Demystifying Compression - 3Mmultimedia.3m.com/mws/media/758418O/nz-coban2-website-resource… · Demystifying Compression Terry Treadwell, MD, FACS Medical Director Institute for

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Demystifying CompressionCompression

Terry Treadwell, MD, FACSMedical DirectorInstitute for Advanced Wound CareMontgomery, Alabama

Compression Questions1. Are all compression bandages the same?2. 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

and cellulitis? 4. Does compression therapy improve the skin of patients with

venous dermatitis? 5. Can compression therapy be used in the patient with edema

and congestive heart failure? 6. Can compression therapy be used in the patient with edema

and acute deep venous thrombophlebitis?7. Do patients care which compression bandage is used?

Looking for the Evidence??

Demystifying Compression

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Are all compression bandages the same?bandages the same?

Compression Therapy• Short stretch or inelastic • Elastic• Single layer• Multiple layers• High pressure • Low pressure

D

Anterior

L

Compartments

Anterior Tibial

Greater Saphenous

Tibia

SuperficialPosterior

DeepPosterior

Lateral

Lesser Saphenous

Dr. HN Mayrovitz

Fibula

Skin

Posterior Tibial

Peroneal


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Pressures of Interest

Tibialis m.

Popliteus m

Pe

• Sub‐bandage• Surface• Contact

Tibia

Soleus m

Gastroc m.

Popliteus m.Tibialis m.

eroneus

•Tissue•Interstitial

Fibula

• Intramuscular

CompressionBandage or Device

Skin

Dr. HN Mayrovitz

Resting Pressure

R

Pressure (P) Due to Tension (T) of

LaPlace’sLaw

Superficial vessels affected the most

Tension (T) of Bandage and the Radius (R) of the Leg

Dr. HN Mayrovitz

P ~P ~ T T RR

Muscles Contract Bandage

Restricts Muscle

Contraction

Working (Dynamic) Pressure

High Pressure

Develops on Deeper Tissues

Pressure Is From WITHINDr. HN Mayrovitz


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Dynamic Pressure Depends onBandage Material Features

Form-fitted Steel Pipe(Cast)

res

su

re

Mayrovitz HN, et al. Clin Physiol. 1997;17(1):105‐117.

Bandage “Stretchability”

No External Compression

0

Inelastic(short stretch)

Elastic(long stretch)D

yna

mic

P

Working vs. Resting PressuresRole of Compression Material

Emptying

ure

(PT) Emptying

TimeDr. HN Mayrovitz

Tis

sue

Pres

s

Time

Pascal’s Law

Equal Distribution of

PPressure Throughout the

Leg with Muscle

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.

Can compression therapy be used in the

ti t ith d patient with edema and an ABI < 0.8?

Venous Ulcers and PVD1416 leg ulcers with venous reflux

14%2%

ABPI >1

0,85‐0,5

Humphreys ML et al. Br J Surg. 2007 Sep;94(9):1104‐7

84%

<0,5


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Venous Ulcer Healing

Marston W et al, J VascSurg 1999; 30:491

Control Leg

BeforeBandage

ml/min

Arterial Flow Pulses Below Knee Blood Flow via Nuclear Magnetic Resonance

Treated Leg

WithBandage

ml/min

Dr. HN Mayrovitz, Univ of Miami

Compression Therapy and Circulation

ABI Bandage Sub-bandage pressure (mm Hg)

> 0.8 4-layer 35-40

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 ti t ith ABPI f 0 6 d 0 7 2) 4 patients with ABPI of 0.6 and 0.7 3) 6 patients with ABPI of 0.7 and 0.8

• All patients treated with 3M Coban 2 Layer Lite Compression System

• Bandage remained on the leg 1 to 4 days• Study stopped after 14 days

Data on file – 3M

Results of 3M™Coban 2 Layer Lite Compression System Study

• An average supine subbandage pressure of ~ 28mmHg was measured just above the medial ankle after bandage application

• No pressure-related skin damage occurred in patients with reduced arterial perfusion

• No pain related to tissue hypoxia was detected

Data on file – 3M

Results of 3M™Coban 2 Layer Lite Compression System Study

• Laser doppler fluxmetry demonstrated positive effects on microcirculation including:– Increased overall tissue microperfusion – Reduced respiratory reflux in limbs with venous p y

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 Compression System Study

• Compression with Coban 2 Layer Lite Compression System is safe and well tolerated by patients with reduced peripheral arterial perfusionp p p

• Results of the laser doppler fluxmetry measurements indicate significant improvements of the dermal microcirculation under this compression therapy

Data on file – 3M

UNDER the Bandage: Increase of Flow

Toe pressure

40

60

80

100

+6% +9% +13%

mm

Hg

TcPO2

20

30

40

50

60

70

+7%

mm

Hg

DISTAL to the Bandage

0

20 n.s.

*** ***

0

10

20***

No impairment of arterial flow up to a pressure of 40 mmHg


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Ejection fraction

60

70

80

normal range

Inelastic Compression Improves Venous Pump

0

20-3

0

31-4

0

0

10

20

30

40

50

*** ***

+72% +103%

%

Venous Ulcer99 year old lady with ulcer for 8 months

ABI - 0.45

Informed that BK amputation was the

l thonly therapy

Treated with light compression and bi-layered tissue engineered skin

Wound healed after 47 weeks

Compression Bandage Too Tight Over Bony Prominences


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Sustained bandage pressure should never exceed the arterial perfusion pressure

(= ankle pressure)!

Warning!!!

Persisting or increasing pain:Remove the bandage!

Can compression therapy be used in

the patient with the patient with edema and 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

Edema and Compression Therapy in Cellulitis

1. Normal anti-Streptococcal properties of skin are inactivated by edema fluid

2. Compression therapy:y• Removes protein-containing fluid from the

subcutaneous tissues• Increases blood flow to tissues • Increases antibiotic concentration in tissues


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Cellulitis of Leg

Healed after10 days of

antibiotics and 5 weeks of

compressioncompression therapy

Does compression therapy improve the skin of patients the skin of patients with venous dermatitis?

Properties of Edema Fluid

1. Edema fluid inhibits mitogenic activity and DNA synthesis.

2 Cytokine environment in edema fluid is more 2. Cytokine environment in edema fluid is more proinflammatory.

3. Protease activity is higher in edema fluid.4. Growth factors levels are decreased in edema

fluid.1. 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

17 60 66AS

4.00.33SK

12.61BB

14.91KM

Wound (%)Normal (%)Patient

Stanley A, et al. J Vasc Surg. 2001;33(6):1206‐1211.

26.32.33FF

210.33RG

14.31.33OB

17.60.66AS

Fibroblasts and Chronic Wound Fluid

60,000

50,000

40,000

(ce

lls

/da

y)

40

30

e C

ell

s(%

)

†

*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.

30,000

20,000

10,000

0

Gro

wth

Ra

te

*

CM VUWF

20

10

0

SA

--G

al

Po

sit

ive

CM VUWF

Proteases and Compression TherapyRelative MMP Levels in Healthy and Ulcer Tissue

Before and After Compression Therapy

400500

600 HealthyBefore TXAfter TX

otal p

rotei

n N=21

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

0100200

300

pg/µ

g to


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normal before after

Inflammatory Cytokines and Compression Therapy

00.002

0.0040.006

0.0080.01

0.012

0.0140.0160.018

0.02

Normal Before Afternormal before after0

0.05

0.1

0.15

0.2

0.25

0.3

normal before afternormal before after

Interleukins

0

2

4

6

8

10

12

14

16

normal tissue ulcer before Rx ulcer after Rx

Il-8

\normal tissue ulcer before RX ulcer after RX0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

0.18

normal before After

Il-1b

normal before after

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 on Advanced Wound Care/Wound Healing Society Meeting, San Diego, CA. April 25, 2008

TNF-alpha

normal before after

IFN-gamma

normal before after\normal tissue ulcer before RX ulcer after RX

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

norm al before after

IL12p40

normal before after

normal before after

Effect of Compression Therapy

1 Week of Compression

Stasis Dermatitis

Improvement after 22 weeks of

compression ptherapy


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Can compression therapy be used in the patient with

edema and congestive edema and congestive heart failure?

Massive Edema and CHF

Photo used with permission

Congestive Heart Failure and Compression Therapy

• No acute pulmonary edema• Once treatment started with

di ti l t di ti d cardiostimulatory medications and diuretics



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Can compression therapy be used in the patient with edema and

acute deep venous thrombophlebitis?

Compression Therapy and Acute Deep Venous Thrombophlebitis

• Increases venous flow• Prevents further clotting

O l d fi i l i th t ld l t• 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 18


Contraindication to Compression in Acute Deep Venous

Thrombophlebitis

Leg 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 compression bandage p g

is used?

Fact: Patients don’t like compression bandages!

• Only 48.8% of patients wore their compression bandages *

• May be as high as 80% *

• Determinants for NOT wearing compression bandages:Determinants for NOT wearing compression bandages:a. Ageb. Pain c. Wound sized. Wound depth

* Miller C, Kapp S, Newell N, et al. Predicting Concordance with Multilayer Compression Bandaging. Jour Wound Care 2011;20(3):101-112

Is this comfortable?


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10

actico k-two profore profore lite proguide short stretch long stretch rosidal sys coban 2 layer coban 2 lite

0

1

2

3

4

5

6

7

8

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

Patient Preference for Compression Therapy

• 72% of patients preferred Coban 2 Layer Compression System over Profore when treated with both for venous ulcer

• 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 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.

Compression Questions

1. Are all compression bandages the same? NO2. 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

cellulitis? YES 4. Does compression therapy improve the skin of patients with venous

dermatitis? YES5. Can compression therapy be used in the patient with edema and

congestive heart failure? YES6. Can compression therapy be used in the patient with edema and

acute deep venous thrombophlebitis? 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

Sponsored by an educational grant from 3M

For more information on 3M Compression Therapy visit 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.


Documents

Demystifying Compression - 3Mmultimedia.3m.com/mws/media/758418O/nz-coban2-website-resource… · Demystifying Compression Terry Treadwell, MD, FACS Medical Director Institute for