Graduated Compression Stockings Controlled studies of graduated compression stockings are limited but do suggest modest benefit when they are carefully fitted (135). Poorly fitted stockings may be hazardous to some patients who develop a tourniquet effect at the knee or midthigh (126). Variations in human anatomy do not allow perfect fit of all patients to available stocking sizes. The simplicity of graduated compression stockings and the absence of significant side effects are probably the two most important reasons that they are included in routine postoperative care. Compared to thigh length stockings, calf-high stockings appear to offer the same degree of venous thromboembolism protection.
Intermittent Pneumatic Compression The largest body of literature dealing with the reduction of postoperative venous stasis deals with intermittent compression of the leg by pneumatically inﬂated sleeves placed around the calf or leg during intraoperative and postoperative periods. Various pneumatic compression devices and leg sleeve designs are available, and the literature has not demonstrated superiority of one system over another. Calf compression during and after gynecologic surgery significantly reduces the incidence of DVT on a level similar to that of low-dose heparin. In addition to increasing venous ﬂow and pulsatile emptying of the calf veins, intermittent pneumatic compression appears to augment endogenous fibrinolysis, which may result in lysis of very early thrombi before they become clinically significant (136).
The duration of postoperative external pneumatic compression differed in various trials. External pneumatic compression may be effective when used in the operating room and for the first 24 hours postoperatively in patients with benign conditions who will ambulate on the first postoperative day (136,137).
External pneumatic compression used in patients undergoing major surgery for gynecologic malignancy reduced the incidence of postoperative venous thromboembolic complications by nearly threefold, but only if calf compression was applied intraoperatively and for the first 5 postoperative days (138,139). Patients with gynecologic malignancies may remain at risk for a longer period than general surgical patients because of stasis and hypercoagulable
Management of Postoperative Deep Venous Thrombosis and Pulmonary Embolism states; therefore, these patients appear to benefit from longer use of intermittent pneumatic compression.
Intermittent pneumatic leg compression has no significant side effects or risks and is considered slightly more cost-effective when compared with pharmacologic methods of prophylaxis (140). Compliance in wearing the leg compression while in bed is of utmost importance, and the patient and nursing staff should be educated to the proper regimen for maximum benefit.
The use of low-dose heparin or LMWH or intermittent pneumatic compression is a reasonable strategy in the care of women at moderate risk for postoperative venous thromboembolism. In high-risk patients, consideration should be given to using a pharmacologic method along with intermittent pneumatic compression.
Because pulmonary embolism is the leading cause of death following gynecologic surgical procedures, identification of high-risk patients and the use of prophylactic venous thromboembolism regimens are essential parts of management (125,126,141).
The early recognition of DVT and pulmonary embolism and immediate treatment are critical. Most pulmonary emboli arise from the deep venous system of the leg following gynecologic surgery; the pelvic veins are a known source of fatal pulmonary emboli.
The signs and symptoms of DVT of the lower extremities include pain, edema, erythema, and prominent vascular pattern of the superficial veins. These signs and symptoms are relatively nonspecific; 50% to 80% of patients with these symptoms will not have DVT (142). Conversely, approximately 80% of patients with symptomatic pulmonary emboli have no signs or symptoms of thrombosis in the lower extremities (143). Because of the lack of specificity when signs and symptoms are recognized, additional tests should be performed to establish the diagnosis of DVT.