水肿评估

介绍[edit|edit source]

Edemais defined as a palpable swelling produced by an accumulation of fluid in the intercellular tissue that results from an abnormal expansion in interstitial fluid volume.

• 间质性和血管内空间之间的流体受毛细管静水压力梯度和整个毛细管的肿瘤压力梯度的调节。
• The accumulation of fluid occurs when local or systemic conditions disrupt this equilibrium, leading to increased capillary hydrostatic pressure, increased plasma volume, decreased plasma oncotic pressure (hypoalbuminemia), increased capillary permeability, or lymphatic obstruction.^[1][2]

与全身性疾病相关的广泛性水肿的快速发展需要迅速的诊断和管理。^[1]

水肿评估[edit|edit source]

History - Should include:

1. Timing of the edema- since when? Acute swelling of a limb over a period of less than 72 hours is more characteristic ofdeep venous thrombosis (DVT),蜂窝织炎，破裂的popliteal囊肿，acute compartment syndromefrom trauma, or recent initiation of calcium channel blockers. The chronic accumulation of more generalized edema is due to the onset or exacerbation of chronic systemic conditions, such as充血性心力衰竭（CHF）, renal disease, or hepatic disease.
2. Changes of edema with position
3. Unilateral or bilateral edema: Unilateral edema can result from深静脉血栓形成,静脉功能不全，静脉阻塞tumor(e.g., tumor obstruction of the iliac vein), lymphatic obstruction (e.g., from a pelvic tumor or lymphoma), or lymphatic destruction (e.g., congenital vs. secondary from a tumor,radiation, or丝虫病）。双侧或广义肿胀表明了系统原因，例如CHF（尤其是右侧），pulmonary hypertension, chronic renal or hepatic disease (causing hypoalbuminemia), protein-losing enteropathies, or severe malnutrition.
4. 用药史和
5. 评估系统性疾病。^[1]
   

   压凹性水肿

体检——体检,πtting, tenderness, skin changes, and temperature are evaluated.^[1]

• Pitting: There are two types of edema, pitting and non- pitting edema。压凹性水肿is described as an indentation that remains in the edematous area after pressure is applied. Its location, timing, and extent are determined for treatment response. It is mainly assessed on the medial malleolus, the bony portion of the胫骨，和背面foot。Non-pitting edema is seen in淋巴水肿，myxedema, and lipedema.^[1]
• Tenderness: Pain to palpation over the edematous area is associated with DVT and complex regional pain syndrome type 1 (i.e.,反射交感神经营养不良）。In contrast,lymphoedemagenerally does not elicit pain with palpation.
  

  右腿的DVT有肿胀和发红
• Change in skin temperature, color, and texture: Warmth in the edematous area is associated with acute深静脉血栓形成andcellulitis。Redness, shinny skin, and ulcer are to be noted. Yellow-brown hemosiderin deposition is seen in venous insufficiency.^[1]

定量评估外周水肿的方法[edit|edit source]

研究中使用了各种方法来评估外围水肿。^[3]

测量水肿的最常用工具是：

1. 体积测量（带有水量计）
2. Girth measurements (with a tape measure).
3. 压凹性水肿assessment (based on the depth and duration of the indentation).

Water displacement and ankle circumference had shown a high inter-examiner agreement (intraclass correlation coefficient 0.93, 0.96 right; 0.97, 0.97 left).

1. 水位（体积测量）

The volumeter:

• Introduced into medicine by Glisson in 1622
• Utilizes the same principle of water displacement first discovered by the ancient Greek mathematician, Archimedes, which states that the water volume displaced is equal to the volume of the object immersed in the water.
• Clear acrylic rectangular box (13″x5″x9″) with a spout at the top of one of the short sides is filled with water until water rushes out of the spout. When the water level is stable, the patient places one foot in the volumeter, displaced water collected and measured in a graduated cylinder. The amount of water displaced in milliliters equals the volume of the foot/ankle or hand.
• For the ankle, a volumetry test can be done in either sitting or standing with knees 90 degrees in sitting and foot flat in the base of the volumeter.^[3]
• For the hand, the participant’s hand is placed slowly into the volumeter with forearm pronated, fingers adducted, and thumb facing the spout until the web of the middle and ring finger rested on the stop dowel of the volumeter.^[4]

优势 - 它是测量水肿的金标准工具。^[5]

缺点- various disadvantages to these methods in a clinical setting.

• 现在需要在测试前几分钟进行设置，因为水位需要稳定。
• 一旦充满水就很难移动。
• It requires specialized equipments.
• It is messy as they require the patients to immerse their hands in water, and it is therefore unsuitable for certain patient populations.^[5]

^[6]

2.周长测量（带有胶带量）

• Circumferential Method

The circumferential method is one of the girth measurement techniques. For consistent measurements, each upper extremity or lower extremity is marked with a semi-permanent marker at a certain part with reference to the bony prominences,^[3]

• Figure-of-Eight method

它也是周长测量技术之一。它比周向方法更可靠，因为它涵盖了更大的区域。比标准胶带相比，优先使用张力控制的尺寸胶带将水肿缠绕在脚踝/脚上或手上，以测量水肿。^[5][3]A figure of 8 method is usually preferred in ankle and hand swelling. It has its own specific points across for consistency.

• A figure of 8 to measure hand swelling

^[7]

• 8个数字来测量踝关节肿胀

^[8]

3.压凹性水肿

评估 - 在每个末端牢固地按至少2秒

• Over the dorsum of the foot
• Behind the medial malleolus
• Lower calf above the medial malleolus

记录了皮肤恢复原始外观（恢复时间）所需的时间。

水肿的分级由凹坑深度（视觉上测量）和0-4级的恢复时间确定。该量表用于评估严重程度，分数如下：

• 0级：没有临床水肿
• Grade 1: Slight pitting (2 mm depth) with no visible distortion that rebounds immediately.
• 2年级：更深的坑（4毫米），没有容易检测到的失真，在不到15秒内反弹。
• 3年级：明显的深坑（6毫米），依赖的肢体充满和肿胀，最多需要30秒才能反弹。
• Grade 4: Very deep pit (8 mm) with the dependent extremity grossly distorted that takes more than 30 seconds to rebound.^[3]

结论[edit|edit source]

• 水位排量和踝部测量更可靠的方法
• 由于其主观性质，临床评估高度可变

Pitting Edema

• The indention recovery time (how long it takes for the indention to refill) can be helpful in determining diagnosis
• There is a direct relation between the serum albumin concentration and the indention recovery time (hypoalbuminemic edema recover time is < 40 seconds)

重点评估：肿胀，疼痛，依赖性的水肿变化，皮肤发现（色素沉着，暂停性皮炎，脂肪性细胞膜硬化，阿特罗菲·布兰奇，溃疡）和静脉血栓栓塞史^[9]

References[edit|edit source]