Intermittent Pneumatic Compression for Hemiparetic Stroke Patients
Direct Answer
Apply IPC devices to both legs in stroke patients with hemiparesis, not just the affected limb. The evidence supports bilateral application for DVT prophylaxis in immobile stroke patients, regardless of whether weakness is unilateral 1, 2, 3.
Application Protocol
Bilateral IPC is Standard Practice
- IPC should be applied to both lower extremities in all immobile stroke patients, including those with unilateral hemiparesis 1, 3.
- The CLOTS 3 trial, which established IPC efficacy in stroke patients, applied devices bilaterally to all participants and demonstrated an 8.5% DVT rate with IPC versus 12.1% without IPC (adjusted OR 0.65,95% CI 0.51-0.84, p=0.001) 2, 3.
- Both legs remain at risk for DVT development even when only one leg is paretic, as immobility and hypercoagulability affect the entire venous system 4.
Timing and Duration
- Apply IPC as soon as possible within the first 24 hours of admission to immobile stroke patients 1.
- Continue IPC for 30 days, or until the patient becomes independently mobile, is discharged from hospital, or develops adverse effects—whichever comes first 1.
- If IPC is being considered after the first 24 hours of admission, perform venous leg Doppler studies first to rule out existing DVT 1.
Patient Selection Criteria
Who Should Receive IPC
- All stroke patients who cannot mobilize to the toilet without assistance from another person are candidates for IPC 1, 3.
- High-risk features include: inability to move one or both lower limbs, inability to mobilize independently, previous history of VTE, dehydration, and comorbidities such as cancer 1.
Contraindications to IPC
Do not apply IPC devices to legs with:
- Confirmed DVT in that limb 4
- Dermatitis or leg ulcers 1, 3
- Severe leg edema 1, 3
- Severe peripheral vascular disease 1, 3
- Gangrene 1
- Recent vein ligation or grafting 1
Safety Monitoring
Daily Assessment Requirements
- Assess skin integrity daily on both legs while IPC devices are in use 1.
- Monitor for skin breaks, which occurred in 3.1% of IPC patients versus 1.4% of controls in the CLOTS 3 trial 1, 3.
- Consult wound care specialists if skin breakdown develops during IPC therapy 1.
- Check both legs regularly for signs of DVT development including pain, swelling, and warmth 4.
Clinical Outcomes
Proven Benefits
- IPC reduces DVT risk by 35% (relative risk reduction 0.69,95% CI 0.55-0.86) in immobile stroke patients 1, 3.
- IPC may improve 6-month survival (HR 0.86,95% CI 0.73-0.99, p=0.042) 1, 3.
- The direct cost of preventing one DVT is £1282 (95% CI £785-£3077), making it cost-effective 2.
Important Caveats
- IPC is preferred over graduated compression stockings alone, which are not recommended for post-stroke VTE prophylaxis 1.
- IPC can be used in addition to routine care (aspirin and hydration) and does not preclude pharmacological prophylaxis when appropriate 1, 3.
- Falls with injury occurred in 2.3% of IPC patients versus 1.7% of controls, though this difference was not statistically significant 1, 3.