Edema resident survival guide

Edema Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sara Zand, M.D.[2]

Synonyms and keywords: Generalized edema, localized edema, unilateral edema, bilateral edema

Overview

Edema is an abnormal collection of fluid in interstitial space because of increased hydrostatic pressure, decreased oncotic pressure, increased capillary permeability, and obstruction in lymphatic drainage. Edema may be due to underlying systemic diseases such as nephrotic syndrome, right sided heart failure, hypothyroidism, hyperthyroidism, side effect of some drugs, complications of recent surgery and malignancy. Edema may be generalized due to cardiac, thyroid, kidney diseases or localized due to cellulitis, deep vein thrombosis (DVT), chronic venous insufficiency and lymphedema. Diagnosis is based on taking history of recent surgery, trauma, systemic illness, malignancy and doing physical examination about the distribution of edema and determination of pitting or non pitting edema, inducing pain on palpation. Duplex sonography is helpful for finding the evidence of DVT. For more investigation about localized edema with unknown etiology, abdominal computer tomography, magnetic resonance venography maybe required.

Causes

Life Threatening Causes of peripheral edema

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Generalized edema caused by decompensated heart failure
• Localized leg edema caused by proximal deep vein thrombosis leading to acute pulmonary embolism

Common Causes of peripheral edema

• Advanced kidney disease
• Nephrotic syndrome
• Systolic or diastolic heart failure
• Constrictive pericarditis
• Pulmonary hypertension
• Anemia
• Nutritional deficiency
• Malabsorption
• Refeeding edema
• Deep vein thrombosis
• Cellulitis
• Superficial thrombophlebitis
• Baker cyst
• Chronic venous insufficiency
• Lymphedema
• Pregnancy
• Menstrual cycle
• Hyperthyroidism
• hypothyroidism
• Medications
• Obstructive sleep apnea

Diagnosis

Shown below is an algorithm summarizing the diagnosis of edema.

Associated injury/illness

Recent surgery/procedure

Malignancy

Painful

Clinical history

Onset (acute,chronic)

Aggravated by activity

Systemic diseases

Changing in medications

Pulse examination

Ulcer

Lymphadenopathy/masses

Pitting

Physical examination

Unilateral/bilateral

Skin texture, color

Distribution

Temperature

Edema

Generalized

Localized

JVP estimation

Unilateral edema

Bilateral edema

Normal

Prominent

Acute DVT, cellulitis, chronic venous insufficiency, lymphedema, tumor, baker cyst, trauma compartment syndrome, hematoma, complex regional pain syndrome, popliteal aneurysm, dependency

Non pitting, non tender

Pitting, tender

Lymphedema

Chronic venous insufficiency, systemic illnesses

Normal cardiac size

Cardiomegaly

Pulmonary evaluation for pulmonary hypertension or cor pulmonale

Echocardiography

Serum albumin

Normal albumin

Decreased albumin

Thyroid function test

Urinary protein

24 hours proteinuria <3.5 gram

24 hours proteinuria >3.5 gram

Normal urinary sediment

Nephrotic syndrome

Liver function test

Normal

Abnormal

Prealbumin, cholesterol level

Evaluation for liver disease

Prealbumin<20 mg/dl, low cholesterol

Malnutrition

Prealbumin>20 mg/dl

Capillary leak, protein losing entropathy, abnormal protein synthesis

Heart failure

Increased capillary hydrostatic pressure from systemic venous hypertension, volume overload

Hepatic disease

Increased capillary hydrostatic pressure from systemic venous hypertension, decreased oncotic pressure from reduced protein synthesis

Mechanism of Edema

Chronic venous insufficiency

Increased capillary hydrostatic pressure due to venous hypertension, venous reflux, poorly functioning venous valves, incompetent venous valves, reduced venous return, blood pooling, hypoxia, and inflammation

Lymphedema

Lymphatic obstruction, lymph node dissection, malignancy, filariasis

Cellulitis

Increased capillary permeability

Obstructive sleep apnea

Increased capillary hydrostatic pressure due to pulmonary hypertension

Renal disease

Increased capillary hydrostatic pressure and plasma volume, decreased plasma oncotic pressure from protein loss

Protein losing entropathy

Decreased plasma oncotic pressure

Deep vein thrombosis

Increased capillary hydrostatic pressure due to venous obstruction

Cellulitis

Increased capillary permeability

Pregnancy

Increased capillary hydrostatic pressure, increased plasma volume

Laboratory Tests should be obtained: ❑ Complete blood count ❑ Urinalysis ❑ Blood sugar ❑ Creatinine ❑ Thyroid-stimulating hormone ❑ Serum Albumin ❑ D-dimer ❑ B-type-natriuretic peptides ❑ Aspartate aminotransferase ❑ Alanine aminotransferase ❑ Total Bilirubin ❑ Prothrombin time ❑ Alkaline phosphatase

Medications Associated With Edema: ❑ Monoamine oxidase inhibitors, trazodone ❑ Beta-adrenergic blockers, dihydropyridine calcium channel blockers, clonidine, hydralazine, methyldopa, minoxidil ❑ Acyclovir ❑Cyclophosphamide, cyclosporine (Sandimmune), cytosine arabinoside, mithramycin ❑ Androgen, corticosteroids, estrogen, progesterone, testosterone ❑ Celecoxib, ibuprofen ❑ Pioglitazone, rosiglitazone ❑ Levofloxacin ❑ Citalopram

Diagnostic tools: ❑ Duplex sonography in patients with unilateral lower limb swelling and positive D-dimer or high clinical suspicion for thrombosis ❑ Abdominal or pelvic CT scan in patients with lower limb swelling and evidence of malygnancy ❑ Magnetic resonance venography of the lower leg in patients with unilateral leg swelling without evidence of thrombosis on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis ❑ Echocardiography in patients with obesity, obstructive sleep apnea, and edema for evaluation of pulmonary arterial pressures and also in patients with evidence of heart failure for assessment of ejection fraction and pulmonary artery pressure and structural heart disease. ❑ Ankle-brachial index in patients with chronic venous insufficiency and cardiovascular risk factors before compression therapy in suspicion of peripheral arterial disease ❑ Lymphoscintigraphy and magnetic resonance lymphangiography in patients with lymphedema

Treatment

Shown below is an algorithm summarizing the treatment of edema.

Congestive heart failure

Loop diuretic, sodium restriction, compression stocking

Nephrotic syndrome

Loop diuretic

Edema Treatment

Lymphedema

Compression stocking, topical steroid , manual lymphatic dranage, bandage

Chronic venous insufficiency

Compression stocking, bandage, topical steroids, venoactive drugs such as daflon

Deep vein thrombosis

Anticoagulant therapy, early walking, compression stocking

Cellulitis

Antibiotic therapy, compression stocking

Pregnancy

External pneumatic compression, compression stockings

Lipedema

Suction lipectomy

Do's

• Before initiation of medical compression therapy, checking the arterial circulation is recommended. If foot pulses or ankle pulses are weak or not palpable, the ankle-brachial index(ABI) should be measured.
• In proximal deep vein thrombosis (DVT), using compression bandage or medical compression stockings and walking accompanied with anticoagulant therapy will lessen the pain and swelling.
• In DVT, using medical compression will not increase the risk of pulmonary thromboembolism and post thrombotic syndrome.

• Early mobilization in acute deep vein thrombosis will not increase the risk of pulmonary thromboembolism.
• In the acute phase of DVT, calf compression reduces irreversible skin alteration, edema, and pain.
• In compensated heart failure NYHA । and ॥, mild compression of both legs may increase cardiac preload.
• Correction the sizing of compression therapy is recommended in diabetic neuropathy for prevention of peripheral nerve damage, especially peroneal nerve palsy and foot drop.

• Obstructive sleep apnea in obese patients may cause bilateral leg edema due to pulmonary hypertension induced by hypoxia.
• After harvesting of leg vein for bypass graft surgery, mild compression stocking about 15-20 mmHg, reduced leg edema significantly.
• Daflon or micronized purified flavonoid fraction (MPFF) is recommended in chronic venous insufficiency because of anti-inflammatory effect and enhancement of venous contractility.
• Topical steroid maybe useful in stasis dermatitis (scaling, erythematous skin changes) due to chronic venous insufficiency and lymphedema.

Dont's

• Do not use medical compression device in the conditions include:
  • Severe peripheral arterial occlusive disease when the ankle-brachial index (ABI)< 0.6, ankle pressure<60 mmHg, transcutaneous oxygen pressure<20 mmHg;
  • Suspected compression of bypassed arteries in coronary artery bypass graft;
  • Severe decompensated heart failure (NYHA 4) due to increased preload leading to deterioration right and left ventricular function;
  • History of allergic reaction to compression material;
  • Severe diabetic neuropathy with sensory loss, microangiopathy, and risk of skin necrosis.

References

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