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Intermittent pneumatic compression prevents venous stasis in the lower extremities in the lithotomy position

[Une compression pneumatique intermittente prévient l'insuffisance veineuse aux membres inférieurs en position gynécoloqique]

Shinji Kohro, MD PhD^*, Michiaki Yamakage, MD PhD, Toshiyuki Takahashi, MD^*, Mitsu Kondo, MD^*, Koichi Ota, MD PhD^* and Akiyoshi Namiki, MD PhD

^* From the Departments of Anesthesia Ebetsu Municipal Hospital Ebetsu, and
the Sapporo Medical University, School of Medicine, Sapporo Hokkaido Japan.

Address correspondence to: Dr. Michiaki Yamakage, Department of Anesthesiology, Sapporo Medical University, School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan. Phone: +81-11-611-2111, ext. 3568; Fax: +81-11-631-9683; E-mail: yamakage{at}sapmed.ac.jp

	Abstract

TOP Abstract Introduction Methods Results Discussion References

 
Purpose: To investigate the interactions of a new lithotomy positioning device (LPD) with two intermittent pneumatic compression (IPC) devices by measuring femoral venous flow velocity.

Methods: Subjects were divided into three groups: 1) supine position as a control, 2) lithotomy position using a conventional LPD, and 3) lithotomy position using a new LPD, Levitator^TM. These three groups were further divided in two according to the type of IPC device used: AV-impulse^TM (rapid IPC) and SeQuel^TM (standard IPC). Peak femoral venous flow velocity was measured by using an ultrasonic echo diagnostic device. Data were analyzed by one-way ANOVA with Fisher's test or by the unpaired two-tailed t test.

Results: Moving to the conventional lithotomy position from the supine position, venous flow velocity was decreased by 38% in both IPC device groups. Even when the new LPD was used to support the lithotomy position, the flow velocity was decreased by 24%, but the velocity was significantly higher than in the conventional lithotomy position. Both rapid and standard IPC devices increased flow velocity to 77% and 107% (first compression) and to 71% and 84% (fifth compression) of the control values during compression, respectively. In the lithotomy position group using the new LPD, similar increases in flow were seen with the use of IPC devices.

Conclusion: Both rapid and standard IPC devices are useful for maintaining venous flow of the lower extremities in the lithotomy position.

	Introduction

TOP Abstract Introduction Methods Results Discussion References

 
THE conventional lithotomy position with fixation of both knees may interrupt venous flow of the lower extremities and cause deep venous thrombosis, leading to pulmonary embolism.¹ A new device (Levitator^TM; Skytron, Grand Rapids, MI, USA) that supports the lower extremities at the heels and calves in the lithotomy position has recently become available. We hypothesized that this new lithotomy positioning device (LPD) would prevent venous stasis of the lower extremities because it avoids compression of the popliteal fossa. On the other hand, two intermittent pneumatic compression (IPC) devices, the high-pressure, rapid-inflation, AV-impulse^TM (Novamedix, Hampshire, UK), and a standard, low-pressure, slow-inflation, SeQuel^TM (Kendall, Mansfield, MA, USA) have been reported to be effective in preventing deep venous thrombosis.^2–5 However, their effectiveness is still controversial.^6–9 To clarify the interactions between position and IPC devices, we compared the effects of these devices on femoral venous flow velocity in the supine and lithotomy positions.

	Methods

TOP Abstract Introduction Methods Results Discussion References

 
Thirty-six volunteers were enrolled in this study. They were randomly divided into three groups according to position: 1) supine position, 2) lithotomy position using a conventional LPD that fixes both knees, and 3) lithotomy position using a newly developed LPD that supports the lower extremities at the heels and calves. These three groups were further divided into two groups according to the type of IPC device used: rapid or standard. Thus, six volunteers were included in each group. While both soles of each volunteer were compressed for three seconds (130 mmHg) at a 0.3-Hz interval during rapid IPC, both legs from ankles to thighs were compressed by the standard IPC device, which has a six-chambered cuff applying 45 mmHg for 12 sec sequentially, followed by a 60-sec noncompression period. Peak femoral venous velocity was measured noninvasively at the common femoral vein 1 cm above the saphenofemoral junction by using an ultrasonic echo diagnostic device, FF sonic UF-8800^TM (Fukuda Denshi, Tokyo, Japan).¹⁰ The venous flow velocity in the supine position was measured as a control in all groups. In the lithotomy position groups (45 and 90 angles at hip and knee joints, respectively), the venous flow velocity was also measured in the lithotomy position with or without the use of each IPC device.

Data were analyzed by one-way ANOVA with Fisher's test or by the unpaired two-tailed t test. P <0.05 was considered significant.

	Results

TOP Abstract Introduction Methods Results Discussion References

 
In the supine position, the mean (± SD) flow velocity of the common femoral vein in the volunteers was 10.8 ± 3.5 arbitrary units. Under this condition, rapid IPC significantly increased maximum femoral venous flow velocity by 59% (P <0.05) during the first compression and by 63% (P <0.05) during the fifth compression (Figure 1). Standard IPC also increased venous flow velocity during the first and fifth compressions by 44% (P <0.05) and by 68% (P <0.01), respectively. There was no significant difference between the flow velocities using these two devices.

View larger version (11K): [in this window] [in a new window]   FIGURE 1 Changes in maximum femoral venous flow velocities by using rapid (closed circles) and standard (open circles) intermittent pneumatic compression in the supine position. Data are expressed as mean ± SD, n=6 at each point [arbitrary units; a.u.]. *P <0.05; **P <0.01 vs control.

View larger version (11K): [in this window] [in a new window]   FIGURE 2 Changes in maximum femoral venous flow velocities with the conventional lithotomy positioning device (LPD; A) or with a new LPD (B) during compression with rapid (closed circles) and standard (open circles) intermittent pneumatic compression devices. Data are expressed as mean ± SD, n=6 at each point [arbitrary units; a.u.]. *P <0.05; **P <0.01 vs control; P <0.05 vs lithotomy position without compression.

	Discussion

TOP Abstract Introduction Methods Results Discussion References

The conventional lithotomy position is anticipated to induce blood stasis in the lower extremities, as shown in our study (Figure 2). A new LPD (Levitator) that supports the lower extremities at the heels and calves without knee compression has become available commercially. This device was designed to minimize the effect of the lithotomy position on blood flow in the lower extremities. As expected, our results showed that this device caused less reduction in femoral venous blood flow than did conventional positioning with knee compression. Thus, this LPD might be useful in patients who are at high risk of deep venous thrombosis.

Recent studies assessing the efficacy and safety of foot impulse technology in the prevention of venous thrombosis have shown promising results.^11,12 In a pilot study, a foot pump was shown to be more effective than low-dose heparin in the prevention of venous thrombosis following total hip replacement.¹¹ A more recent study demonstrated that low-molecular-weight heparin prophylaxis was superior to foot compression in the prevention of postoperative thrombosis in orthopedic patients.¹³ Elliott et al.⁶ reported that calf-thigh sequential pneumatic compression prevents deep-vein thrombosis more effectively than does plantar venous IPC after major trauma without lower extremity injuries. Other investigators, however, have reported that there are no differences in the effects of calf and thigh length pneumatic compression systems and intermittent plantar compression on prevention of venous thrombosis.^7–9 Our study showed that both rapid and standard IPC significantly increased femoral venous blood flow in the supine and in the lithotomy position and that the effects of these IPC devices were similar. Foot/leg compression by IPC devices may have some effect on blood coagulability by increasing sheer stress on platelets and endothelial cells.¹⁴ Changes in fibrinolytic activity due to the use of an IPC device may be involved also. Some investigators have reported that an IPC device increased fibrinolytic activity,^15,16 while others reported that an IPC device had no effect.^17,18 Further investigations using more reliable coagulation/fibrinolysis monitors are needed to clarify this point.

In conclusion, a new LPD that does not require popliteal fossa compression has less effect on femoral venous flow velocity than does conventional positioning. Rapid and standard IPC are useful for maintaining venous flow of the lower extremities in the lithotomy position.

	Footnotes

 
Supported in part by an incentive grant (Y-058, 1999) for research from the Hokksaitec Foundation, Sapporo, Japan.

Revision received November 16, 2001. Accepted for publication October 1, 2001.

	References

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