing the Carolon measuring technique
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140	"For Thigh Length" For Thigh Length 1. Measure smallest ankle circumference 2. Measure largest calf circumference Measure thigh upper thigh circumference (if thigh circumference exceeds 76 cm refer to the ATS stocking 3A. Measure distance from heel to gluteal crease
141	Select Proper Size From Size Chart
142	Proper Sizing Stocking sizes are not standardized from one manufacturer to another. A “Large” for one manufacturer may be a “Medium” for another. Utilizing the Carolon fitting system will insure proper fit and performance. Carolon provides the broadest fitting range available
143	Applying the Stocking Slide your hand inside the foot section of the stocking, with the heel (blue) section on top of the hand
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145	"Stretching heel area sideways" Stretching heel area sideways, fit stocking over patient’s foot and heel.
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148	"Be sure that the patient’s..." Be sure that the patient’s heel is in center of heel pocket
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150	Thigh Band Gusset For Thigh Length Turn thigh band gusset to the inside of the leg over the femoral. This insures a pressure break preventing restriction and reduced blood flow.
151	For ATS Thigh Stocking Referring to the transfer located at the top of the stocking, select the correct position to attach the Velcro® panel
152	Color Coding All stockings are color coded for both size and length.
153	Tips for Applying the Stocking Place the bag that contains the stocking over the foot This ensures ease of application as the stocking ‘slips’ over the bag The bag MUST be removed through the toe of the stocking
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155	Continuing Care Provide the patient with information on care of the hosiery (leaflets and verbal explanations) Patient should wear the stockings until fully ambulatory. Consultant should be contacted for advice to continue compression therapy.
156	Do Not Apply The calf measurements vary more than one size from the ankle measurement on the wall chart. Occasionally, ankle measurements indicates a different size than the calf measurement. Rely on the ankle measurement on those occasions to select the proper size. Example: The Ankle measurement indicates a Large, the Calf a Medium, choose the Large Size. This will provide the appropriate ankle compression and ease application.
157	Contraindications Dermatitis, gangrene, phlebitis, open ulcers, recent skin graft or vein ligation. Severe arteriosclerosis or other ischemic vascular disease or absence of pedal pulse. Massive leg edema associated with pulmonary edema. Extreme deformity of the leg. Diabetic conditions with compromised circulation.
158	Stocking Key Features Stocking fabric designed with two-way stretch for comfort and to help the stocking stay in place on the leg Externally Certified by MTL Laboratories for 18mmHg at the ankle and graduated up the leg Floating Blue Heel for proper placement and easy stretch foot inspection hole Largest Fitting Range ATS Orthopedic/Bariatric stocking fits to a 90.5 cm thigh circumference Short knee sizes available Seamless Construction 100% Latex Free
159	Washing Carolon Stockings can be machined washed and are dryer safe. Washing actually helps the stocking maintain the compression values. Washing Instructions: Machine wash stockings in hot water not exceeding 95 c Tumble dry on medium heat If the patients are wearing the stockings at home, it is best that the stockings be washed every 2 days. Washing instructions are located on each bag and on the Patient Information Card
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161	History of Carolon
162	The Carolon Company Located in the US in Rural Hall, North Carolina, Carolon has been involved in the design, manufacture and sales of anti-embolism stockings and medical vascular hosiery for over 25 years.
163	The Carolon Company Responsible for many innovations in design Carolon has set the standard for the industry
164	The Carolon Company Carolon Medical Stockings are manufactured in a state of the art facilities, utilizing over 56,000 square feet of manufacturing space
165	The Carolon Company Over 300 different styles of stockings are manufactured on the most recent circular knitting machines This provides the latest in computer control and precision construction
166	The Carolon Company All areas of manufacturing are both humidity and temperature controlled to insure uniform yarn and product performance
167	The Carolon Company Product quality is of the utmost concern
168	The Carolon Company Careful attention is paid during manufacturing to such factors as: raw material selection machine performance in-process testing end-product testing superior product design in-service educational materials
169	Carolon Education CD presentation on DVT to be used by lecturers, individual nurses and students Study days on prevention of DVT Representatives will provide one to one education on DVT and applying hosiery
170	The Carolon Company Carolon medical hosiery products are the market leaders in the area of DVT prevention and vascular treatment Their success is complimented by their commitment to education
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