Research Proposal: GCS to Prevent DVT in Post-Operative Patients

This research proposal presents a systematic review on the use of graduated compression stockings (GCS) to prevent deep vein thrombosis (DVT) in post-operative patients. The background section discusses the prevalence, risks, and complications associated with DVT, including factors that increase the risk in surgical patients. It explores both pharmacological and mechanical interventions for DVT prevention, highlighting the mechanism of action of GCS. The review aims to assess the usefulness and safety of GCS across various patient groups, testing hypotheses related to the effectiveness of stockings for different risk levels and potential side effects. The proposal also identifies the importance of the review by recognizing the need to address the increasing number of at-risk patients, the potential long-term impact of DVT, and the need for further evaluation of GCS effectiveness in clinical settings. The review analyzes nineteen randomized controlled trials and aims to determine the efficacy of GCS in reducing DVT incidence, particularly in the proximal thigh, and to identify any associated side effects. The proposal also acknowledges the limitations of the current research and the need for further studies to determine the optimal use of GCS.

GCS AND POST OPERATIVE PATIENTS 1
Systematic Review; Research Proposal
Name
Nam of the Class
Instructor
Institution
City and State
Date

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Research proposal: Graduated Compression Stockings (GCS) to Prevent Deep Vein Thrombosis
(DVT) in Post Operative Patients
Background
Deep vein/venous thrombosis is a situation where the blood clot forms in the deep veins
of the body, especially in the legs. The state can cause swelling of legs or pain, and can also
occur without any symptoms (Baldwin et al. 2013). It can also develop if a person has specific
medical conditions that affect the rate at which blood clots. Else way, the state can occur for
people who cannot move for a long time like after an accident, surgery, or when a person is
confined to bed. Diagnosis of the condition is difficult since the patients/clients history cannot be
specific. Also, the symptoms can vary from one person to the other. The sequelae of the
condition can change from a full clot resolution with no ill impact via death because of the P.E,
pulmonary embolism.
In earlier past, the incidence of deep vein thrombosis at the community level was almost
negligible while about 24 percent of those in hospitals contracted the condition (Caprini 2010).
However, recent data from regulatory arms of RCTs show that the prevalence of deep vein
thrombosis in surgical clients was 28 percent contrary to 23 percent to those in the medical
clients. Also, the incidence of symptomatic pulmonary embolism was three and one percent
respectively.
Data from the Britain cohort study pointed out that women going through inpatients
surgical procedures had a higher probability compared to those who did not performed the
procedure to be admitted having developed venous thromboembolism within the first one month
after surgery; Also, those going through the day case process had higher chances of being

GCS AND POST OPERATIVE PATIENTS 3
admitted. According to CLOTS (2013), the risks which were left increased seven to twelve
weeks after surgery, where the pattern of risk was the same to that of pulmonary embolism and
deep vein thrombosis. Ideally, the risks varied significantly due to surgery type. However it is
approximated that over 20, 000 people in England are at risk of dying each year due to
potentially preventable venous thromboembolism developed while in healthcare centres.
Surgical patients are however at high risk of venous thromboembolism if they can
achieve the following guidelines. First, is the surgical procedure having a complete anaesthetic
as well as a surgical period of more than 1.5 hours or 1 hour if the process involves the lower
limb or the pelvis (De et al. 2010). Second is acute surgical admission with intra-abdominal
condition or inflammatory, obesity, dehydration, critical care admission, active cancer/ cancer
treatment, and known thrombophilias to mention just a few.
As of late, there have been shifts in some of the factors that influence the risk of post-
surgery deep vein thrombosis. De et al. (2010) postulates that, surgical practices have changed to
the extent at which the time of general anaesthetic becomes short; the operation is done using a
local anaesthetic. However, the time at which the client stays in the healthcare unit is very short
with lots of procedures being done on a daily basis. Therefore, patients are mobilised
immediately while those discharged home get help from physiotherapists in the community.
Moreover, modern anticoagulants like rivaroxaban can be used for an extended period providing
long protection to clients. For example, in 2010, the health department developed a risk
assessment for VTT or venous thromboembolism tool for use in people in healthcare units
(CLOTS 2013). It’s also the NICE quality standards that every person on admission to healthcare
unit gets an assessment of the personal risk of venous thromboembolism as well as bleeding
using clinical risk evaluation criterion which is described in the tool mentioned above.

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Irrespective of such efforts to prevent postoperative deep vein thrombosis, other aspects like the
increasing number of aged clients undergoing surgery as well as proportion overweight plus
morbidly obese clients, puts more pressure on the postoperative DVT population risk.
The rate of a disease due to deep vein thrombosis entails post-thrombotic syndrome
abbreviated as (PTS) that comprises of chronic-venous hypertension (CVH) leading to pain in
the limbs, swelling, hyper-pigmentation, skin inflammation commonly known as dermatitis,
ulcers as well as the skin becoming hard which may lead to a brown/red pigmentation which is
usually associated with wasting of fat. Most importantly, data from different cohort studies
showed that 42% of people with symptomatic deep vein thrombosis develop features of PTS,
post-thrombotic syndrome at two years follow up.
Mortality linked with deep vein thrombosis is higher in the first one month, at three to six
percent, also the risk of death is always high at a long-term follow-up (Goldhaber &
Bounameaux, 2012). According to different reports, 29 % to 42 % of people with deep vein
thrombosis subsequently developed pulmonary embolism, which is directly connected with a rise
in the risk of thirty-day mortality to about 12%. However, those at the risk of contracting deep
vein thrombosis is classified into three distinct categories; low, medium, as well as higher risk as
per the international consensus statement abbreviated as (ICS) as well as thromboembolism risk
factor consensus group guideline. According to Caprinini (2010), the principles on prophylaxis
of VT or venous thromboembolism from the Scottish intercollegiate guideline framework as well
as National Institute of Health and Care Excellence do not group people either into low, medium
or high risk subsets. Besides, such frameworks consider the risk factors for improving deep vein
thrombosis in hospitalised clients especially on a personal level.

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Description of the Interventions
Pharmacological, as well as mechanical techniques can be used to prevent DVT. For the
pharmacological procedure, it changes the blood coagulation profile (Hamel-Desnos et al. 2010).
Besides, the main drawback of this technique is bleeding especially for patients who have
undergone an operation. E.g. the altered coagulation can cause joint haematomas following a
replacement of the joint operation as well as intracranial haemorrhage after neurosurgery or brain
injury. On the other hand, mechanical technique entails procedures such as wearing of GCS as
well as IPC or intermittent pneumatic compression. These methods might have a psychological
action, plus they are used in moderation as well as in high-risk clients.
Hill and Treasure (2010) asserts that the exact mechanism through which graduated
compression stockings is not known, there’s proof which suggests that they put a circumferential
pressure which is distally to proximally. However, if it involves muscular activities of the limb, it
is perceived to substitute blood straight from the superficial to the DVS through the perforating
veins. It also raises the volume use as well as velocity in the inner system hence altering
thrombosis.
Also, physiotherapists can encourage mobilisation as well as leg exercise in DVT to
induce the calf muscle pump. Breathing exercise is also beneficial when it comes to venous
return (Marsh et al., 2010). However, patients need to be advised to be keen on the signs as well
as symptoms that suggest deep vein thrombosis. They can also inform their medical doctors if
concerned. Antiembolism stockings can also serve several functions which include; providing
continuous stimulation of linear blood flow, stimulating endothelial fibrinolytic activity as well
as preventing venous distillation. However, the physicist's responsibility is to examine for
contraindications of anti-embolism stockings through physical assessment as well as clinical

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history or to measure as well as fit the right stockings’ as per the directions from the
manufacturer. According to De et al. (2010), the client’s skin integrity needs to be checked
regularly to provide written as well as verbal info on how to wear or keep anti-embolism
stockings. A client should know that stocking needs to be smooth and that the toe hole is
supposed to lie below the toes. Moreover, a tight gusset must be on the inner thigh, and a heel
path in proper position amongst other information.
Anticoagulants like low molecular weight (LMW) of heparin raise the action of
antithrombin as well as inhibits some coagulation proteins. The heparin weight should be
administered in prophylactic doses, through subcutaneous injection (SI) using a predictable
anticoagulant response. However, in medium risk deep vein thrombosis people, the use of anti-
embolism stockings should be used together with anticoagulants to lower risk (Morris &
Woodcock 2010). Most interestingly, physicists should know that low weight molecular heparin
derivatives are obtained from pigs; hence they should take clients cultural as well as spiritual
beliefs into perspective.
Why is it Important to do this Review?
Patients can contract DVT in the pelvic veins as well as legs immediately after an
operation of in the event they cannot move due to medical illness. According to Naccarto et al.
(2010) symptoms can also shift from none to pain as well as swellings of the limbs. Also, blood
clot may shift to the lungs with thus causing the risk of PE or worse. Besides, deep vein
thrombosis can have a long-term impact like HVP, high venous pressure, swelling and darkening
of the skin hence the need for doing this review of GCS in the prevention of DVT in post
operative clients. Alternatively, the condition can be treated with drugs or compressions. At

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times, medications may lead to bleeding which is a threat especially for the postoperative
person’s. Therefore, graduated compressed stockings come to the rescue of a blood clot
formation in the limbs. One can apply varying pressure to various sections of the limb (Qaseem
et al. 2011). In the review 19 randomised controlled trials have been identified of 2745 analytical
units comprising of 1064 and 1681 individual legs and patients respectively. Out of these
experiments, eight of them compared stockings with no stockings, where ten compared stockings
with another technique in people undergoing an operation. Out of the nineteen trials, nine
comprised of clients going through general surgery, six orthopaedic surgeries and one trial
comprised of a medical client. However, the compression stocking was put a day before or
during the day of operation.
The stocking was worn until the client was completely mobile or discharge. In a vast
number of studies, deep vein thrombosis had a radioactive of I125 uptake test (Sachdeva et al.,
2010). Besides, all other studies were of quality standards. This review is of great significance
since it confirms that graduated compression stockings are very helpful when it comes to
lowering the risks of DVT in hospitalised postoperative person’s. It also shows that stockings
may assist in lowering the risks of contracting deep vein thrombosis in thighs, a condition
referred to as proximal DVT (Sajid et al. 2012).
However, the incidence of side effects, as well as risks associated with putting on
graduated compression stockings, was not adequately reported in the studies included in this
review. There was little proof for the hospitalised medical clients with one study showing the
usefulness of GCS in the prevention of DVT.
Regardless, of theoretical effectiveness and the prevalence of the use of GCS, their
clinical efficacy should be appraised further. However, poor application of stockings can

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potentially lead to problems such as arterial ischemia, oedema of the legs as well as deep vein
thrombosis (Salmaggi et al., 2013). Stockings are also contraindicated for medical purposes.
However, the degree at which a leg profile of a client limits its usefulness has not yet been
addressed. Moreover, a recommendation concerning the proper length of stockings that is thigh
length and knee measurement is not a subject of this proposal review.
Objectives
The main aim of this proposal review is to show the usefulness as well as the safety of
GCS in the prevention of DVT of people hospitalised in different groups. Throughout the
proposal review, the following hypothesis was tested; stockings are not necessary for low-risk
clients; side effects are linked with the use of GCS; GCS are very much useful when it comes to
the prevention of DVT in hospitalised people apart from those with paralysis. Lastly, is that in
every moderate risk client GCS alone is not enough for deep vein thrombosis prophylaxis, unless
for clients where the stockings are contraindicated.
Methods:
1. Types of Studies
A review by Sajid and co-authors (2012) had three randomised control trials that
compared the efficiency of knee and thigh length in hospitalised surgical clients. No statistical
significant difference was found in regard to the clinical efficacy of the stocking measures about
lowering the incidence of the condition, deep vein thrombosis. Besides, there was substantial
heterogeneity in the trials plus significant methodological restrictions. Sajid et al. then concluded
that there was inadequate standard proof to investigate if knee or thigh length stocking would

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vary in their effectiveness when it comes to lowering the prevalence of deep vein thrombosis in
hospitalised persons. However, the authors proposed for a more substantial multicentre
randomised control trial to be done to address the problem. In another review by Sachdeva and
co-authors (2010), they had 18 randomised control trials that compared the usefulness of
graduated compressed stockings, with or without another technique of deep vein thrombosis
prophylaxis without stockings in hospitalised people.
However, the prevalence of the condition, DVT was too way lower in the stockings and
other prophylactic technique group compared to another prophylactic alone group. Henceforth,
the reviewers concluded that stockings are very useful when it comes to reducing the risks of
deep vein thrombosis in postoperative people. Besides, the entire randomised control trials used
thin length stockings, and the authors recommended a randomised control trial comparing knee
as well as thigh length GCS.
Ideally, only the RCT that used compression stockings for DVT prophylaxis would be
included in this review. Moreover, the moment the allocations of concealments were enough and
the cover-ups were not used, then the studies would not be included (Salmaggi et al., 2013).
The above-mentioned reviews by Sajid and Sachdeva with their co authors did not answer the
research question. However, a study by Sajid included only three randomised control trial but did
not seek indirect proof. Also, the study by Sachdeva and his associates did not also limit the
inclusion aspect to postoperative clients or even compare the usefulness of knee and thigh length
stockings. Above all, the measurement of stocking in others studies remained unclear.

GCS AND POST OPERATIVE PATIENTS 10
2. Types of Participant and Interventions
Patients of any age or sex hospitalised for a condition other than paralysis. However,
trials where the use of GCS was compared without prophylaxis as well as those studies where the
use of graduated compressed stocking was examined without stocking on the background of a
different technique of deep vein thrombosis prophylaxis in the control groups as well as the
treatments, for instance, heparin and aspirin (SOBIERAJ‐TEAGUE et al 2012). However, the
group trials would be analysed in this review since they all had equal treatment effect, i.e.
graduated compressed stockings versus no graduated compression stockings. When it comes to
the impact of interventions outcome, it should be read paying attention to the description studies
since this might impact the analysis. This is due to the variation in the included trials like the use
of the second limb as a control. Besides, in all the trials, the analysis favoured the use of stocking
in the prevention of DVT, but there was no big variation in the studies (Struijk-Mulder et al.,
2013).
Primary and Secondary Outcomes
There are two outcome measures in this review; primary outcomes and the secondary
outcomes. The main aim of this proposal review was to investigate the usefulness of graduated
compressed stockings as a prophylactic technique in lowering deep vein thrombosis. It
comprised of; diagnosis of the condition, DVT is identified through venogram, isotope studies or
ultrasound. The other outcome was a complication as well as implications resulting from use of
graduated compressed stockings. The secondary outcome was the diagnosis of P.E popularly
known as pulmonary embolism which was identified by autopsy examination; pulmonary
angiogram as well as perfusion lung scans (Toker et al 2011).

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Search Strategy
Electronic searches; in this review, the Cochrane peripheral vascular disease (CPVD)
group, trial search coordinator, abbreviated as TSC looked for the specialised register as well as
the Cochrane central registrar of controlled trials. However, the trial search coordinator keeps the
specialised registrar. Else way, it is constructed from database searches such as AMED,
EMBASE, MEDLINE, and CINAHL as well as through hand searching essential journals. The
complete list of journals, databases as well as comprehensive lists that have been identified plus
the search technique is found in a specific register section of CPVD. According to Wade et al.,
(2015) the reference list of every study that meets threshold for the electronic sources were
checked for extra trials.
Data Collection and Analysis
Studies selection; A criterion of choosing trials has been identified in the write up above.
However, the choices of trials of inclusions in this proposal were executed by MJD plus AS,
where they assessed as well as recommended by other two authors, TAL and SVA. Also the first
screening of the obtained data was executed by AS basing on the titles as well as abstract for
exclusion or studies of no importance to this review. In places without certainty about the need
of specific research, a different author, MJD was consulted (Wade et al. 2015). However, the
rest of the records were assessed each on its own by different authors (MJD and AS). This was
done to avoid the exclusion of other important articles in such phase. However, in the second
phase, papers were removed for the articles that remained as well as assessed by MJD and plus
AS basing on the aspect of considering studies of this proposal review and in the situations

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where there was lack of consensus between authors judgement concerning authenticity of
relevant studies. Besides, a conclusion was arrived via discussion with TAL, a third author.
Ultimately, every other authentic study based on the criteria as mentioned above was included in
the review.
The extraction of data; Here, a review author that is, AS did extraction of data and
then entered it into the form of extraction. Afterwards, cross-examination of data was done by s
different review author, MJD. Some of the data retrieved was; the incidences of the DVT, PE,
age, sex, DVT risk groups where the participants belonged, side effects, the length of application
of stockings as well as the investments used in making the diagnosis among other
information(Walker and lamont 2008)
Risk of bias; two review authors who are the MJD and AS independently examined the
risks of bias in all the studies included using different domains such as allocation concealment,
incomplete outcome data, sequence generation, blinding plus other biases. According to Struijk-
Mulder et al. (2013), the tool mentioned in the review of interventions known as Cochrane
systematic review was used to find if the studies were potential biased free. Also, studies were
identified in three different types; yes to imply low risk, yes for high risk and unclear. If there
was availability of inadequate information, bias risk would be ambiguous. However, differences
between the review authors point of views were analysed and then an agreement was reached.
Treatment measures; The efficiency of treatment, i.e use of GCS was identified through
recording the incidences of deep vein thrombosis in the group of treatment in relation to that in
the non-stocking group. However, deep vein thrombosis was diagnosed with the real strategy of
assessments like the isotope studies and ultrasound. Also, individual information of the patient
from various trials was not combined. Instead, cumulative data analysis done using Peto’s odds