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Demystifying Demystifying CompressionCompression
Terry Treadwell, MD, FACSMedical DirectorMedical DirectorInstitute for Advanced Wound CareMontgomery, Alabama
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Compression Questionsp Q1. Are all compression bandages the same?p g2. Can compression therapy be used in the patient with edema
and an ABI < 0.8? 3 Can compression therapy be used in the patient with edema 3. Can compression therapy be used in the patient with edema
and cellulitis? 4. Does compression therapy improve the skin of patients with
d titi ? venous dermatitis? 5. Can compression therapy be used in the patient with edema
and congestive heart failure? g6. Can compression therapy be used in the patient with edema
and acute deep venous thrombophlebitis?7 Do patients care which compression bandage is used?7. Do patients care which compression bandage is used?
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Looking for the Evidence??Looking for the Evidence??
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Are all compression bandages the same?
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Compression Therapyp py• Short stretch or inelastic • Elastic
Si l l• Single layer• Multiple layersp y• High pressure
L • Low pressure
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Compartmentsp
Tibia
AnteriorAnterior Tibial
Greater Saphenous
DeepPosterior
Later
Fib l Posterior
Superficiali
ralFibula Posterior Tibial
PosteriorSkinPeroneal
Lesser Saphenous
Dr. HN Mayrovitz(c) 3M 2012
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Pressures of Interest
• Sub‐bandage• Surface
Tibia
Tibialis m.
• Surface• Contact
Popliteus m.Tibialis m.
PeroneuFib lCompression
Soleus m
usFibula Bandage or Device
Gastroc m.•Tissue•Interstitial
• Intramuscular
Skin
• Intramuscular
Dr. HN Mayrovitz
(c) 3M 2012
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Resting Pressure
Pressure (P) LaPlace’sLaw
RDue to Tension (T) of Bandage and
Law
TTgthe Radius (R) of the Leg
P ~P ~ T T RR
Superficial vessels affected the mostSuperficial vessels affected the mostDr. HN Mayrovitz
(c) 3M 2012
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Working (Dynamic) Pressure
Muscles Contract Bandage Contract
Restricts Muscle
Contraction
High
Contraction
Pressure Develops on DeeperDeeper Tissues
Pressure Is From WITHINDr. HN Mayrovitz
(c) 3M 2012
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Dynamic Pressure Depends onBandage Material Features
Form-fitted Steel Pipe(Cast)
ure
Inelastic(short stretch)
mic
Pre
ssu
No External Compression
Elastic(long stretch)D
ynam
B d “St t h bilit ”0
Mayrovitz HN, et al. Clin Physiol. 1997;17(1):105‐117.
Bandage “Stretchability”
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Working vs. Resting PressuresR l f C i M t i lRole of Compression Material
EmptyingEmptyingp y g
e(P
T)
Emptying
essu
reue
Pre
Tiss
u
TimeDr. HN Mayrovitz
Time(c) 3M 2012
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Pascal’s Law
Equal Distribution of
Pressure Th h t thThroughout the
Leg with MuscleMuscle
Contraction
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Short Stretch Vs. Multi-stretch• Short stretch systems are effective at a lower resting
pressure than multi-stretch systems
• A lower resting pressure offers safer compression in the compromised limb
• Both systems can produce effective, dynamic working and resting pressures.
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Can compression Can compression therapy be used in the therapy be used in the patient with edema pand an ABI < 0.8?
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Venous Ulcers and PVDVenous Ulcers and PVD1416 leg ulcers with venous reflux
14% 2%
ABPI >1ABPI >10,85‐0,5<0,5
84%84%
Humphreys ML et al. Br J Surg. 2007 Sep;94(9):1104‐7
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Venous Ulcer Healing
Marston W et al, J VascSurg 1999; 30:491
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Arterial Flow Pulses
Control Leg Below Knee Blood Flow via Nuclear Magnetic Resonance
Treated LegControl Leg
BeforeBandage
ml/min
Treated Leg
Bandage
WithBandage
ml/min
Bandage
Dr. HN Mayrovitz, Univ of Miami
(c) 3M 2012
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Compression Therapy and Circulationp py
ABI Bandage Sub-bandageABI Bandage Sub bandage pressure (mm Hg)
> 0.8 4-layer 35-400 8 aye 35 0
0.7 2-layer 17-25
0.6 2-layer 17-25
<0.5 Only with medical supervision
---
Moffatt C. www.worldwidewounds.com (12/5/09)
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Compression and Arterial Insufficiency
• 15 patients suffering from peripheral arterial occlusive disease with an ankle brachial pressure index (ABPI) of 0.5-0.8
1) 5 patients with ABPI of 0.5 and 0.6 2) 4 patients with ABPI of 0.6 and 0.7 3) 6 patients with ABPI of 0 7 and 0 83) 6 patients with ABPI of 0.7 and 0.8
• All patients treated with 3M Coban 2 Layer Lite Compression System Compression System
• Bandage remained on the leg 1 to 4 days• Study stopped after 14 days• Study stopped after 14 days
Data on file – 3M
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Results of 3M™Coban 2 Layer Lite Compression System Study
• An average supine subbandage pressure of ~ 28mmHg was measured just above the medial g jankle after bandage application
• No pressure-related skin damage occurred in patients No pressure related skin damage occurred in patients with reduced arterial perfusion
• No pain related to tissue hypoxia was detected
Data on file – 3M
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Results of 3M™Coban 2 Layer Lite Compression S stem St d Lite Compression System Study
• Laser doppler fluxmetry demonstrated positive effects on pp y pmicrocirculation including:– Increased overall tissue microperfusion – Reduced respiratory reflux in limbs with venous
insufficiency– Maintained stable capillary perfusion
• Limb volume reduction (reduced edema) compared to baseline
• High wearing comfort
Data on file – 3M
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Conclusions: 3M™Coban 2 Layer Lite 3M™Coban 2 Layer Lite Compression System Study p y y
• Compression with Coban 2 Layer Lite Compression System is safe and well tolerated by patients with System is safe and well tolerated by patients with reduced peripheral arterial perfusion
• Results of the laser doppler fluxmetry measurements pp yindicate significant improvements of the dermal microcirculation under this compression therapy
Data on file – 3M
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UNDER the Bandage: Increase of Flowg
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DISTAL to the Bandage
Toe pressure100
TcPO2
60
80
100
+6% +9% +13%
Hg
40
50
60
70
+7%
Hg
20
40
n.s *** ***
mm
10
20
30
40
***
mm
H
0.
0
No impairment of arterial flow up to a pressure of 40 mmHg
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Inelastic Compression Improves Venous P
Ejection fraction
PumpEjection fraction
7080
normal range
405060
g%
203040
+72% +103%
%
0 0 0
010 *** ***
0
20-30
31-40
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Venous UlcerVenous Ulcer99 year old lady with ulcer for 8 months
ABI - 0.45
Informed that BKInformed that BK amputation was the only therapy
Treated with lightTreated with light compression and bi-layered tissue engineered skin
Wound healed after 47 weeks
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Compression Bandage Too Tight Over B P iBony Prominences
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Warning!!!Warning!!!
Sustained bandage pressure should never exceed the arterial perfusion pressure
(= ankle pressure)!
Persisting or increasing pain:Remove the bandage!
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Can compression ptherapy be used in
the patient with d d edema and cellulitis?cellulitis?
Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, in press
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Edema and Compression Therapy in Cellulitis
1. Normal anti-Streptococcal properties of skin are inactivated by edema fluid
2. Compression therapy:• Removes protein-containing fluid from the p g
subcutaneous tissues• Increases blood flow to tissues • Increases antibiotic concentration in tissues
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Cellulitis of LegCellulitis of Leg
Healed after10 days of
antibiotics andantibiotics and 5 weeks of
compression therapy
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Does compression therapy improve
fthe skin of patients with venous with venous dermatitis?dermatitis?
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Properties of Edema FluidProperties of Edema Fluid
1. Edema fluid inhibits mitogenic activity and DNA synthesis.synthesis.
2. Cytokine environment in edema fluid is more proinflammatory.proinflammatory.
3. Protease activity is higher in edema fluid.4 Growth factors levels are decreased in edema 4. Growth factors levels are decreased in edema
fluid.1 R tliff C R "W d d t i fl ti l f t i h li " Ad N P t 16 7 (2008) 32 351. Ratliff, C. R. "Wound exudate: an influential factor in healing." Adv.Nurse Pract. 16.7 (2008):32-35.2. Trengove, N. J., H. Bielefeldt-Ohmann, and M. C. Stacey. "Mitogenic activity and cytokine levels in non-healing and healing chronic leg ulcers." Wound Repair Regen. 8.1 (2000):13-25.3. Trengove, N. J., S. R. Langton, and M. C. Stacey. "Biochemical analysis of wound fluid from nonhealing and healing chronic leg ulcers." Wound Repair Regen. 4.2 (1996): 234-39.
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Fibroblast Senescence and Venous Ulcers
Wound (%)Normal (%)Patient
12.61BB
14.91KM
14 31 33OB
17.60.66AS
4.00.33SK
26.32.33FF
210.33RG
14.31.33OB
Stanley A, et al. J Vasc Surg. 2001;33(6):1206‐1211.
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Fibroblasts and Chronic Wound Fluid
60,000
50,000
40 000s/da
y)
40
30ls(%
)
†
40,000
30,000
Rat
e (c
ells 30
20
ositi
ve C
ell
20,000
10,000Gro
wth
*10
A-
-Gal
Po
0CM VUWF
0S
CM VUWF
*P = .006; †P<.03.CM = complete media; VUWF = venous ulcer wound fluid; SA‐‐Gal = senescence‐associated ‐galactosidaseactivity.Mendez MV, et. al. J Vasc Surg. 1999;30:734‐743.
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Proteases and Compression TherapyRelative MMP Levels in Healthy and Ulcer Tissue
Before and After Compression Therapyp py
500
600 HealthyBefore TXAfter TXro
tein N=21
200
300
400
µg to
tal pr
0100200pg
/
Marston WA, Beider S, Davies S, Berndt DF. Protease and Cytokine Levels in Non-Healing Venous Leg Ulcers Before and After Compression Therapy. Presented at Symposium on Advanced Wound Care/Wound
Healing Society Meeting, San Diego, CA. April 25, 2008
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Inflammatory Cytokines and Compression Therapy
Interleukins
0 0060.008
0.010.0120.0140.0160.018
0.02
0.1
0.15
0.2
0.25
0.3
Interleukins
810
121416
Il-80.080.1
0.120.140.160.18
Il-1b
normal before after0
0.0020.0040.006
Normal Before Afternormal before after0
0.05
0.1
normal before afternormal before after024
6
normal tissue ulcer before Rx ulcer after Rx\normal tissue ulcer before RX ulcer after RX
1.4
1.6
1.8
00.020.040.060.08
normal before Afternormal before after
normal before after
TNF-alpha IFN-gamma
0
0.2
0.4
0.6
0.8
1
1.2
norm al before after
IL12p40
normal before after
Marston WA, Beider S, Davies S, Berndt DF. Protease and Cytokine Levels in Non-Healing Venous Leg Ulcers Before and After Compression Therapy Presented at Symposium onVenous Leg Ulcers Before and After Compression Therapy. Presented at Symposium on Advanced Wound Care/Wound Healing Society Meeting, San Diego, CA. April 25, 2008
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Effect of Compression TherapyEffect of Compression Therapy
1 Week of Compression(c) 3M 2012
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Stasis Dermatitis Stasis Dermatitis
Improvement after 22
weeks ofweeks of compression
therapy
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Can compression therapy Can compression therapy be used in the patient with p
edema and congestive heart failure?
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Massive Edema and CHFMassive Edema and CHF
Photo used with permission
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Congestive Heart Failure and Compression Therapy
• No acute pulmonary edemaO t t t t t d ith • Once treatment started with cardiostimulatory medications and diureticsdiuretics
Treadwell TA Fowler E Bates Jensen BB Management of Edema in Wound Care:Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, in press
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Can compression therapy be used in the patient with edema and patient with edema and
acute deep venous pthrombophlebitis?
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Compression Therapy and Acute Deep Venous Thrombophlebitis
• Increases venous flow• Prevents further clotting• Prevents further clotting• Occludes superficial veins that could clot• Does not cause an increase in pulmonary
embolism
Dale AW. The Swollen Limb. Current Problems in Surgery, Year Book Medical Publishers, Inc., USA 1973 (September) p 18USA. 1973 (September), p 18
Treadwell TA, Fowler E, Bates-Jensen BB. Management of Edema in Wound Care: A Collaborative Practice Manual for Health Professionals, 4th Edition, Ed. BB Bates-Jensen, in press
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Contraindication to Compression i A t D V in Acute Deep Venous
ThrombophlebitisThrombophlebitis
Leg so painful that compression cannot be toleratedLeg so painful that compression cannot be tolerated.
Dale AW. The Swollen Limb. Current Problems in Surgery, Year Book Medical Publishers, Inc., USA. 1973 (September), p 18
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Do patients care which i b d compression bandage
is used?is used?
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Fact: Patients don’t like i b d !compression bandages!
• Only 48 8% of patients wore their compression bandages *Only 48.8% of patients wore their compression bandages
• May be as high as 80% *
• Determinants for NOT wearing compression bandages:a. Ageb. Pain c. Wound sized Wound depthd. Wound depth
* Miller C, Kapp S, Newell N, et al. Predicting Concordance with Multilayer Compression Bandaging. Jour Wound Care 2011;20(3):101-112
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Is this comfortable?Is this comfortable?
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9
10Slippage in cm: after 24 and 48 hours
actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite
After 48 hours of wear
6
7
8
After 48 hours of wear
3
4
5
0
1
2
actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite
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Patient Preference for C i ThCompression Therapy
• 72% of patients preferred Coban 2 Layer Compression System over Profore when treated with both for venous yulcer
• Coban 2 Layer Compression System showed less slippage than Profore
• Quality of Life assessments were better with Coban 2 Layer Compression System than with Profore (p<0.05)
Moffatt CJ Edwards L Collier M Treadwell T Miller M Shafer L Sibbald G Brassard A McIntosh AMoffatt CJ, Edwards L, Collier M, Treadwell T, Miller M, Shafer L, Sibbald G, Brassard A, McIntosh A, Ryzelman A, Price P, Kraus SM, Walters SA, Harding K. Randomized Controlled 8-Week Crossover Clinical Evaluation of the 3M Coban 2 Layer Compression System Versus Profore to Evaluate the Product performance in Patients with Venous Leg Ulcers. Int Wound Journal 2008; 5:267-279.
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Compression Questions
1. Are all compression bandages the same? NOp g2. Can compression therapy be used in the patient with edema and
an ABI < 0.8? YES3 Can compression therapy be used in the patient with edema and 3. Can compression therapy be used in the patient with edema and
cellulitis? YES 4. Does compression therapy improve the skin of patients with venous
d titi ? YESdermatitis? YES5. Can compression therapy be used in the patient with edema and
congestive heart failure? YESg6. Can compression therapy be used in the patient with edema and
acute deep venous thrombophlebitis? YES7 Do patients care which compression bandage is used? YES7. Do patients care which compression bandage is used? YES
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“It is the individual patient who we treat, not the disease. It is the patient who recovers or dies, not the illness.”James Peck, MD, Am. Jour. Surg. 2004;187:569-574
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Sponsored by an educational grant from 3MSponsored by an educational grant from 3M
For more information on For more information on 3M Compression Therapy visit
www.3m.com/coban2layer
3M is a provider approved by the California Board of Registered Nursing, Provider Number CEP 5770. Nurse participants may receive continuing education credit upon completion of education module.
(c) 3M 2012