Adjunctive Intermittent Pneumatic Compression in Hospitalized Patients Receiving Pharmacologic Prophylaxis for Venous Thromboprophylaxis: A Systematic Review and Meta‐Analysis

Abstract

Objectives This study assessed the effect of adjunctive intermittent pneumatic compression (IPC) on venous thromboembolism incidence in hospitalized patients receiving pharmacologic thromboprophylaxis. Methods We searched Medline, Embase, and the Cochrane Central Register with no language restrictions from inception until May 15, 2019, for randomized clinical trials comparing adjunctive IPC in pharmacologic thromboprophylaxis and pharmacologic thromboprophylaxis for venous thromboembolism. Two researchers extracted data from published reports independently. A meta‐analysis was conducted to calculate the risk ratio (RR) using random‐effects models. Primary outcomes were deep venous thrombosis (DVT) and pulmonary embolism (PE). Results Eight trials with a total of 7,354 participants were eligible for analysis. Addition of IPC to pharmacologic prophylaxis compared to pharmacologic prophylaxis alone reduced the risk of DVT by 43% (RR 0.57, 95% confidence interval [CI] 0.35–0.93; I2 = 0%), with benefit only seen in surgical patients (RR 0.30, 95% CI 0.15–0.59; I2 = 0%) and not in medical patients (RR 0.80, 95% CI 0.60–1.07; I2 = 0%; p for interaction = .008). Addition of IPC reduced the risk for PE by 54% (RR 0.46, 95% CI 0.30–0.72; I2 = 0%), with benefit only seen in surgical patients (RR 0.40, 95% CI 0.24–0.65; I2 = 0%) and not in medical patients (RR 0.82, 95% CI 0.32–2.26; I2 = 0%; p for interaction = .18) Conclusions Addition of IPC to pharmacologic prophylaxis confers moderate benefit on venous thromboembolism, with benefit confined to surgical patients. For medical patients, there was a trend toward reduced DVT with adjunctive IPC, which warrants further investigation. Clinical Relevance Venous thromboembolism is not unusual among hospitalized patients despite pharmacologic thromboprophylaxis. Nursing personnel should use adjunctive IPC in surgical patients receiving pharmacologic thromboprophylaxis to prevent venous thromboembolism.

What does the future hold for mechanical thromboprophylaxis?

“…9 Finally, in regard to IPCDs, a recent meta-analysis of their use as an adjunct to pharmacological thromboprophylaxis demonstrated a modest risk reduction of VTE compared to pharmacological therapy alone in surgical patients. 10 However, this effect was not reproduced in medical patients. 10 In favour of the use of GCS, there is high-grade evidence from a recent Cochrane review to suggest that their use in surgical patients is effective at reducing the rate of VTE, with or without the use of background pharmacological thromboprophylaxis.…”

“…10 However, this effect was not reproduced in medical patients. 10 In favour of the use of GCS, there is high-grade evidence from a recent Cochrane review to suggest that their use in surgical patients is effective at reducing the rate of VTE, with or without the use of background pharmacological thromboprophylaxis. 11 The same review only included one RCT examining the use of GCS in a medical inpatient cohort 12 and thus concluded, reasonably, that there was too scarce evidence to pronounce a verdict on the effectiveness of GCS in medical patients.…”

“…9 Finally, in regard to IPCDs, a recent meta-analysis of their use as an adjunct to pharmacological thromboprophylaxis demonstrated a modest risk reduction of VTE compared to pharmacological therapy alone in surgical patients. 10 However, this effect was not reproduced in medical patients. 10…”

Thromboprophylaxis; what is the future, for high risk surgical patients?

“…They noted that there was evidence that the addition of IPC reduced VTE in medical patients but not enough to be significant. 11 This isn't the first systematic review to highlight the question about whether IPC is an additional benefit to pharmacological prophylaxis. Kakkos et al published a Cochrane review in 2016 on the same topic which did suggest a potential benefit in the reduction in VTE when combining IPC with pharmacological prophylaxis vs a single modality (GCS or pharmacological thromboprophylaxis alone), but it was moderate quality evidence due to concerns in the methodology, including risk of bias, of the studies included and needs to now be updated.…”

“…They noted that there was evidence that the addition of IPC reduced VTE in medical patients but not enough to be significant. 11…”