To reduce the risk of venous thromboembolism, it is essential that patients are given the right support regarding the use of antiembolism stockings
All inpatients should be assessed for venous thromboembolism risk and supplied with antiembolism stockings if no contraindications are present. This article explains how antiembolism stockings are selected, the procedure for applying them, and what ongoing care of the patient should involve once stocking are applied. Citation: Gee E (2019) How to apply antiembolism stockings to prevent venous thromboembolism. Nursing Times [online]; 115: 4, 24-26. Author: Emma Gee is nurse consultant in thrombosis and coagulation, King’s College Hospital Foundation Trust, and lead for the VTE National Nursing and Midwifery Network.
Venous thromboembolism (VTE) is a major cause of potentially preventable death and morbidity in hospitalised patients (National Institute for Health and Care Excellence, 2018). To reduce the risk of hospital-associated thrombosis, all inpatients should be assessed to determine their individual risk of VTE. Antiembolism stockings (AES) and intermittent pneumatic compression (IPC) devices can be used to reduce the risk of VTE. The choice of prophylaxis should be based on:
This article focuses on the use of AES. AES reduce the risk of VTE by exerting graduated circumferential pressure, which increases blood flow velocity and promotes venous return. In preventing venous distension, stockings are thought to reduce subendothelial tears and inhibit the activation of clotting factors. Thigh-length stockings increase blood flow velocity in the femoral vein, preventing dilatation of the popliteal vein, and may offer more protection above the knee than knee-length stockings (Benko et al, 1999), although NICE (2018) does not specify which length should be used. If AES are indicated, patients should be supplied with them as soon as possible. They should be advised to wear them day and night until their mobility is no longer significantly reduced. Patients and carers must receive clear information on how to manage their stockings at home, as well as what to do if problems arise (NICE, 2018). Patients and carers may need help to apply and remove stockings and to monitor their skin health. Indications for antiembolism stockingsSurgical patientsThe NICE (2018) guideline offers slightly different guidance depending on the type of surgery patients are having and their risk factors. Due to the variation in this guidance, many trusts have opted for a simplified approach, so it is important to make sure that local guidance is also reviewed and followed. Medical patientsUnder the NICE (2018) guidance, medical patients who have a high risk of developing VTE should not receive mechanical thromboprophylaxis. The exception is patients in critical care, who should be considered for mechanical measures only if pharmacological thromboprophylaxis is contraindicated. Patients who have had a stroke should not be given AES at all (NICE, 2018) as these stockings have been found to be ineffective at reducing the risk of deep vein thrombosis in this patient group and they are associated with an increased risk of skin damage (Dennis et al, 1999). IPC can be considered for patients who are immobile and have had an acute stroke. It should be started within three days of the stroke and discontinued when the patient is mobile, discharged or after 30 days, whichever is soonest. If IPC is unsuitable, hydration and early mobilisation may be the only safe preventative options available. All patients who have impaired mobility at the time of discharge and who have had AES should continue to wear their stockings at home until their mobility is restored, providing that this is considered to be safe. NICE (2018) defines people with significantly reduced mobility as “patients who are bed bound, unable to walk unaided or [those who are] likely to spend a substantial proportion of the day in bed or in a chair”. AssessmentAES carry a potential risk of skin damage and restriction of blood flow to the lower legs if applied to patients with contraindications – outlined in Box 1 – or if patients receive inadequate care. Risk is reduced by ensuring:
The risk must be reassessed if a patient is discharged from hospital with stockings to ensure the benefit outweighs the risk.
Box 1. Contraindications to antiembolism stockings Do not offer antiembolism stockings to a patient with:
If you are unsure about contra-indications, particularly regarding the presence of arterial disease, seek expert help. Clinical judgement and caution should be used when applying stockings to legs with venous ulcers or wounds. Source: Adapted from National Institute for Health and Care Excellence (2018) Applying antiembolism stockingsEquipment
The procedure
Source: Peter Lamb
Source: Peter Lamb
Box 2. Information to document
ConclusionIt is important that nurses follow local guidance on the use of AES and monitor their patients for signs of complications. Adherence to treatment can be challenging for patients, so nurses should explain the reasons for AES and support patients to manage their care.
Selecting stocking length Before selecting a length of stocking (knee or thigh) consider:
Key points
Benko T et al (1999) The physiological effect of graded compression stockings on blood flow in the lower limb: an assessment with colour Doppler ultrasound. Phlebology; 14: 1, 17-20. Dennis M et al (1999) Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial. The Lancet; 373: 9679, 1958-1965. National Institute for Health and Care Excellence, (2018) Venous Thromboembolism in over 16s: Reducing the Risk of Hospital-acquired Deep Vein Thrombosis or Pulmonary Embolism. |