Phlegmasia Cerulea Dolens
OVERVIEW
- Massive venous thrombosis of deep and collateral venous system causes obstruction to venous outflow
- Ensuing venous congestion compromises arterial flow
- Limb-threatening condition
- Part of a spectrum with Phlegmasia Alba Dolens and venous gangrene
CLINICAL FEATURES
- Sudden onset colour change in leg
- Severe venous congestion
- Venous gangrene (skin, subcutaneous tissue and muscle)
- Shock
- Arterial insufficiency
- Fluid sequestration
In Phlegmasia Alba Dolens (PAD), thrombosis spares collateral veins. Venous drainage is decreased but still present. Lack of venous congestion differentiates this from PCD.
INVESTIGATION
- Urgent Doppler ultrasound
- Non-compressible veins
- Absent respiratory variation at level of iliac vessels
- CT venogram
- Assess clot burden including pelvic/IVC vessels
- Map for intervention
MANAGEMENT
Limb-threatening condition.
Management is controversial and evolving – options include:
- Anticoagulation — Heparin bolus 80 IU/kg then 18 IU/kg/hr
- Thrombectomy
- Catheter-directed thrombolysis or systemic thrombolysis
COMPLICATIONS
- Venous infarction leading to gangrene
- PE
- Post-phlebitic syndrome
- Fluid sequestration in the affected limb and SIRS leading to hypotension and shock
- Arterial insufficiency due to congestion
References and Links
LITFL
- Cardiovascular Curveball 002 — Sudden Onset Blue Leg
Critical Care
Compendium
Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Co-creator of the LITFL ECG Library. Twitter: @rob_buttner
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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