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Acute Edema Management: Acute Venous Edema vs Lymphedema

What is Lymphedema ?

Incurable disease process causing insufficiency of the lymphatic system

Key parts of the definition:

  • Chronic inflammatory Condition
  • Excess water and protein in the tissues
  • Lymphatic system dysfunction or deficit
  • Skin Changes - fibrosis

What is Acute Venous Edema?

Transudate: consists of electrolytes and water which are small molecular substances that readily diffuse back into venous system

AKA - LOW protein edema

Lymphedema

Case Presentation

Two Types of Lymphedema

Acute Venous Edema

1) Primary Lymphedema

  • Congenital defect

2) Secondary Lymphedema

  • Non congenital
  • Caused by a known insult to the lymphatic system

Delayed Sternal Closure

Patient:

WH, born at 38 6/7

Surgical Repair:

Complete repair with PFO creation

Assessment:

Initial and Post-op

Goals of treatment:

Similar, however post include edema management and post-op teaching

Compression:

  • Long Stretch - Compressive Force
  • Short Stretch - Resistive Force

Congenital Heart Disease has an estimate prevalence of 4 to 50 per 100 live births with more than 2 million American living with a congenital heart defect

Open Sternotomy and delayed sternal closure is a supergical technique that has been used in children for the past 30 years

Treatment Strategies with WH

Everyday Practice Takeaways

Treatment Strategies for Lymphedema

Treatment Strategies for Acute Venous Edema

Because we are involving very small molecule, re-absorption works by gradient pressure changes

  • Manual Lymphatic Treatment
  • Therapeutic Exercise
  • Compression following
  • Daily PROM with inclusion of central stimulation and clearing of lymph node
  • Daily positive sensory supports with RN cares and preparatory support prior and during PROM
  • Education with family regarding post op and developmentally appropriate engagement
  • Compression garments
  • Treating the underlying cause

Pye S, McDonnell M. Nursing considerations for children undergoing delayed sternal closure after surgery for congenital heart disease. Crit Care Nurse. 2010 Jun;30(3):50-62; quiz 63. doi: 10.4037/ccn2010712. PMID: 20515883.

Nicholson GT, Clabby ML, Mahle WT. Is there a benefit to postoperative fluid restriction following infant surgery? Congenit Heart Dis. 2014 Nov-Dec;9(6):529-35. doi: 10.1111/chd.12165. Epub 2014 Jan 21. PMID: 24444098.

Hurtado-Sierra D, Calderón-Colmenero J, Curi-Curi P, Cervantes-Salazar J, Sandoval JP, García-Montes JA, Benita-Bordes A, Ramírez-Marroquin S. Outcomes of Delayed Sternal Closure in Pediatric Heart Surgery: Single-Center Experience. Biomed Res Int. 2018 Apr 19;2018:3742362. doi: 10.1155/2018/3742362. PMID: 29850507; PMCID: PMC5933025.

Tabbutt S, Duncan BW, McLaughlin D, Wessel DL, Jonas RA, Laussen PC. Delayed sternal closure after cardiac operations in a pediatric population. J Thorac Cardiovasc Surg. 1997 May;113(5):886-93. doi: 10.1016/S0022-5223(97)70261-7. PMID: 9159622.

Contraindications

  • Generally cardiac infants with system edema have acute venous edema
  • Best treatment for venous edema is treatment of underlying cause
  • Lymphedema strategies can help with fluid movement and decrease of edema in this population
  • Sensory supports with edema management need to be considered with all infants

When can we use lymphedema strategies to help with Acute Venous Edema?

  • Acute infection/cellulitis
  • Blood clot/hematoma in the area
  • Acute/active/untreated cancer
  • Acute injury/wound
  • Renal failure/sever kidney disease
  • Severe pulmonary edema
  • DVT or PE
  • Uncontrolled CHF

Lymphatic drainage treatment is NOT 1st treatment choice by can certainly add to treatment

Lower Extremity Pump Points

Strategies with all patients

Upper Extremity Pump Points

  • Start proximally
  • Deep breathing
  • Massaging lymph nodes at terminus and neck (~10 times, deeper pressure than lymph massage)
  • Incorporation of active movement
  • Axilla
  • Anterior/posterior deltoid
  • Medial elbow/triceps insertion
  • Volar wrist and dorsum of hand
  • L2/L3/Sacrum
  • Inguinal nodes
  • Lateral thigh
  • Medial thigh
  • Popliteal nodes
  • Dorsum of ankle
  • Achilles
  • Dorsum of foot
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