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
- Renal
- 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: | |||||||||||||||||||||
Medications Associated With Edema:
| |||||||||||||||||||||
Treatment
Shown below is an algorithm summarizing the treatment of [[peripheral edema]] according to the [...] guidelines''PMID: 2987483 PMID: 22336900
Diagnostic tools:
with out evidence of thrombosis on duplex ultrasonography if there is high clinical suspicion for deep venous thrombosis
| |||||||||||||||||||||
Congestive heart failure | loop diuretic,sodium restriction,compression stocking | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 therapy,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 in chronic venous insufficiency because of anti-inflammatory effect and enhancing venous contractility .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