What are the guidelines for using intermittent pneumatic compression (IPC) and graduated compression stockings (GCS) for venous thromboembolism (VTE) prophylaxis?

Guidelines for Using Intermittent Pneumatic Compression (IPC) and Graduated Compression Stockings (GCS) for VTE Prophylaxis

Pharmacological prophylaxis should be used as the primary method for VTE prevention in most hospitalized patients, with mechanical methods reserved for those with contraindications to anticoagulants or as adjunctive therapy in very high-risk patients. 1

Primary Recommendations for Mechanical Prophylaxis

When to Use Mechanical Prophylaxis

1. First-line recommendation:

   • Pharmacological prophylaxis with LMWH, LDUH, or fondaparinux is preferred over mechanical prophylaxis for most acutely ill hospitalized medical patients at increased VTE risk 1

2. Indications for mechanical prophylaxis alone:

   • Patients who are bleeding or at high risk for major bleeding 1, 2
   • Contraindications to anticoagulants (active bleeding, severe thrombocytopenia with platelets <25×10⁹/L, recent intracranial hemorrhage) 2

3. Combined mechanical and pharmacological prophylaxis:

   • Not routinely recommended for most patients 1
   • May be considered in selected patients at very high risk of VTE 2, 3
   • Should be considered when bleeding risk decreases in patients initially started on mechanical prophylaxis 1

Choice Between IPC and GCS

• Both IPC and GCS are acceptable options when mechanical prophylaxis is indicated [1, @10@]
• Evidence suggests IPC may be superior to GCS in surgical settings 4, 5
• For patients at high risk of VTE with contraindications for pharmacological prophylaxis, IPC is preferred over GCS 5

Efficacy and Safety Considerations

Efficacy

• Mechanical prophylaxis reduces DVT risk compared to no prophylaxis 1
• Combined IPC and pharmacological prophylaxis reduces DVT incidence compared to pharmacological prophylaxis alone (5.48% vs 9.28%, OR 0.38) 3
• Combined therapy reduces PE incidence compared to pharmacological prophylaxis alone (0.91% vs 1.84%, OR 0.46) 3

Safety

• Mechanical prophylaxis has no risk of bleeding, making it suitable for patients with bleeding risks 6
• GCS use may increase risk of skin complications, including breaks, ulcers, and blisters 1
• Patient compliance is often lower with IPC than with GCS 4
• Patients averse to skin complications, cost, and clinical monitoring may decline mechanical prophylaxis 1

Special Populations

Cancer Patients

• Mechanical prophylaxis should not be used as monotherapy unless pharmacological methods are contraindicated 2
• For surgical cancer patients, LMWH is preferred over mechanical methods 1
• Small RCTs have shown superiority of LMWH over IPC alone in reducing VTE complications in cancer surgical patients 1

Critically Ill Patients

• For critically ill patients who are bleeding or at high risk for major bleeding, mechanical thromboprophylaxis with GCS and/or IPC is suggested until bleeding risk decreases 1
• When bleeding risk decreases, pharmacological thromboprophylaxis should replace mechanical methods 1

Common Pitfalls and Caveats

1. Inappropriate use of mechanical prophylaxis:

   • Using mechanical methods as first-line when pharmacological prophylaxis is not contraindicated 1
   • Failing to transition from mechanical to pharmacological prophylaxis when bleeding risk decreases 1

2. Skin complications:

   • Not monitoring for skin breaks, ulcers, or blisters, particularly with GCS 1
   • Not properly fitting GCS, which can lead to skin damage or reduced efficacy

3. Compliance issues:

   • Poor patient adherence, particularly with IPC devices 4
   • Removing devices for extended periods (e.g., during ambulation) without resuming use

4. Overreliance on mechanical methods:

   • Assuming mechanical methods provide equivalent protection to pharmacological prophylaxis 1
   • Using mechanical prophylaxis in low-risk patients where no prophylaxis is recommended 1

Algorithm for Decision-Making

1. Assess VTE risk:

   • Use validated tools like Padua score (high risk ≥4) or IMPROVE VTE Risk Assessment Model (increased risk ≥2) 2

2. Assess bleeding risk:

   • Use IMPROVE Bleeding RAM (high bleeding risk ≥7) 2
   • Check for active bleeding, severe thrombocytopenia, recent intracranial hemorrhage

3. Select prophylaxis strategy:

   • Low VTE risk: No prophylaxis needed 1
   • Increased VTE risk without bleeding risk: Pharmacological prophylaxis with LMWH, LDUH, or fondaparinux 1
   • Increased VTE risk with high bleeding risk: Mechanical prophylaxis with IPC preferred over GCS 5
   • Very high VTE risk (e.g., multiple risk factors): Consider combined mechanical and pharmacological prophylaxis 2, 3

4. Reassess regularly:

   • When bleeding risk decreases, transition from mechanical to pharmacological prophylaxis 1
   • Continue prophylaxis until patient is fully mobile or discharged 1

By following these guidelines, clinicians can optimize VTE prophylaxis while minimizing risks associated with both mechanical and pharmacological approaches.