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
• Unilateral leg 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 thrombophelebitis
  • 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 [[ edema]] .10.3122/jabfm.19.2.148

Associated injury/illness

Recent surgery/procedure

Malygnancy

Painful

Clinical 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

{{familytree | | | | | | | | | |)|-| R1 |-| R2 | | | | | | | | |R1=Lymphedema |R2=Lymphatic obstruction,lymph node dissection,[[malignancy],filariasis| }}

{{familytree | | | | | | | | | |)|-| G01 |-| G02 | | | | |G01=Cellulitis| G02=Increased [[capillary permeability]}}

Heart failure

Increased capillary permeability from Systemic venous hypertension,volume overload

Hepatic disease

Increased capillary permeability from systemic venous hypertension, decreased oncotic pressure

Mechanism of Edema

Chronic venous insufficiency

venous reflux, poorly functioning venous valves, incompetent venous valves, reduced venous return, blood pooling, hypoxia, and inflammation

Obstructive sleep apnea

Pulmonary hypertension, increased capillary hydrostatic pressure

Renal disease

Increased plasma volume, decreased plasma oncotic pressure from protein loss

Protein losing entropathy

Decreased plasma oncotic pressure

Deep vein thrombosis

Increased capillary permeability

Cellulitis

Increased capillary permeability

Pregnancy

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

Treatment

Shown below is an algorithm summarizing the treatment of [[peripheral edema]] according to the [...] guidelines''PMID: 2987483 PMID: 22336900

Diagnostic tools: ❑ Duplex sonography in patients with unilateral lower limb swelling and positive D-dimer, or high clinical suspicion of 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 with out 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, which is contraindicated in peripheral arterial disease

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,venoactive drugs such as daflon

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 alteration, 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
• Daflon or micronized purified flavonoid fraction (MPFF) has an anti-inflammatory effect and increases venous contractility, is recommended for treatment of chronic venous insufficiency.PMID: 29874834

• • 
    

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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