You are managing a 56 year old woman with severe pneumonia in the Intensive Care Unit when you are called to see her because her leg has suddenly turned blue - diagnosis/ treatment/ complications ??



Phlegmasia cerulea dolens (painful blue edema) is an uncommon severe form of deep venous thrombosis which results from extensive thrombotic occlusion (blockage by a thrombus) of the major and the collateral veins of an extremity. It is characterized by sudden severe pain, swelling, cyanosis and edema of the affected limb. There is a high risk of massive pulmonary embolism, even under anticoagulation. Foot gangrene may also occur. An underlying malignancy is found hi in 50% of cases. Usually, it occurs in those afflicted by a life-threatening illness., Contrast venography is still considered the gold standard for the diagnosis of deep venous thrombosis (DVT), though at present, it is rarely used . Duplex ultrasonography has replaced venography as the preferred imaging modality, with an accuracy exceeding 90%. Features suggestive of DVT on duplex ultrasonography are as follows: Lack of compressibility of the vein Lack of spontaneous flow Increased vein diameter Increased echogenicity within the lumen The diagnosis of phlegmasia cerulaea dolens (PCD) is made on clinical grounds in patients who have extensive DVT on imaging. Treatment of phlegmasia cerulea dolens should be initiated as soon as the diagnosis is suspected. The patient is started on anticoagulation, and the involved extremity is elevated. Heparin administration is initiated with an IV bolus of 80-100 U/kg, followed by continuous infusion at a rate of of 15-18 U/kg/hr. The activated partial thromboplastin time (aPTT) should be monitored, with a goal in the range of 2-2.5 times the laboratory reference range. Platelet counts should be monitored to allow early detection of heparin-induced thrombocytopenia. Heparin drip is preferred because it has a shorter half-life and can be rapidly titrated in the event of bleeding or need for surgical intervention. The goal of early anticoagulation is to halt thrombus propagation and prevent pulmonary embolism (PE). ,Catheter-directed thrombolytic therapy is the mainstay of therapy for the extensive DVT that is usually associated with phlegmasia. It is minimally invasive, effective, and safe,

Thank you Dr neeraj for the nice case

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We must precisely know that if it really sudden recent or we recognize as sudden event. DVT takes insidious course, first painful selling then gradually edema increases that result in to compartment syndrome and atrial insufficiency. Therefore without wasting time get urgent arterial and venous Doppler If only arterial insufficiency than reperfusion intervention ( embolectomy, by pass grafting), if DVT then fasiotomy and if both are absent Revise diagnosis with high index of suspicion of necrotizing fascitis. In all are limb emergency may lead to life emergency.

Cold and blue And PAINFUL pulseless or Just Warm, oedematus Painful and blue,? Progress in time over how many hours Was patient on heparin ECG and doppler studies with D dimer Check platelets if patient was on heparin

If patient was on heparin and now has lower levels would consider stopping heparin, send for antibody levels to GP4 start on alternative anti coagulation. If heparin naive then start on heparin pending Investigation

The turning of leg to blue colour in a patient confined to bed , we have to rule out calf or deep vein thrombosis. Arterial and venous doppler study to be done to assess the vascularity status. Treatment is limb elevation antibiotics platelet inhibitors if not better faciotomy decompression of the compartment.

Phlegmasia cerulau dolens is very well explained by Dr Shivaji

Thank you sir

It's a case of DVT.

Vascular surgeons, opinion if there is definite blacks and circulatory disturbance.

DVT...pls chk liver gall bladder..spleen...Order a Doppler test...

necrotysing fascitis. .impending gangrene. blood born.organisms

?dvt /sepsis/drug allergy

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