You have just come home from an exhausting 12- (really 13) hour shift and left with the final two perpetual decisions residents must face before sleep:

  1. What to eat?
  2. Watch Netflix or study?

Both choices are easy. As the water begins to boil for your ramen, you turn on Arrested Development and are greeted with your favorite never-nude, analyst and therapist – Tobias Funke. His blue legs reminds you of a DVT you saw earlier this month that seemed especially concerning…

What is Phlegmasia cerulea dolens?
[hr]The literal translation is “painful blue edema” and is on a spectrum of infrequent but high-morbidity complications of deep venous thrombosis of the lower extremity.

Phlegmasia alba dolens (painful white edema) occurs when there is severe occlusion of the deep venous drainage, sparing the collateral superficial veins.

It can then progress to phlegmasia cerulea dolens where collateral/superficial venous return is obstructed leading to severe pain, edema, and blue discoloration. The final state is venous gangrene where tissue death occurs.

F1.large

 

What are three warning signs of cerulea dolens?
Edema, violaceous discoloration, and severe pain mark cerulea dolens.

Be aware that patients prone to clots (bedbound, intubated, etc) may not be able to always verbalize pain.

 

What are risk factors for this condition?
Malignancy, surgery, pregnancy, heparin induced thrombocytopenia, antiphospholipid syndrome, and femoral vein catheterizations are risk factors.

 

What are the major complications?
Venous infarction of the limb may occur due to hypoperfusion combined with edema that compresses arterial blood supply. This is a vascular emergency. Compartment syndrome may also develop.

Hypotensive shock secondary to fluid sequestration in the limb.

Pulmonary embolism is a major possible complication of any DVT.

 

How do we manage cerulea dolens?
Call vascular surgery immediately as there is the threat of limb loss and even death. Start anticoagulation and elevate the affected limb to increase venous return as much as possible. Start IV fluids if there are signs of intravascular fluid depletion. Surgery may decide to perform catheter directed thrombolysis or venous thrombectomy.

References:

Mumoli et al. Circulation. Phlegmasia Cerulea Dolens. Circulation. Feb 28 12.125:8

 

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3 Comments

ablumenberg · August 19, 2016 at 6:03 pm

There are dozens of us! Dozens!

chrishanuscin · July 4, 2017 at 7:21 pm

Phlegmesia alba dolens aka “painful white edema” is a complication of a lower extremity deep vein thrombosis, where severe occlusion of the deep venous drainage occurs, but the collateral superficial veins are spared. This can progress to Phlegmesia cerulea dolens (“painful blue edema”) were both the deep and superficial venous drainage are fully occluded. This leads to severe pain, edema, and blue discoloration.

bibem · July 6, 2017 at 10:54 pm

Thanks great post!

What role does AC play in the ED for initial management?

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