When Preparing To Apply Elastic Stockings, Why Does The Nurse Assess For Skin Discoloration?
CMAJ. 2014 Jul 8; 186(10): E391–E398.
Graduated pinch stockings
Compression therapy is a frequently used concrete therapy in conditions involving venous and lymphatic insufficiency in the lower limbs, including varicosities, lymphedema, venous eczema and ulceration, deep vein thrombosis and postthrombotic syndrome. The many forms of pinch therapy include elastic and non-elastic bandages, boots, hosiery or stockings (Box 1), and pneumatic devices.1 Graduated compression stockings (Figure 1) are often prescribed and have the advantage of being more acceptable, relatively easier to put on and less cumbersome than bandaging and pneumatic devices. However, not all patients tolerate graduated compression stockings, and bug with compliance are non uncommon.
Below-knee and thigh-length compression stockings.
We review the current evidence of the therapeutic roles of graduated compression stockings and the bug associated with their use. The evidence used in this review is described in Box 2.
What are the mechanisms of activity of compression stockings?
Figure 2 summarizes the mechanisms of action of graduated compression stockings. The stockings piece of work past exerting the greatest degree of compression at the ankle, with the level of compression gradually decreasing upwards the garment. The pressure level gradient ensures that blood flows upward toward the centre instead of refluxing down to the foot or laterally into the superficial veins. The awarding of acceptable graduated pinch reduces the diameter of major veins, which increases the velocity and volume of blood menstruum.2 Graduation compression can contrary venous hypertension, broaden skeletal-muscle pump, facilitate venous return and meliorate lymphatic drainage.3 It also initiates complex physiologic and biochemical effects involving the venous, arterial and lymphatic systems, although the verbal mechanisms remain unclear.two , four , 5 One study that used nigh-infrared spectroscopy to monitor changes in tissue oxyhemoglobin and deoxyhemoglobin reported that limb oxygenation increased with the use of graduated compression stockings, especially with high-compression stockings.4 Another study showed that levels of proinflammatory cytokines (east.thou., interleukin-1α, interleukin-vi and interferon-γ) in ulcer tissue in patients with active ulcers were significantly reduced following compression therapy.5
The mechanisms of action of graduated compression stockings.
How is the strength of compression graded?
Graduated pinch stockings are classified according to the sub-cast compression pressure applied by the garment at the ankle level. The pressures are determined past the manufacturer based on laboratory measurements. The degree of pressure is classified into several standards. Unfortunately, there is no single standard used worldwide, which may crusade defoliation. In general, though, low pinch refers to pressure level of less than 20 mm Hg or class 1; medium compression to pressure of 20–30 mm Hg or class 2; and high compression to pressure of greater than 30 mm Hg, or class 3 or higher. The overall pressure is affected by factors such as the elasticity and stiffness of stocking material, the size and shape of the wearer's legs, and the movements and activities of the wearer.6
What are the bug associated with pinch stockings?
Contraindications and complications
The contraindications of graduated compression stockings are listed in Box 3.6 – 9 The stockings are by and large safety to use, with relatively few complications. Poorly fitting stockings tin can cause discomfort and, at worst, pressure level necrosis. The apply of graduated compression stockings on legs with impaired arterial menstruation tin can worsen ischemia.6 , 7 Patients who are allergic to the stocking material may develop contact dermatitis, skin discoloration and blistering. For instance, in CLOTS (Clots in Legs or Stockings after Stroke) trial 1 — a multicentre randomized controlled trial (RCT) that assessed the effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke in near 2500 patients — skin breaks, ulcers, blisters and necrosis were significantly more common amidst patients wearing the stockings than among those not wearing them (5.1% five. one.iii%).8 Cloth properties, including cloth roughness, thermoregulation and dye, may contribute to skin reactions.9
Many complications of graduated compression stockings are preventable if patients are assessed, measured and fitted appropriately. If complications occur, many are easily overcome by refitting the stockings, changing the fabric, applying an emollient and reducing the degree of pinch. Accurate measurement of the limb diameter that conforms to the stocking manufacturer'southward guidelines should be performed by a trained wellness care professional, frequently a nurse.
Noncompliance
The noncompliance rate for graduated compression stockings has been reported to be xxx%–65%.10 , 11 Commonly cited reasons include pain, discomfort, difficulty donning the stockings, perceived ineffectiveness, excessive estrus, skin irritation, cost and appearance.6 , x , 12 Clinicians should ask their patients why the stockings are non being used, considering many of these factors are easily amenable by simply changing the stocking material, lowering the degree of pinch or providing adequate information and reassurance to patients. Box iv shows the information that nosotros believe should be given to patients when prescribing graduated compression stockings.
What are the clinical indications?
Principal chronic venous affliction
Patients with chronic venous disease may present with symptoms and signs of leg pain, heaviness, itchiness, edema, eczema, lipodermatosclerosis, thrombophlebitis and ulceration.thirteen , 14 Chronic venous disease is often classified using the CEAP (clinical, etiologic, anatomic and pathophysiologic) arrangement.thirteen Tabular array 1 shows the simplified CEAP organisation in which only the highest clinical form is stated.1
Table i:
Clinical classification of chronic venous affliction according to the CEAP system1
| Class | Description |
|---|---|
| C0 | No visible or palpable signs of venous disease |
| C1 | Telangiectases or reticular veins |
| C2 | Varicose veins |
| Cthree | Edema |
| C4a | Pigmentation or eczema |
| C4b | Lipodermatosclerosis or atrophie blanche |
| Cv | Healed venous ulcer |
| C6 | Active venous ulcer |
The utilize of compression is a bourgeois measure. It does non cure varicosities, although information technology may salvage symptoms and prevent deterioration.15 Many studies that investigated the effectiveness of graduated compression stockings in patients of all CEAP classes reported improvement in symptoms such as pain and swelling and in activity levels and well-being.1 A multicentre RCT assessing the efficacy of graduated compression stockings (pressure 10–15 mm Hg) in 125 female person patients with CEAP class Cone–C3 reported a meaning improvement in relieving global painful discomfort and quality-of-life criteria with the stockings compared with placebo stockings.xvi However, these findings were limited by the recruitment of a heterogeneous grouping of patients, and no subgroup analysis was performed.6 , xi
Uncomplicated varicose veins
The testify for the benefit of graduated compression stockings in unproblematic varicose veins was equivocal, and the published literature was often contradictory and had methodologic flaws.
A Cochrane systematic review of graduated compression stockings for the initial treatment of varicosities in patients without venous ulceration (CEAP class C2–C4) included seven RCTs (due north = 356).11 Although the participants' symptoms and physiologic measures subjectively improved in all of the studies when graduated pinch stockings were worn, there was a risk of bias because the assessments were not fabricated by comparing one randomized arm with a control arm. Another systematic review of graduated pinch stockings for uncomplicated varicosities identified 25 studies.vi Wearing the stockings improved symptom direction, but the findings may accept been confounded by the exclusion of a high number of noncompliant patients within the trials. The review likewise found no evidence that wearing the stockings slowed the progression or prevented the recurrence of varicose veins.
Consensus statements from the Lodge for Vascular Surgery/American Venous Forum Guideline Committee cautiously recommended the use of graduated compression stockings in this grouping of patients and accepted that the evidence supporting this recommendation was express.i Recently, the National Found for Health and Care Excellence (Dainty) in the United kingdom recommended against the utilize of graduated compression stockings to treat varicosities unless interventional treatment is unsuitable.17
Some studies reported that low-compression stockings were as effective as high-compression stockings but had a better compliance charge per unit.xvi , 18 A meta-analysis of 11 RCTs reported that compression of 15–xx mm Hg showed beneficial effects on edema and symptoms, as compared with pinch of less than 10 mm Hg or no compression; in that location was no difference between compression of 10–20 mm Hg and greater than twenty mm Hg.19
There was bereft testify to determine which length of graduated compression stocking (beneath knee or thigh length) was most beneficial.6 , 11
Chronic venous insufficiency
Although nosotros plant no RCT that compared pinch with no compression in patients with venous skin changes (CEAP class C4), it is generally accepted that the management of such patients should include graduated compression stockings if tolerated.one , 20 There is high-quality evidence that venous ulcers heal more than rapidly with than without pinch therapy.1 , 21 , 22
Patients with venous ulcers are often treated with compression bandages. Nonetheless, there is some evidence that graduated pinch stockings are every bit effective.22 , 23 A meta-assay of 8 RCTs (n = 692) reported that the proportion of ulcers that healed was significantly college with graduated compression stockings than with bandages (62.vii% five. 46.half-dozen%).23 The average time to ulcer healing was likewise significantly shorter with the stockings, by 3 weeks. Graduated pinch stockings may too exist associated with less pain than bandages are.21 , 23
There is evidence that loftier-compression (thirty–xl mm Hg) stockings are more than effective than medium- and low-compression stockings in promoting venous ulcer healing and preventing recurrence.22 , 24 A Cochrane systematic review of four RCTs (due north = 979) concluded that there is some bear witness, although not stiff, that graduated pinch stockings may prevent recurrence of venous ulcers and that loftier-pinch stockings may be more efficacious than those with moderate pinch.24
Postsurgical or interventional treatment of varicose veins
Compression therapy in the class of bandages or stockings is widely used immediately after surgical or interventional handling of varicose veins, although few RCTs accept assessed this.25 , 26 For example, compression after sclerotherapy has been shown to reduce the germination of thrombi and to prevent pigmentation and matting by minimizing inflammation and angiogenesis.27 However, one study that randomly assigned 60 patients to wear graduated compression stockings for iii weeks or to go without compression later on ultrasound-guided foam sclerotherapy plant no difference in efficacy, adverse furnishings, satisfaction scores, symptoms and quality of life between the two groups.26 Nosotros found no evidence that i form of compression was amend than another, although graduated compression stockings may be amend accepted by patients than bandages.25
Prevention of venous thromboembolism
Hospital patients
Many studies that assessed the role of graduated compression stockings in preventing venous thromboembolism were ofttimes small, used asymptomatic deep vein thrombosis detected through screening tests equally the study outcome and focused on surgical patients.28
A systematic review of graduated compression stockings for the prevention of deep vein thrombosis in patients admitted to infirmary because of atmospheric condition other than stroke identified xviii RCTs.29 Graduated pinch stockings were used alone or in combination with another form of prophylaxis (e.g., heparin, acetylsalicylic acid and sequential compression). All merely one of the RCTs assessed surgical patients. Deep vein thrombosis was diagnosed by and large through screening with ultrasonography, venography or isotope studies. Deep vein thrombosis developed in 13% of patients given graduated compression stockings, every bit compared with 26% of those with no stockings. In the trials in which stockings were given in combination with another condom method, deep vein thrombosis developed in iv% of patients given the stockings plus another method, as compared with 16% of those given the other method lonely. It was concluded that graduated compression stockings were effective in reducing the risk of deep vein thrombosis amid patients in hospital, specially when used with another method of prophylaxis.29
In CLOTS trial 1, symptomatic and asymptomatic deep vein thrombosis occurred in 126 (ten.0%) patients wearing graduated pinch stockings and in 133 (ten.5%) not wearing them, for a nonsignificant absolute reduction in take chances of 0.5% (95% confidence interval [CI] –1.nine% to 2.ix%).8
These findings call into question whether graduated compression stockings forbid venous thromboembolism and support the demand for further trials evaluating their efficacy in medical and surgical patients.28
Travel-related venous thromboembolism
One meta-analysis reported that travel of long duration is associated with a three-fold increased adventure of venous thromboembolism, with a dose–response association of 18% increased take chances per two-hour increase in duration.30 In 1 study, 231 airline passengers anile over l years with no history of venous thromboembolism were randomly assigned to wear class 1 (twenty–xxx mm Hg) below-knee graduated compression stockings or no stockings in journeys lasting more than than 8 hours.31 None of the passengers who wore the stockings had deep vein thrombosis, whereas 12 of 116 who did non wear stockings had asymptomatic deep calf vein thrombosis identified through screening with D-dimer assay and duplex ultrasonography.
A systematic review of ten RCTs concluded that wearing graduated compression stockings may reduce the incidence of asymptomatic deep vein thrombosis and leg edema in airline passengers. However, none of the trials was big plenty to appraise the effect of graduated compression stockings on death, pulmonary embolus or symptomatic deep vein thrombosis.32
Postthrombotic syndrome
Prevention
A common complexity of deep vein thrombosis, postthrombotic syndrome is characterized by clinical features ranging from leg hurting, swelling or minor skin changes to severe ulceration.33 , 34 A meta-analysis of five RCTs showed that astringent postthrombotic syndrome occurred in 5% of patients given graduated pinch stockings and 12% of patients with no compression (relative take chances 0.38, 95% CI 0.22 to 0.68).35 Postal service-thrombotic syndrome of whatsoever severity occurred in 26% with stockings and 46% without stockings (relative take a chance 0.54, 95% CI 0.44 to 0.67).35
In the UK, Squeamish recommends that patients with proximal deep vein thrombosis wearable below-knee graduated compression stockings with an ankle pressure level greater than 23 mm Hg for at to the lowest degree two years beginning a week after diagnosis or when swelling is reduced sufficiently, and if there is no contraindication.36 The recommendation was based on show from ii RCTs.37 , 38 Both studies found that about half of the patients with a start episode of proximal deep vein thrombosis had postthrombotic syndrome within ii years, and graduated pinch stockings decreased this rate by about l%. These studies showed a clinically important reduction in the incidence of postthrombotic syndrome (254 fewer per thousand, 95% CI 172 to 311 fewer), although there were no comparative data on adverse events.36
A recent double-bullheaded multicentre RCT (the SOX trial) involving 806 patients compared the effectiveness of compression and placebo stockings worn on affected legs daily for two years. Information technology showed that graduated compression stockings did not forestall the occurrence or influence the severity of postthrombotic syndrome later on a first proximal deep vein thrombosis. The cumulative incidence of the syndrome by 750 days was similar between the intervention and control groups (xiv.2% and 12.seven%).39
Treatment
A systematic review of RCTs on pharmacologic and compression therapies for postthrombotic syndrome reported that there was depression-quality evidence to support the use of graduated compression stockings for treatment of the condition.34 This was based on two RCTs.twoscore , 41 In the showtime report, 35 patients with symptomatic postthrombotic syndrome a year after having proximal deep vein thrombosis were randomly assigned to vesture graduated compression stockings (30–xl mm Hg) or a matched placebo stocking.xl The proportion of patients with treatment failure did non differ significantly between the two groups (61% and 59%, respectively). In the 2nd study, patients with postthrombotic syndrome were randomly assigned to wear below-knee graduated compression stockings (thirty–forty mm Hg) on the affected leg, to take hydroxyethylrutoside (a venoactive drug) orally, or to use both interventions, for 12 months; there were 40 participants in each group.41 No clear differences were found in improvement or worsening of the postthrombotic syndrome between the groups.
Lymphedema and chronic leg edema
Lymphedema refers to conditions involving dumb lymphatic drainage causing chronic build-up of fluid and swelling in the limbs. The current international standard of care for lymphedema is formalized in a 2013 consensus document of the International Society of Lymphology.42
Treatment of lymphedema often includes complex decongestive therapy and generally involves a ii-phase arroyo. The offset phase is intensive reduction of swelling, consisting of skin care, manual massage or lymph drainage, exercises and pinch typically with multilayered bandages. The second phase is the long-term maintenance of volume, which includes pare intendance, exercises, compression therapy, cocky-lymph drainage and, in some patients, pneumatic lymph drainage.
Graduated compression stockings are often used in the second phase to maintain long-term lymphedema reduction.42 There is evidence that high-compression stockings (thirty–40 mm Hg) are constructive.22 Mostly, the highest level of compression (20–60 mm Hg) that the patient tin can tolerate is likely to exist the most benign.42 However, lower compression can be used for milder lymphedema or general leg edema.43
Superficial thrombophlebitis
Graduated compression stockings can be used as part of the management of superficial thrombophlebitis, which may include other topical therapy, anticoagulation, nonsteroidal anti-inflammatory drugs and surgery. Graduated pinch stockings help to relieve local symptoms and may preclude extension of venous thrombosis. A systematic review reported that the combination of surgical handling and employ of graduated compression stockings was associated with a lower rate of venous thromboembolism and progression of superficial thrombophlebitis compared with stockings alone.44
Pregnancy
A nonrandomized trial described that graduated compression stockings may provide improvement of venous emptying and subjective consolation of leg problems such as swelling, tiredness and pain in significant women.45 A small RCT reported that graduated compression stockings failed to forestall varicose veins but improved leg symptoms in significant women.46 A Cochrane systematic review ended that graduated compression stockings do not announced to reduce leg edema in pregnant women.47
Conclusion
Although unanswered questions about the apply of graduated pinch stockings remain (Box five), loftier-quality evidence supports their use past patients with chronic venous insufficiency, especially those with ulcers. There is show of depression to moderate quality for the prophylactic upshot of the stockings against deep vein thrombosis in medically ill patients, just low-quality prove in general surgical and orthopedic patients. The latest testify from a large multicentre RCT did non support the use of graduated compression stockings to prevent postthrombotic syndrome, and nosotros constitute no evidence to support their use for treatment of the syndrome. Graduated compression stockings are constructive during the long-term maintenance of volume in lymphedema. For superficial thrombophlebitis, there may be some do good from wearing graduated compression stockings in combination with surgery. There is insufficient evidence to support their utilize during pregnancy.
When used, graduated compression stockings demand to exist measured and fitted properly. Patients likewise need to be informed of their indication and risks. Addressing patients' concerns, providing adequate information and reassurance, irresolute the stocking material or lowering the caste of pinch usually helps improve compliance in our experience.
Cardinal points
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Graduated compression stockings vary in terms of caste of pinch, length, textile material, color, blueprint and manufacturer.
-
There is high-quality evidence for the use of the stockings in patients with chronic venous insufficiency, particularly those with ulcers.
-
Graduated pinch stockings need to be measured and fitted properly.
-
Although use of the stockings is commonly condom, several adverse furnishings and complications, including allergic reaction and pare necrosis, have been reported.
-
Clinicians frequently underestimate the importance of patients' compliance with compression therapy, which is known to be depression.
-
Addressing patients' concerns, providing adequate information and reassurance, changing the stocking fabric or lowering the degree of pinch usually helps amend compliance.
Footnotes
Competing interests: None declared.
This commodity has been peer reviewed.
Contributors: Both authors contributed to the design and conception and to the drafting and revising of the article. Both gave final approval of the version to be published and act as guarantors of the work.
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