Phlegmasia Cerulea Dolens


  • 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


  • 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.


  • 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


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


  • 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


CCC 700 6

Critical Care


MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of three amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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