Edema resident survival guide

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

Overview

Edema is an abnormal collection of fluid in interstitial space because of an imbalance in hydrostatic pressure, oncotic pressure, increased capillary permeability, and obstruction in lymphatic drainage.

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
• Unilateralleg edema caused by proximal deep vein thrombosis leading acute pulmonary embolism

Common Causes of peripheral edema

• • Renal
    • Advanced kidney disease
    • Nephrotic syndrome PMID: 30697163
  • Cardiovascular
    • Systolic or diastolic heart failure PMID: 22287864
    • Constrictive pericarditis
    • Pulmonary hypertension

• • Hematologic:
    • Anemia
  • Gastrointestinal
    • Nutritional deficiency
    • malabsorption
    • Refeeding edema

• • Deep vein thrombosis PMID: 22287864
  • Cellulitis
  • Superficial thrombophlebitis
  • Baker cyst
  • Chronic venous insufficiency
  • lymphedema PMID: 31453511
  • Hormones
    • Pregnancy
    • Menstrual cycle
    • Hypothyroidism PMID: 22935075.
    • Cushing disease
  • Medications
  • Obstructive sleep apnea

Diagnosis

Shown below is an algorithm summarizing the diagnosis of [[peripheral edema]] .10.3122/jabfm.19.2.148

Associated injury/illness

Recent surgery/procedure

Malygnancy

Painful

History

Onset(acute,chronic)

Aggravated by activity

Underlying illness

Changing in medications

Pulse examination

Ulcer

lymphadenopathy/masses

Pitting

Physical examination

Unilateral/bilateral

Skin texture,color

Distribution

Temperature

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/div

Laboratory Tests: ❑ 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/div

Treatment

Shown below is an algorithm summarizing the treatment of [[peripheral edema]] according to the [...] guidelines.

Diagnostic Approach: ❑ Magnetic resonance venography of the lower extremity in patients with unilateral leg swelling and negative results on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis ❑ Echocardiography in patients with obesity, obstructive sleep apnea, and edema to evaluate pulmonary arterial pressures. ❑Ankle-brachial index in patients with chronic venous insufficiency and cardiovascular risk factors before compression therapy, which is contraindicated in peripheral arterial disease/div

Congestive heart failure

loop diuretic,sodium restriction

Nephrotic syndrome

Loop diuretic

Edema Treatment

Lymphedema

Compression stocking,topical steroid,manual lymphatic deraning,bandage

Chronic venous insufficiency

Compression stocking,bandage,topical steroid,adjunctive devices,pneumatic pumps

Deep vein thrombosis

Anticoagulant therapy,early walking, compression stocking

Cellulitis

Antibiotic,compression stocking

Lipedema

Suction lipectomy

Do's

• Before initiation of medical compression therapy, checking the arterial circulation is recommended. if foot pulse or ankle pulse is weak or not palpable, the ankle-brachial index(ABI) should be measured.
• In proximal DVT, using compression bandage or medical compression stockings and walking accompanied with anticoagulant therapy will lessen the pain and swelling PMID: 11054217
• In DVT and SVT using medical compression will not increase the risk of pulmonary thromboembolism and post thrombotic syndrome. PMID:11054217, PMID: 29217387,PMID: 11204585, PMID: 18480967

• Early mobilization in acute deep vein thrombosis will not increase the risk of pulmonary thromboembolism PMID: 11204585
• In the acute phase of DVT, calf compression reduces irreversible skin signs, edema, and pain PMID: 29856509
• In compensated heart failure NYHA । and ॥, mild compression of both legs may increase cardiac preload DOI:10.1002/ehf2.12848 Corpus ID: 68752450
• correction the sizing of compression therapy is recommended in diabetic neuropathy for prevention of peripheral nerve damage especially peroneal nerve palsy and foot drop.https://doi.org/10.3928/0147-7447-20001001-29 https://doi.org/10.3928/0147-7447-20001001-29 https://doi.org/10.1111/j.1365-2133.2004.06010.x
• Obstructive sleep apnea in obese patients may cause bilateral leg edema due to pulmonary hypertension induced by hypoxia doi:10.1001/archinte.160.15.2357
• After harvesting of leg veins for bypass graft surgery, mild compression stocking about 15-20 mmHg, reduced leg edema significantly. PMID: 25478535 . https://doi.org/10.4081/vl.2016.5989

• • 
    

Don'ts

• • 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 epifacial bypassed arteries
  • Severe decompensated heart failure (NYHA 4) because of increasing right arterial pressure leading to deterioration right and left ventricular function DOI:10.1002/ehf2.12848
  • History of an allergic reaction to compression material
  • Severe diabetic neuropathy with sensory loss, microangiopathy, and risk of skin necrosis

References

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