Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, e136ee137
CORRESPONDENCE AND COMMUNICATION An unusual referral with skin loss following intermittent pneumatic compression therapy
and managed with leg elevation until she was referred to our clinic five days later with worsening pain, swelling and blistering. At presentation, the patient was noted to have skin changes confined to the lower legs with scattered blisters of varying size. Areas of mottled skin, worse on the left leg, were visible, with the skin distal to the ankles spared (Figure 1). Distal pulses were palpable and movement and sensation were intact. Under aseptic conditions the blisters were de-roofed, and serous fluid with organized
Dear Sir, Mechanical devices are widely employed for deep venous thrombosis (DVT) prophylaxis. Their ease of application and lack of bleeding risk in contrast to anticoagulants has increased their use in both medical and surgical patients. They can be used in conjunction with other modalities such as low molecular weight heparin (LMWH). Intermittent pneumatic compression therapy (IPC) works by reducing the luminal diameter of leg veins resulting in an increase in the venous flow velocity and inhibiting an important aspect of Virchow’s triad. By reducing venous stasis, the risk of thrombus formation and propagation is decreased.1 A number of complications caused by IPC therapy has been previously reported, such as local tissue injury and bleeding.1 We report a case of a significant skin loss secondary to IPC, which appears as yet undescribed in the literature. An 81 year old female was referred to the local plastic surgery service 7 days after a left total hip replacement for a hip fracture. The reason for referral to us was bilateral blistering of the lower legs. The patient’s past medical history included ischaemic heart disease, hypertension and osteoarthritis. Her medications were aspirin 75 mg once daily as well as antihypertensive medications. She had no history of peripheral venous or arterial disease, chronic skin conditions or corticosteroid use. The patient was started on IPC therapy (Flowtron) and prophylactic dose LMWH intra-operatively and this continued until the third post-operative day, at which stage she was able to mobilise with a frame. She noticed pain associated with the IPC therapy, and when it was discontinued she discovered skin changes in her lower legs. This was followed by the development of blisters. An initial diagnosis of bilateral lower limb oedema was established
Figure 1 Photo for the lower legs on presentation. Large blister can be seen on the anterior aspect of the left leg. Other multiple scattered smaller blisters in both legs can also be seen with skin changes around, which is confined to the lower legs and sparing the ankles and feet.
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.051
Correspondence and communication
e137 have resulted in a significant area of skin non-viability after only three days of therapy. Clearly major orthopaedic surgery in the elderly population poses a significant risk of venous thrombo-embolism (VTE), which, in a proportion of cases, is fatal. Whilst all appropriate measures should therefore be taken to reduce the risk of VTE, health providers should ensure that: appropriate patient selection; correctly fitting stockings are applied; an appropriate compression pressure is used; and legs are regularly checked for evidence of skin breakdown or pre-tibial haematoma, particularly in patients complaining of pain. Such complications can result in the need for surgery, skin grafting and subsequent chronic problematic wounds. This case is a reminder that all interventions we perform as clinicians, even those as seemingly innocuous as prophylactic IPC, can have detrimental effects on patients, and they should be warned of this before application.
Sources of financial support None.
Conflict of interest None. Figure 2
Photo of the left lower leg after debridement.
haematoma was subsequently drained. Debridement of all non-viable skin resulted in a large wound on the left leg (Figure 2) and smaller wound on the lateral aspect of right leg. The skin loss was more extensive on the left leg and all wounds were managed non-surgically with regular dressings and elevation. IPC is an effective modality in DVT prophylaxis, however a few complications have been reported following their use. These include local tissue injury and bleeding,1,2 which may also lead to patient non-compliance.1 Knudson et al.3 reported 4 cases of local skin changes, however did not specifically observe any ulceration or blistering. Won et al.4 described the development of haemorrhagic bullae following the use of IPC, which were treated conservatively, healing over a period of few days. Other previously reported complications are common peroneal nerve injury and compartment syndrome.5 In this case, the localized distribution of skin changes, the bilateral nature of the injury, and the history given by the patient and nursing staff, provide convincing evidence of an injury secondary to IPC. The combination of thin, fragile skin, anticoagulant medication, and IPC appears to
References 1. Datta I, Ball CG, Rudmik L, et al. Complication related to deep venous thrombosis prpphylaxis in trauma: a systematic review of the literature. J Trauma Manag Outcomes 2010;4:1. 2. Ginzburg E, Cohn SM, Lopez J, et al. Randomized clinical trial of intermittent pneumatic compression and low molecular weight heparin in trauma. Br J Surg 2003;90:1338e44. 3. Knudson MM, Morabito D, Paiement GD, et al. Use of low molecular weight heparin in preventing thromboembolism in trauma patients. J Trauma 1996;41:446e59. 4. Won S, Lee Y, Suh Y, et al. Extensive Bullous Complication associated with Intermittent pneumatic compression. Yonsei Med J 2013;54(3):801e2. 5. Lachmann EA, Rook JL, Tunel R, et al. Complications associated with intermittent compression. Arch Phys Med Rehabil 1992;73:482e5.
Fergal Marlborough Ammar Allouni Matt Erdmann University Hospital of North Durham, UK E-mail address: [email protected] 30 October 2013
CORRESPONDENCE AND COMMUNICATION An unusual referral with skin loss following intermittent pneumatic compression therapy
and managed with leg elevation until she was referred to our clinic five days later with worsening pain, swelling and blistering. At presentation, the patient was noted to have skin changes confined to the lower legs with scattered blisters of varying size. Areas of mottled skin, worse on the left leg, were visible, with the skin distal to the ankles spared (Figure 1). Distal pulses were palpable and movement and sensation were intact. Under aseptic conditions the blisters were de-roofed, and serous fluid with organized
Dear Sir, Mechanical devices are widely employed for deep venous thrombosis (DVT) prophylaxis. Their ease of application and lack of bleeding risk in contrast to anticoagulants has increased their use in both medical and surgical patients. They can be used in conjunction with other modalities such as low molecular weight heparin (LMWH). Intermittent pneumatic compression therapy (IPC) works by reducing the luminal diameter of leg veins resulting in an increase in the venous flow velocity and inhibiting an important aspect of Virchow’s triad. By reducing venous stasis, the risk of thrombus formation and propagation is decreased.1 A number of complications caused by IPC therapy has been previously reported, such as local tissue injury and bleeding.1 We report a case of a significant skin loss secondary to IPC, which appears as yet undescribed in the literature. An 81 year old female was referred to the local plastic surgery service 7 days after a left total hip replacement for a hip fracture. The reason for referral to us was bilateral blistering of the lower legs. The patient’s past medical history included ischaemic heart disease, hypertension and osteoarthritis. Her medications were aspirin 75 mg once daily as well as antihypertensive medications. She had no history of peripheral venous or arterial disease, chronic skin conditions or corticosteroid use. The patient was started on IPC therapy (Flowtron) and prophylactic dose LMWH intra-operatively and this continued until the third post-operative day, at which stage she was able to mobilise with a frame. She noticed pain associated with the IPC therapy, and when it was discontinued she discovered skin changes in her lower legs. This was followed by the development of blisters. An initial diagnosis of bilateral lower limb oedema was established
Figure 1 Photo for the lower legs on presentation. Large blister can be seen on the anterior aspect of the left leg. Other multiple scattered smaller blisters in both legs can also be seen with skin changes around, which is confined to the lower legs and sparing the ankles and feet.
1748-6815/$ - see front matter ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.12.051
Correspondence and communication
e137 have resulted in a significant area of skin non-viability after only three days of therapy. Clearly major orthopaedic surgery in the elderly population poses a significant risk of venous thrombo-embolism (VTE), which, in a proportion of cases, is fatal. Whilst all appropriate measures should therefore be taken to reduce the risk of VTE, health providers should ensure that: appropriate patient selection; correctly fitting stockings are applied; an appropriate compression pressure is used; and legs are regularly checked for evidence of skin breakdown or pre-tibial haematoma, particularly in patients complaining of pain. Such complications can result in the need for surgery, skin grafting and subsequent chronic problematic wounds. This case is a reminder that all interventions we perform as clinicians, even those as seemingly innocuous as prophylactic IPC, can have detrimental effects on patients, and they should be warned of this before application.
Sources of financial support None.
Conflict of interest None. Figure 2
Photo of the left lower leg after debridement.
haematoma was subsequently drained. Debridement of all non-viable skin resulted in a large wound on the left leg (Figure 2) and smaller wound on the lateral aspect of right leg. The skin loss was more extensive on the left leg and all wounds were managed non-surgically with regular dressings and elevation. IPC is an effective modality in DVT prophylaxis, however a few complications have been reported following their use. These include local tissue injury and bleeding,1,2 which may also lead to patient non-compliance.1 Knudson et al.3 reported 4 cases of local skin changes, however did not specifically observe any ulceration or blistering. Won et al.4 described the development of haemorrhagic bullae following the use of IPC, which were treated conservatively, healing over a period of few days. Other previously reported complications are common peroneal nerve injury and compartment syndrome.5 In this case, the localized distribution of skin changes, the bilateral nature of the injury, and the history given by the patient and nursing staff, provide convincing evidence of an injury secondary to IPC. The combination of thin, fragile skin, anticoagulant medication, and IPC appears to
References 1. Datta I, Ball CG, Rudmik L, et al. Complication related to deep venous thrombosis prpphylaxis in trauma: a systematic review of the literature. J Trauma Manag Outcomes 2010;4:1. 2. Ginzburg E, Cohn SM, Lopez J, et al. Randomized clinical trial of intermittent pneumatic compression and low molecular weight heparin in trauma. Br J Surg 2003;90:1338e44. 3. Knudson MM, Morabito D, Paiement GD, et al. Use of low molecular weight heparin in preventing thromboembolism in trauma patients. J Trauma 1996;41:446e59. 4. Won S, Lee Y, Suh Y, et al. Extensive Bullous Complication associated with Intermittent pneumatic compression. Yonsei Med J 2013;54(3):801e2. 5. Lachmann EA, Rook JL, Tunel R, et al. Complications associated with intermittent compression. Arch Phys Med Rehabil 1992;73:482e5.
Fergal Marlborough Ammar Allouni Matt Erdmann University Hospital of North Durham, UK E-mail address: [email protected] 30 October 2013
