Are We Already Too Late?

In patients with acute or chronic edema or after closure of a venous ulcer, health care providers generally recommend compression socks or hose for their patients. There are many manuscripts extolling the virtues of this therapy, but most of the time, we do not know how to maximize our efforts. It is well known that when a person with normal venous anatomy or one with diseased veins stands up, the pressure in the veins at the ankle increases due to gravity and the pressure of the column of blood in the vessels from the heart to the ankle.¹ Also, venous pressure at the level of the ankle can increase to as much as 90 mm Hg, a 10-fold increase.^2,3 I know that we would say we understand this and tell our patients to put their compression hose on first thing in the morning as they are getting out of bed; I seriously doubt that most of our patients do that. But, does it really matter? The answer provided by other researchers is a decided yes. 

Blätter and colleagues⁴ showed that healthy patients with no evidence of venous disease had such a rapid increase in leg volume upon standing that it could not be measured! It took 40 seconds from the time the patient stood up until the volume measurement could be obtained. During that time, an estimated 59 mL of volume filled the leg. From the first measurement at 40 seconds after standing to 2 minutes, the leg volume increased another 22 mL of fluid. From the measurement at 2 minutes until the final measurement 10 minutes after getting out of bed, another 22 mL of fluid accumulated in the leg. This is an astounding accumulation of about 103 mL of fluid in the subcutaneous tissues of a normal leg within 10 minutes of standing!⁴ It would seem that most of our patients begin each day trying to catch up with their edema by applying their compression therapy at least 10 minutes or more after getting out of bed. 

Does this mean our patients are doomed to sleep in their compression hose if they want to have reasonable control of their leg swelling? What about putting the compression garment on the legs before getting out of bed? Dr. Blätter and his group⁴ tried to answer that question as well. They tested 2 types of compression garments on the patients: the first garment had 10 to 15 mm Hg compression at the ankle and the other had 23 to 32 mm Hg compression at the ankle. For patients using the lower compression garment, the total fluid accumulation at 10 minutes was reduced by 32 mL. The total accumulation of fluid in the patients with the higher compression garments at 10 minutes was reduced 24 mL. Also of interest, knee-high garments and those to mid-thigh with the same pressure showed no difference in fluid reduction.⁴ 

As clinicians, what are we to do with these data? The information was obtained in healthy people without any venous disease. Without a doubt, the numbers would be considerably worse in patients with venous disease. It does show that to be the most effective, compression garments should be on the patient’s legs before the legs are put in a dependent position for any length of time. Second, all compression garments, whether of low or high compression, knee-high, or thigh-high, do not completely control leg swelling when patients are standing. And, finally, as of now, we do not have a solution to this problem. Until we find a solution, it seems that no matter what we try, we are already too late.