ʻO Phlegmasia Cerulea Dolens, Massive Iliofemoral DVT, a me nā ʻehaʻeha polū a keʻokeʻo paha.¶

ʻO ka phlegmasia cerulea dolens (unuhi maoli ʻia ʻo "ʻeha polū ʻeha") he maʻi vascular ulia pōpilikia, hoʻoweliweli a hoʻoweliweli i ke ola i hana ʻia e kahi thrombosis hohonu hohonu (DVT) e hoʻopaʻa loa i ka 100 pākēneka o nā awāwa hohonu a me nā collateral venous outflow e hoʻoheheʻe ana i ka ʻaoʻao hema a me ka maʻamau o ka ʻōpū hema. ʻAʻole like me ka DVT wāwae haʻahaʻa maʻamau, kahi e hiki ai ke hoʻihoʻi ke koko i ka puʻuwai ma o nā aʻa liʻiliʻi liʻiliʻi, hoʻopau ʻia ka iliofemoral outflow obstruction i ke koko aʻa i loko o ka wāwae me kahi ʻole e puka ai. I loko o nā hola, piʻi aʻe ka piʻi ʻana o ka hydrostatic i loko o nā moena capillary, e koi ana i nā lita o ka wai i loko o nā ʻiʻo a puni, e hoʻohuli i ka wāwae holoʻokoʻa mai ka ʻāʻī a hiki i nā manamana wāwae a pehu ikaika, hoʻohuli i ka ʻili i ka poni poni-uliuli, e hoʻonui ai i ka hemorrhagic fluid blisters (bullae), a ma waho o ka hoʻopiʻi ʻana i ka maʻi ʻaʻa kiʻekiʻe. venous gangrene, hypovolemic circulatory shock, and fatal pulmonary embolism. Inā loaʻa kekahi i ka pehu ʻana o ka wāwae holoʻokoʻa (mai ka ʻūhā a hiki i ka wāwae) i hele pū ʻia me ke keʻokeʻo waxy loa (phlegmasia alba dolens, a i ʻole "waewae waiu") a i ʻole ka poni-uliuli hohonu (phlegmasia cerulea dolens), e kelepona i kou wahi. helu pilikia koke. ʻOiai e kali ana no ka lawe ʻana i ka pilikia, e nīnau i nā alakaʻi alakaʻi vascular a me nā maʻi e pili ana pulmonary embolism and deep vein thrombosis (DVT), lala ischemic acute, occlusion arterial, a me ka pulseless extremity, a cellulitis, erysipelas, lymphangitis, a me ka holomua o ka sepsis.

Ma muli o ka noho mālie ʻana o ka iliofemoral clot i loko o nā aʻa pelvic ākea ma ka ʻīpuka o ka vena cava haʻahaʻa, ʻo kāu mau kānāwai koʻikoʻi ʻelua ma mua o ka haukapila ʻo ** ʻaʻole loa e lomilomi, ʻimi, ʻomi, a i ʻole e kau i kahi lima hoʻopaʻa pipi mechanical i ka wāwae pehu** (hiki ke ʻoki i ka puʻuwai nui i loko o ka puʻuwai lua) ma luna o ke kiʻekiʻe o ka puʻuwai** (ʻaʻole e like me ka acute arterial ischemia, kahi e piʻi ai ke kiʻekiʻe i ka pōloli, hoʻohana ka hoʻokiʻekiʻe ʻana i ka wāwae venous-occluded e hoʻemi i ke kiʻekiʻe o ka venous hypertension a me ka puʻe haʻahaʻa.

E hana i kēia i kēia manawa¶

1. E kāhea koke i kāu helu ulia pōpilikia a noi aku i ka lawe ʻana i kahi haukapila me Vascular Surgery and Interventional Radiology. Kāhea iā 911 ma ʻAmelika Hui Pū ʻIa a me Kanada, 112 ma waena o ʻEulopa, 999 ma United Kingdom, 000 ma Australia, a i ʻole e nānā i kā mākou papa inoa o helu pilikia. E wehewehe pono: "He phlegmasia cerulea dolens / massive iliofemoral deep vein thrombosis: ʻo ka wāwae holoʻokoʻa mai ka ʻāʻī a hiki i ka wāwae he pōhaku paʻakikī, pehu nui, ʻeha nui, a lilo i poni-uliuli."
2. E mālama pono i ka mea maʻi ma kahi moe i ka hoʻomaha loa (mai ʻae iā lākou e hele i ka lumi ʻauʻau a i waho paha i ke kaʻa). ʻO ka hele wāwae e hoʻopaʻa i ka ʻūhā ikaika a me nā ʻiʻo pelvic e kū'ē i kahi kolamu nunui o ka thrombus hou, ʻaʻole i hoʻopili ʻia i loko o nā vemoral femoral a me iliac maʻamau, hiki ke hoʻokuʻu i kahi puʻu nui i loko o ka puʻuwai a me ka māmā (embolism)
3. AOLE e lomilomi, hamo, kawili, a i ole e kau i ke kapa komo pa'a a i ole ke kamaa lomilomi pneumatic ma ka wawae. No ka mea, ke kumu o ka phlegmasia i ka eha nui a hohonu e like me ka lio charley a i ole i ka i'o uha huki, ua hamo pinepine na hoa o ka ohana i ka uha a i ke keiki bipi a i ke kaula paha i ka pu lomilomi a i ole ka lima. Hiki i ka ʻoki ʻana i waho ke wehe i kahi embolus make a i ʻole e wāwahi i nā moena capillary ischemic.
4. **Wehe koke i nā pālule, nā pūkini, nā kāmaʻa, nā kūpeʻe wāwae, a me nā apo manamana wāwae, a e hoʻokiʻekiʻe iki i ka wāwae ma luna o nā uluna palupalu (ma kahi o 15 a 30 degere ma luna o ke kiʻekiʻe o ka puʻuwai). ʻO ke kiʻekiʻe haʻahaʻa ma luna o ka pae puʻuwai e hōʻemi ana i ke kaomi hydrostatic venous i loko o ka pūnaewele capillary i hoʻopaʻa ʻia a kōkua i ka lohi i ka piʻi ʻana i ka compartment syndrome (koe naʻe ua nalo loa nā pulse arterial a hoʻonui ʻia ke kiʻekiʻe i ka ʻeha wāwae ischemic, a laila mālama i ka pae wāwae me ka puʻuwai).
5. **Mai hoʻopili pono i nā pā hoʻomehana, nā ʻōmole wai wela, a i ʻole nā ​​ʻeke hau i ka ʻili uliuli a i ʻole keʻokeʻo. ʻO nā pads hoʻomehana e hoʻolalelale i ke koi o ka ʻiʻo oxygen a hoʻoulu i ka wela wela, aʻo nā ʻeke hau e hoʻoulu i ka vasospasm arterial reflex e hoʻolalelale i ka gangrene venous.
6. E mālama pono i ka mea maʻi i ka NPO (ʻaʻohe mea ma ka waha) a nānā no ka pōkole hikiwawe o ka hanu, ka ʻeha o ka umauma, a me ka maule. No ka mea, ʻo ka hoʻoheheʻe nui ʻana i ka wai i loko o ka ʻūhā pehu hoʻokahi a me ka wāwae hiki ke pahele ** 3 a 5 mau lita (0.8 a 1.3 galani)** o ke koko a me ka plasma i waho o ke kahe holoʻokoʻa, ʻike ʻia ka maʻi ʻeha haʻahaʻa o ke koko. ʻoiai me ka ʻole o ke kahe ʻana o waho, a pono lākou e mākaukau koke no ka thrombolysis a i ʻole ka thrombectomy i kuhikuhi ʻia e ka catheter.

ʻO ka lāʻau hoʻoholo: ʻeha nui, pehu, ʻulaʻula, keʻokeʻo, a i ʻole poni-uliuli hoʻāʻo wāwae¶

flowchart TD
    Start["ʻEha Koʻikoʻi Puʻuwai, Pehu, a i ʻole Hoʻololi kala (ʻulaʻula, Keʻokeʻo, a i ʻole Poni-Blue)"] --> CheckExtent{"KaʻAnuʻu Hana 1: E nānā i ka pehu a me ka hoʻohele kala: Ua pehu ka wāwae holoʻokoʻa mai ka ʻāʻī a i ka ʻūhā a hiki i ka wāwae?"}

    CheckExtent -->|"ʻAe: He pehu nui ka wāwae holoʻokoʻa mai ka ʻāʻī a hiki i nā manamana wāwae"| CheckColor{"KaʻAnuʻu 2: He aha ke kala o ka wāwae pehu nui?"}

    CheckColor -->|"Poni ʻulaʻula-ʻulaʻula a i ʻole Violaceous, Rock-Paʻa Woody Edema, ʻEha ʻehaʻeha, ʻEha ʻili (Bullae), Nawaliwali a i ʻole nā ​​Naʻi wāwae wāwae."| PCD["PHLEGMASIA CERULEA DOLENS (FULMINANT VENOUS OUTFLOW OCCLUSION): E kelepona iā 911 / 112 / 999 koke; 4 a hiki i 6 mau hola e pale aku ai i ka Gangrene Venous, ʻoki ʻia, a me ka haʻalulu"]

    CheckColor -->|"ʻO Stark Waxy Keʻokeʻo / Pale ('Milk Leg'), ʻO ka Edema Paʻa mai ka ʻāʻī a i ka wāwae, ka ʻili mehana a i ʻole ʻoluʻolu, ʻo nā naʻau wāwae e paʻa mau."| PAD["PHLEGMASIA ALBA DOLENS (SUBTOTAL ILIOFEMORAL DVT WITH ARTERIAL SPASM): Kāhea koke i nā lawelawe pilikia; ʻO ka mua o ka Phlegmasia Cerulea Dolens"]

    CheckExtent -->|"ʻAʻole: ʻAʻole pehu ka wāwae (a i ʻole ua ʻemi ʻia), ʻeleʻele/ʻeleʻele, Ice-Cold, Pulseless, with Foot Drop / Numbness"| AcuteArterial["ACUTE ARTERIAL LIMB ISCHEMIA (ARTERIAL EMBOLISM OR THROMBOSIS): Kāhea koke i nā lawelawe ulia pōpilikia; Mālama i ka wāwae (ma lalo iki o ka puʻuwai), ʻaʻole e hoʻokiʻekiʻe"]

    CheckExtent -->|"ʻAʻole: Ua kaupalena ʻia ka pehu ʻana i ka wāwae haʻahaʻa/bipi wale nō, A i ʻole ka ʻili ʻulaʻula wela me ke kuni"| DiffCellDVT{"KaʻAnuʻu Hana 3: E hoʻokaʻawale i ke keiki bipi maʻamau DVT vs. Acute Cellulitis vs. Necrotizing Fasciitis"}

    DiffCellDVT -->|"Laha koke ka ʻili ʻulaʻula wela, ke kuni kiʻekiʻe/ke anu, ka ʻiʻo ʻana o ka pūni lymph inguinal, nā palena ʻokoʻa a ʻaʻole maopopo."| CheckNecFasc{"He ʻeha paha, ʻeleʻele poni, ʻeha ʻili, a i ʻole crepitus?"}

    CheckNecFasc -->|"ʻAE"| NecFasc["NECROTIZING FASCIITIS (MAʻI ʻAʻI IʻO): E kāhea koke i nā lawelawe ulia pōpilikia no ka hoʻopau ʻana i ka ʻoki kino."]
    CheckNecFasc -->|"ʻAʻOLE"| Cellulitis["Acute Limb Cellulitis a i ʻole Erysipelas: E ʻimi koke i ka loiloi lāʻau lapaʻau i ka lā hoʻokahi no nā lāʻau antibiotic oral a i ʻole IV (a me ka Ultrasound Duplex inā loaʻa ka DVT)"]

    DiffCellDVT -->|"ʻO ka pehu ʻana o ka bipi unilateral (3 knm a ʻoi aku ka nui ma mua o nā keiki bipi ʻē aʻe), ʻeha hohonu, nā aʻa ʻaʻa pāpaʻa ākea, ʻoki ʻoki hou/immobility/cancer."| StandardDVT["Manaʻo ʻia ʻo Distal a Femoropopliteal DVT: Mai Lomilomi; E hele koke i ka 'Oihana Ho'opilikia no ka Ultrasound Venous Duplex a me Anticoagulation"]

    PCD --> PreHospBundle["ʻO ke kaʻina hana mua ma mua o ka hale maʻi: Hoʻomaha moe piha, ZERO Massage, ʻoki i nā lole paʻa, hoʻokiʻekiʻe wāwae haʻahaʻa (15 a 30 mau Degere), NPO koʻikoʻi, Heparin IV Unfractionated + Catheter-Directed Mechanical Thrombectomy a i ʻole Surgical Venous Thrombectomy"]
    PAD --> PreHospBundle

Pathophysiology: ka piʻi ʻana o ʻekolu mau pae mai ka DVT maʻalahi i ka wāwae waiū, ka wāwae uliuli, a me ka gangrene venous¶

No ka hoʻomaopopo ʻana i ke kumu o ka ʻokoʻa o ke ʻano o ka phlegmasia cerulea dolens mai ke koko koko maʻamau i loko o ka bipi keiki, kōkua ia i ka nānā ʻana i ke anatomy o ka venous drainage ma ka ʻaoʻao haʻahaʻa a me ke pelvis. ʻO ka mea maʻamau, hoʻi ke koko i loko o ka wāwae ma o ke aʻa femoral i ka puʻuwai ma o nā ʻōnaehana pili ʻelua: ʻo ka mana kiʻekiʻe ** ʻōnaehana venous hohonu ** (anterior tibial, posterior tibial, peroneal, popliteal, deep femoral [profunda femoris], femoral, a me nā veins iliac) a me ka **superficial a me veveous saphenous liʻiliʻi (ingreat saphenous system) pelvic cross-collateral networks).

I loko o ka thrombosis hohonu o ka bipi keiki a i ʻole ka ʻaʻa femoral superficial, e hāmama ka profunda femoris (deep thigh vein) a me ka great saphenous vein. Kaʻalo wale ke koko i ka ʻāʻī ma o kēia mau alahele koʻikoʻi, e hoʻoulu ai i ka pehu o ka wāwae haʻahaʻa haʻahaʻa me ka hoʻoweliweli ʻole i ke ola o ka lālā. Ke hoʻonui ʻia ka ʻāʻī i luna e hoʻopaʻa i ka ** aʻa femoral maʻamau ** a me ** aʻa iliac maʻamau / waho ma ka ʻāʻī a me ke pelvis, akā naʻe, ua pani ʻia kēlā mau puka koʻikoʻi koʻikoʻi. A laila e holomua ana ka maʻi maʻi ma waena o ʻekolu mau pae hemodynamic ʻokoʻa:

Ka Papa 1: ʻO Phlegmasia Alba Dolens ("Waewae Milk" a i ʻole wāwae ʻeha keʻokeʻo)¶

• Subtotal venous occlusion with patent micro-collaterals: Na ka thrombus nui e poloka loa i ka iliofemoral venous trunk nui, oiai he hapa uuku o ka microscopic dermal a me pelvic collateral veins e hamama ana.
• Ka hoʻololi ʻana o ka wai hydrostatic nui me ka ʻole o ka stasis capillary: Piʻi ʻoi aku ka piʻi ʻana o ka venous, e alakaʻi ana i ka nui o ka wai plasma maʻemaʻe ma waena o nā paia capillary i loko o ke ākea interstitial subcutaneous (Starling force imbalance). Ma muli o ka hoʻopiha ʻana o ka ʻiʻo subcutaneous i ka wai edema maʻemaʻe kiʻekiʻe e kaomi kino i nā capillaries dermal subpapillary liʻiliʻi liʻiliʻi (a hoʻoulu i ka vasospasm sympathetic reflex o nā arterioles ʻili), ʻo ka ʻili ma luna o ka ʻūhā holoʻokoʻa a me ka bipi keiki e huli i ka ** ʻeleʻele, keʻokeʻo, keʻokeʻo waiū** (phlegmasia alba dolens).
• Inoa mōʻaukala ("Milk Leg"): No nā kenekulia, ua ʻike nā kauka i kēia pehu keʻokeʻo ʻehaʻeha o ka wāwae hema holoʻokoʻa i nā wahine i ka pau ʻana o ke kolu o ka mahina o ka hāpai ʻana a i ʻole ma hope koke o ka hānau ʻana (i ka wā i hoʻopaʻa ʻia ai ka ʻōpū kaumaha nui i ke aʻa iliac hema i ka ʻāʻī lumbar) a manaʻo hewa ua hoʻi ka waiu waiu i ka wāwae.
• No ke aha ia he pae ʻōlelo aʻoaʻo koʻikoʻi: Ma ka pae alba, paʻa mau ke kahe ʻana o ke aʻa, ke komo nei ka oxygen i nā ʻiʻo ʻiʻo, a ʻaʻole i hoʻomaka ka ischemia. Eia naʻe, me ka loaʻa ʻole o ka anticoagulation intravenous a me ka decompression venous, a hiki i ka 40 a i ka 50 pakeneka o nā maʻi phlegmasia alba dolens e hoʻopaʻa i ko lākou mau aʻa liʻiliʻi liʻiliʻi liʻiliʻi a holomua pololei i loko o phlegmasia cerulea dolens.

Ka Papa 2: Phlegmasia Cerulea Dolens (Waewae Polu ʻeha)¶

• 100 pakeneka occlusion o ka hohonu A me ka collateral/superficial venous outflow: I ka manawa e hooloihi ai ka thrombosis ma kahi mamao a kokoke e hoopau i na aa kolateral i koe (me ka profunda femoris, saphenous junction, a me ka iliac tributaries o loko/waho), ** hiki i ke koko ke ha'alele i ke koko ki'eki'e* me ka pume o ke koko. kēlā me kēia puʻuwai.
• ** ʻElima piʻi i loko o ke kaomi hydrostatic capillary a me ke kolu-spacing nui:** I loko o 2 a 6 mau hola, piʻi ke kaomi hydrostatic i loko o nā venules a me nā capillaries a hiki i 50 a 80 mmHg (ʻelima mau manawa maʻamau). Pehu ka wāwae i nā ʻāpana nui, e hoʻokaʻawale ** 3 a 6 mau lita o ke koko a me ka wai** i loko o ka wēlau.
• Deoxygenated stagnation a me ka cyanosis: Noho ʻole nā ​​​​keʻena koko ʻulaʻula i paʻa ʻia i loko o nā ʻāpana dermal a me nā ʻaoʻao lalo, kahi e wehe ai nā ʻiʻo a puni i kēlā me kēia mole o ka oxygen mai ko lākou hemoglobin. Nā kiʻekiʻe o ka hemoglobin deoxygenated (>5 g/dL i loko o ka moena capillary) e hoʻohuli i ka ʻaoʻao holoʻokoʻa mai ka ʻāʻī ʻāʻī a hiki i ka piko o nā manamana wāwae i **hohonu, ʻeleʻele, ʻulaʻula poni-uliuli a ʻeleʻele ʻeleʻele paha **, i hele pinepine ʻia me ka pinpoint dermal hemorrhages (petechiae a me purpura) ke pohā nā capillaries ma lalo o ke kaomi.
• Ke piʻi ʻana o ke aʻaʻa lua a me ka maʻi venous compartment: Ke piʻi aʻe nei ke kaomi ʻana o ka ʻiʻo interstitial i loko o nā keʻena ʻiʻo i pani ʻia o ka bipi a me ka ʻūhā ma luna o 30 a i 50 mmHg (a ʻoi aku ma mua o ke koko systolic arterial blood pressure), nā ʻiʻo paʻa i ka wai ** e hōʻeha i ke aʻa i pani ʻia i waho**, ʻoiai ʻaʻohe kahe koko i loko. I kēia manawa, nalowale nā ​​puʻupuʻu wāwae (dorsalis pedis a me posterior tibial), huli ka wāwae i ke anu, a hoʻomaka nā aʻalolo sensory e make (numbness and paralysis).

Ka Papa 3: Venous Gangrene (Irreversible Tissue Necrosis)¶

• Ma loko o 4 a 12 mau hola o ka phlegmasia cerulea dolens i mālama ʻole ʻia, hoʻopaʻa piha ʻia ka hoʻoheheʻe capillary i ka necrosis piha-mānoanoa o ka ʻili, ka momona subcutaneous, a me ka ʻiʻo iwi (venous gangrene).
• Nā hōʻailona hōʻailona: ʻO nā ʻōhū wai nui a paʻa i hoʻopiha ʻia me ke koko poni ʻeleʻele a ʻeleʻele paha (hemorrhagic bullae) e hū aʻe ma ka wāwae, kuʻekuʻe wāwae, a me ka wāwae lalo; ili ka ili; ʻeleʻele nā ​​manamana wāwae a me ka wāwae mua; ʻO ka haʻihaʻi nui o ka ʻiʻo wāwae e make ana e kahe ana i ke kahe koko me ka potassium (hyperkalemia), myoglobin (rhabdomyolysis and acute kidney failure), a me ka lactic acid (severe metabolic acidosis).
• Ka nui o ka make a me ka ʻoki ʻana: Ke piʻi ka phlegmasia cerulea dolens i ka venous gangrene, koi ʻia ka ʻoki ʻana o nā wāwae nui ma 20 a 50 pakeneka o ka poʻe i pakele, a hiki i ka nui o ka make ma ka haukapila i 25 a 40 pakeneka.

No ke aha i hahau ʻia ai ka wāwae hema he 3 a 4 mau manawa ʻoi aku ka nui ma mua o ka ʻākau: May-Thurner Syndrome (Iliac Vein Compression)¶

ʻO kahi hōʻike maʻi koʻikoʻi o ka phlegmasia alba dolens a me ka phlegmasia cerulea dolens ʻo ia ka 75 a hiki i ka 85 pākēneka o nā maʻi āpau ma ka wāwae hema ma mua o ka wāwae ʻākau. Hoʻokumu ʻia kēia nāwaliwali anatomical e May-Thurner syndrome (iliocaval compression syndrome):

1. Ka pahele anatomical scissor in the pelvis: I ka anatomy o ke kanaka, i ka iho ana o ke aorta abdominal ma ka aoao hema o ka iwi kuamoo lumbar a moku ana i ke a'a iliac ma'amau akau a hema, ka manoanoa, paakiki, ke kaomi ki'eki'e ** e kea pololei ana ke a'a iliac ma'amau ma mua o ke alo o ke a'a lahilahi, pa'a ha'aha'a hema i ka ilia ma'amau**. ka piko o ka lima lumbar vertebra (L5).
2. ** ʻO ka hammering pulsatile maʻamau a me nā "venous spurs":** Me kēlā me kēia puʻuwai puʻuwai (ʻoi aku ma mua o 100,000 mau manawa i ka lā), ʻo ke aʻaʻa iliac ʻākau ʻākau e hāmama i ka ʻaʻa iliac hema i paʻa i ka iwi kuamoʻo. I loko o nā makahiki, ʻo kēia hoʻonāukiuki mechanical e hoʻoulu ai i ka lining i loko (intima) o ka vein iliac hema e hana i nā pūnaewele fibrous, synechiae, a me nā alahaka ʻili kūloko ("venous spurs") e hōʻemi i ke kahawai vein e 50 a 80 pakeneka.
3. Ka hoʻomaka koke ʻana: Ke loaʻa ka lua o ka maʻi prothrombotic, e like me ka maʻi maʻi ma lalo (pancreatic, lung, ovarian, a i ʻole gastrointestinal cancer, nona ka 20 a 40 pakeneka o nā maʻi phlegmasia cerulea dolens), hāpai ʻana, hoʻohana ʻana i ka waha, pelvic nui a i ʻole orthopedic thrombocydration, ʻokiʻoki ʻana i ka maʻi o ka maʻi, heparin-induced. he thrombosis kānana vena cava haʻahaʻa (IVC), ua pani koke nā ʻaʻaʻaʻa iliac hema haiki, e hoʻoulu ana i ka thrombosis retrograde pahū ma lalo o ka wāwae hema holoʻokoʻa.

Hoʻokaʻawale i ka Phlegmasia Cerulea Dolens, Phlegmasia Alba Dolens, Acute Arterial Ischemia, a me Acute Cellulitis¶

Ma muli o ke kuhi hewa ʻole ʻana i ka phlegmasia cerulea dolens ma ke ʻano he bacterial cellulitis maʻalahi (a me ka hoʻouna ʻana i ka mea maʻi i ka home me nā lāʻau antibiotic waha) a i ʻole ka huikau ʻana me ka arterial embolism (a kau i ka wāwae i lalo o ka moena) e alakaʻi ai i ka poho a i ʻole ka make, hoʻohana nā kauka i kahi papa hoʻohālikelike ʻaoʻao moe.

Pehea e hana ai i kahi hōʻoia neurovascular palekana, lima lima a hemodynamic ma ka home¶

ʻOiai e kali ana i ke kaʻa kaʻa, e hōʻiliʻili i ka ʻike kumu no ke kauka lapaʻau me ka ʻole o ke kuʻi ʻana i ka wāwae:

1. E nānā i ka palena o luna o ka pehu ʻana ma ka ʻāʻī a me ka ʻōpū: E nānā i ka peʻe ʻāʻī (inguinal ligament), ʻāʻī, a me ka paia o lalo o ka ʻōpū. Inā hoʻonui ʻia ka ʻili poni-uliuli a i ʻole nā ​​ʻaʻa o ka ʻili i hoʻonui ʻia ma ka ʻāʻī ma ka ʻōpū a i ʻole ke pelvis, e hoʻonui ʻia ka ʻāʻī i ka ** iliac vein maʻamau ** a i ʻole ** inferior vena cava (IVC)**.
2. E nānā i ke ʻano o ka manamana wāwae, ka neʻe ʻana, a me ka ʻōhū ("The Venous 6 Ps"):
3. E hoʻopā mālie i ka manamana wāwae nui: E nīnau inā he maʻamau ka manaʻo o ka ʻili (paresthesia), a i ʻole ʻeha (anesthesia).
4. E nānā i ka wili wāwae ikaika: E noi i ka mea maʻi e wili mālie i ko lākou manamana wāwae i luna a i lalo (mai hoʻoikaika ikaika i ko lākou wāwae i luna iā ʻoe iho, no ka mea, ʻaʻole hiki ke hilinaʻi ʻia ka hana hōʻailona Homans kahiko a hiki ke wehe i kahi ʻōpū). ʻO ka hiki ʻole ke hoʻoneʻe i nā manamana wāwae a i ʻole nā ​​kuʻekuʻe wāwae (** hāʻule wāwae**) e hōʻike ana i ka ischemia koʻikoʻi.
5. E nānā i ka ʻili o ka ʻili: E ʻike inā ua hana ʻia nā maʻi maʻemaʻe (serous bullae) a i ʻole nā ​​pehu koko ʻeleʻele (hemorrhagic bullae); ʻo ka ʻōhū koko e hōʻike ana i ka hiki mai o venous gangrene.
6. Mālama i ka puʻuwai a me nā hōʻailona haʻalulu: No ka mea, hiki i ka 3 a 5 mau lita o ka wai ke ʻauʻau i loko o ka wāwae, ʻoi aku ka nui o ka puʻuwai ma mua o 100 a i ka 120 paʻi i kēlā me kēia minuke, ʻeleʻele ʻeleʻele o ka ʻili, a i ʻole ka ʻūhā e hōʻike ana i ka hypovolemic shock.
7. E hoʻomākaukau i ka papa inoa moʻolelo olakino: Kākau i lalo i nā maʻi maʻi ʻike ʻia, nā mea hoʻokahe koko o kēia manawa (a me nā ʻano i hala ʻole), ka loaʻa ʻana o kahi Kanala IVC, a me kekahi mea i ʻike ʻia i ka heparin i loko o 5 a 14 mau lā i hala. Hiki i ka hōʻike ʻana i ka heparin i ka haukapila hou ke hoʻoulu i ka Heparin-Induced Thrombocytopenia (HIT), he hopena kūlohelohe e hoʻoulu ai i nā venous a me nā arterial clots pahū e koi koke i ka anticoagulation non-heparin (argatroban a i ʻole bivalirudin).

ʻO ka hoʻōla hou ʻana i ka haukapila a me nā kaʻina hana hoʻopakele lālā¶

Ke hōʻea ka mea maʻi me ka phlegmasia cerulea dolens i ke keʻena pilikia, e nānā ka mālama ʻana i ka decompression venous koke:

1. Aticoagulation Intravenous koke a me ka hoʻihoʻi hou ʻana i ka wai: Hāʻawi nā kauka i kahi bolus intravenous a me ka hoʻokomo mau ʻana o ** heparin unfractionated (UFH)** (a i ʻole argatroban inā kānalua ʻia ka HIT) me ka ʻeha ** intravenous isotonic crystalloids** e hoʻohuli i ka haʻalulu hypovolemic mai ka myoglobin. Hoʻokiʻekiʻe ʻia ka wāwae (30 a 60 degere) e hōʻemi i ka edema.
2. Kūnaʻi Moʻa Duplex a me CT Venography (CTV): Hōʻike ʻia ke kani ʻana o ka puʻupuʻu ma ka ʻaoʻao moe i ka thrombus i loko o nā veins femoral a me popliteal maʻamau i nā minuke, ʻoiai ʻo pelvic CT Venography ka palapala ʻāina i ka ʻaoʻao o luna o ka clot i loko o nā vena iliac a me ka vena cava inferior a ʻike ʻia ** May-Thurner iliac compression** a i ʻole pelvic compression.
3. Active Clot Removal (Endovascular vs. Open Surgical Thrombectomy): No ka mea, ʻaʻole hiki i nā mea hoʻoheheʻe koko wale nō ke hoʻopau i kahi ʻāʻī obstructing nui me ka wikiwiki e pale ai i ka gangrene venous, Society for Vascular Surgery (SVS) a me European Society for Vascular Surgery (ESVS) kauoha hou i ka thrombus:
4. Catheter-Directed Mechanical Thrombectomy (PMT) a me Thrombolysis (CDT): Hoʻomaka ka poʻe loea interventional i ka manaʻo nui a i ʻole ka rheolytic catheters (e like me ClotTriever, Indigo, a i ʻole AngioJet) a i ʻole nā catheters thrombolysis i kōkua ʻia e ultrasound (EKOS infusing alteplase i ka vassolveal [rtPA]) iliofemoral clot, a ukali ʻia e iliac vein stenting inā loaʻa kahi maʻi koʻikoʻi o Mei-Thurner ma ka ultrasound intravascular (IVUS).
5. Open Surgical Iliofemoral Venous Thrombectomy: I nā poʻe maʻi me ka fulminant venous gangrene, e hiki mai ana ka hāʻule ʻana o ke aʻa, a i ʻole nā ​​kūʻē i ka lāʻau thrombolytic, e hōʻike nā kauka lapaʻau i ke aʻa femoral maʻamau i loko o ka ʻāʻī, e hoʻokomo i kahi Fogarty balloon catheter i loko o ke aʻa iliac, a hoʻopaʻa paʻa i ka ʻeha o ka wāwae** ʻāʻī. Inā noho mau ke kaomi o ke keʻena ma luna o 30 mmHg ma hope o ka hoʻihoʻi ʻia ʻana o ka venous outflow, hana ʻia kahi fasciotomy bipi ʻāpana ʻehā.

Nā helu ulia pōpilikia āpana a me nā protocols oihana¶

Pono nā phlegmasia cerulea dolens a i ʻole phlegmasia alba dolens e lawe koke i kahi kaʻa kaʻa i kahi haukapila kula nui i lako me 24-hour Vascular Surgery, Interventional Radiology, and Intensive Care:

• ** ʻAmelika Hui Pū ʻIa a me Kanada:** Kāhea i ka 911. Noi i ka lawe ʻana i kahi keʻena ulia pōpilikia nui me ka Vascular Surgery a me Interventional Radiology hiki (mai hele i kahi keʻena mālama koʻikoʻi). Mālama ʻia ma lalo o Society for Vascular Surgery (SVS), American Venous Forum (AVF), a me American Heart Association (AHA) nā alakaʻi.
• United Kingdom: Kāhea i ka 999 no ke kaʻa kaʻa ulia pōpilikia i kahi haukapila koʻikoʻi nui ** Keʻena ʻEmergency (A&E)** e lawelawe ana ma ke ʻano he Arterial/Vascular Surgery Hub. Mālama ʻia ma lalo o National Institute for Health and Care Excellence (NICE NG158) a me Vascular Society of Great Britain and Ireland (VSGBI) protocols.
• Uni ʻEulopa: Kāhea 112. Mālama ʻia ma lalo o ka ** European Society for Vascular Surgery (ESVS) Clinical Practice Guidelines on the Management of Venous Thrombosis**.
• Australia a me New Zealand: Kāhea i ka 000 ma Australia a i ʻole 111 ma New Zealand. Mālama ʻia ma lalo o Australian and New Zealand Society for Vascular Surgery (ANZSVS) a me Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) nā alakaʻi.
• India a me Asia-Pacific: Kāhea i ka 112 (a i ʻole 108 ma India), 995 ma Singapore, 119 ma Iapana a me South Korea, a i ʻole 999 ma Malaysia a me Hong Kong. Noi i ka halema'i kula ki'eki'e me nā lawelawe 'oki kino endovascular a me vascular.

Nīnau pinepine¶

He aha ka ʻokoʻa ma waena o phlegmasia alba dolens ("wāwae waiu") a me phlegmasia cerulea dolens ("wāwae uliuli"?¶

Hoʻokumu ʻia nā kūlana ʻelua e kahi thrombosis hohonu hohonu (DVT) e ālai ana i ka iliac nui a me nā vemoral veins i loko o ke pelvis a me ka ʻāʻī, a ke hōʻike nei lākou i ʻelua mau pae o ka spectrum hoʻoweliweli hoʻokahi. I loko o ka phlegmasia alba dolens (ka pae mua o ka "wāwae waiu"), ua ālai ʻia nā aʻa hohonu nui he 100 pākēneka, akā hāmama nā aʻa liʻiliʻi liʻiliʻi; kahe ka wai i loko o ka ʻiʻo a ʻomi i nā capillaries ʻili i pehu ka wāwae holoʻokoʻa a lilo i keʻokeʻo waiu keʻokeʻo, ʻoiai ke kahe ʻana o ke koko a me nā puʻupuʻu wāwae e paʻa mau. I loko o ka phlegmasia cerulea dolens (ka pae kiʻekiʻe o ka "wāwae uliuli"), ua paʻa loa nā aʻaʻaʻa hohonu a me nā aʻa koʻa; ʻAʻole hiki i ke koko ke puka i waho o ka wāwae, ʻo ke koko deoxygenated stagnant e hoʻohuli i ka lālā holoʻokoʻa i ka poni-uliuli hohonu me nā maʻi koko, a ʻo ke kaomi kiʻekiʻe o ka lani e paʻa i nā aʻa e pani ʻia, e alakaʻi ana i ka gangrene venous i loko o nā hola inā ʻaʻole e hoʻemi koke ʻia.

No ke aha ʻaʻole pono ʻoe e lomilomi a hamo i ka wāwae ʻeha i loaʻa i ka DVT?¶

Ke hoʻokumu ʻia kahi ʻāʻī koko nui i loko o nā aʻa hohonu o ka bipi, ʻūhā, a i ʻole pelvis, ʻo ka ʻaoʻao o luna o kēlā clot he palupalu, palupalu, a lana pinepine ʻia i loko o ka vein femoral a iliac ākea e like me ka sausage me kahi huelo manuahi. Inā ʻoe e lomilomi, kāwili, hamo, a hoʻopili paha i kahi kāmaʻa kaomi mīkini i ka wāwae e hōʻoluʻolu ai i ka ʻeha ʻeha o ka ʻiʻo, hiki i ka ʻomi ʻana i ke kino ke haki i kahi ʻāpana nui o kēlā clot. I loko o nā kekona, e hele ana kēlā ʻāʻī haʻihaʻi i ka vena cava haʻahaʻa, e hele ma ka ʻaoʻao ʻākau o ka puʻuwai, a hoʻopaʻa i nā aʻa kumu nui o ka māmā (he pulmonary embolism nui), hiki ke hoʻopaʻa koke ʻia ka naʻau.

Pono ʻoe e hoʻokiʻekiʻe i ka wāwae a mālama paha i lalo inā loaʻa kekahi phlegmasia cerulea dolens vs.¶

He ʻokoʻa koʻikoʻi kēia i ke kōkua mua vascular. I ka paʻa ʻana o ke aʻa (kahi i hoʻopaʻa ʻia ai ke aʻaʻa femoral a popliteal paha i hiki ʻole i ke koko ke komo i loko o ka wāwae haʻihaʻi, ʻokiʻoki, hau-anu), ʻaʻole pono ʻoe e hoʻokiʻekiʻe i ka wāwae ma luna o ka puʻuwai no ka mea e kūʻē ana ka ʻumekaumaha i ke kahe ʻana o ke aʻa; mālama i kahi pae wāwae ischemic arterial a i ʻole hilinaʻi iki. ʻO ka ʻokoʻa, i loko o ka phlegmasia alba dolens a i ʻole phlegmasia cerulea dolens, ke kahe nei nā aʻa i ke koko i loko o ka wāwae, akā ua paʻa 100 ka nui o nā aʻa no laila ʻaʻole hiki ke koko i waho o ka wāwae poni nui; hoʻokiʻekiʻe mālie i ka wāwae ma luna o nā uluna (15 a 30 degere ma luna o ka pae o ka naʻau) hoʻohana i ka gravity e hoʻohaʻahaʻa i ke kaomi hydrostatic venous a hoʻemi i ka pehu ʻana o ka ʻāpana ʻoiai e kali ana i ka thrombectomy o ka haukapila.

No ke aha e ulu pinepine ai ka iliofemoral koko 3 a 4 manawa ma ka wāwae hema ma mua o ka wāwae ʻākau?¶

I loko o ke anatomy pelvic kanaka, hele pololei ke aʻaʻaʻaʻaʻa ʻāʻī maʻamau maʻamau me ka paʻa kiʻekiʻe ma ke alo o ke aʻa iliac maʻamau palupalu me ka paia lahilahi, e hoʻopaʻa paʻa ana i ka aʻa hema i ka iwi ʻelima lumbar vertebra o ka iwi kuamoʻo. ʻIke ʻia ʻo May-Thurner syndrome (iliac vein compression syndrome), ʻo kēia puʻupuʻu arterial mau e hoʻopololei i ka vein iliac hema a hana i nā pūnaewele fibrous kūloko i ka manawa. Ke hoʻonui ʻia ke koko e like me ka hāpai ʻana, ka ʻokiʻoki, ka maloʻo ʻana, a i ʻole ka maʻi kanesa, ʻoi aku ka maʻalahi o ka paʻi ʻia ʻana o ka iliac vein hema ma mua o ka vein iliac ʻākau ʻole.

Pehea ʻoe e ʻike ai i ka ʻokoʻa ma waena o ka thrombosis vein hohonu (DVT) a me ka cellulitis bacterial?¶

Hiki ke ʻano like ke ʻano o ka DVT maʻamau a me ka bacterial cellulitis no ka mea ke kumu ʻelua i ka wāwae haʻahaʻa mehana, pehu, palupalu, ʻulaʻula-ʻulaʻula a me ke kuni haʻahaʻa. Eia nō naʻe, ʻo ka cellulitis kahi maʻi ʻili o ka ʻili (e hoʻomaka pinepine ana mai ka ʻili ʻāhaʻi ma waena o nā manamana wāwae mai ka wāwae o ka mea pāʻani a i ʻole ka ʻāʻī ʻana) e hoʻoulu ai i ka ʻili ʻulaʻula ahi, ka pehu kūloko ma lalo o ke kuli, nā ʻōpū lymph nodes, a me ke kuni kiʻekiʻe, ʻoiai e ikaika mau ana nā puʻupuʻu wāwae. ʻO ka DVT iliofemoral nui ke kumu o ka pehu ʻana o ka wāwae ENTIRE mai ka ʻāʻī a hiki i ka wāwae, nā veins ākea ākea, ka ʻeha o ka ʻiʻo hohonu, a me ka ʻulaʻula keʻokeʻo a i ʻole ka poni poni-uliuli. No ka mea hiki i nā mea ʻelua ke nānā like i ka wā mua (a i ʻole i hui pū ʻia), ʻo ka ultrasound venous duplex ultrasound wale nō ke ala palekana e haʻi aku iā lākou.

Hiki paha i ka phlegmasia cerulea dolens ke hōʻailona mua o kahi maʻi maʻi ʻaʻole i ʻike ʻia a i ʻole ka hopena heparin?¶

ʻAe. I loko o nā haʻawina olakino, ma waena o 20 a me 40 ka nui o nā maʻi e hoʻomohala ana i ka phlegmasia cerulea dolens i loaʻa kahi maʻi maʻi hypercoagulable (e like me ka pancreatic, lung, ʻōpū, ovarian, a i ʻole ka maʻi maʻi hematologic) e hoʻokuʻu i nā mea hoʻoikaika i ke koko. Eia kekahi, hiki i nā poʻe maʻi i loaʻa i nā mea hoʻokahe koko heparin i loko o ka haukapila i loko o nā lā he 5 a hiki i ka 14 i hala ke hoʻomohala i ka Heparin-Induced Thrombocytopenia (HIT), kahi hopena kūlohelohe kahi e hoʻoulu ai nā antibodies i ka pahū venous a me ke koko koko; E haʻi mau aku i ke kauka ulia pōpilikia inā i hoʻopaʻa ʻia ka mea maʻi i ka haukapila i hiki iā lākou ke nānā i ka helu platelet a hoʻohana i nā mea hoʻokahe koko non-heparin inā pono.

Nā kumu a me ke alakaʻi kūhelu¶

• European Society for Vascular Surgery (ESVS, Europe): ESVS 2021 Clinical Practice Guidelines on the Management of Venous Thrombosis (Kakkos et al., European Journal of Vascular and Endovascular Surgery, Section 4.6: Management of Phlegmasia Cerulea Dolens, immediate heparin, unfractioned heparin IV. ka ho'ōla hou ʻana, ka thrombolysis i kuhikuhi ʻia e ka catheter, a me ka wehe ʻana i ka thrombectomy venous).
• Society for Vascular Surgery (SVS) & American Venous Forum (AVF, United States): Early Thrombus Removal Strategies for Acute Deep Venous Thrombosis: Clinical Practice Guidelines (ka lāʻau lapaʻau a i ʻole ka thrombectomy e hoʻoweliweli ʻia no ka iliofemoral DVT a me ka iliofemoral DVT a me ka ulephalegmasia o nā lālā).
• Ahahui Puʻuwai ʻAmelika (AHA, ʻAmelika Hui Pū ʻIa): Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: He ʻōlelo ʻepekema mai ka American Heart Association (Circulation, endovascular or surgical decompression decompression no ka maʻi maʻi o ka maʻi maʻi Mayliaphlebial ka hoʻopaʻa ʻana o ka vein).
• American College of Chest Physicians (CHEST, United States): Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report (nā hōʻailona no ka thrombolysis i kuhikuhi ʻia i ka catheter a me ka thrombectomy venous ʻokiʻoki i ka gangrene venous e hiki mai ana).
• National Institute for Health and Care Excellence (NICE, United Kingdom): Venous Thromboembolic Diseases: Diagnosis, Management and Thrombophilia Testing (NICE Guideline NG158).

Nā alakaʻi pili¶

• ʻO ka pulmonary embolism a me ka thrombosis vein hohonu (DVT)
• ʻO ka lālā ischemic aʻe, ka occlusion arterial, a me ka pulseless extremity
• ʻO ka cellulitis, erysipelas, lymphangitis, ʻulaʻula, a me ka holomua o ka abscess sepsis
• ʻO ka maʻi maʻi o ka lima, ka wāwae, a i ʻole ka forearm, ka ʻokiʻoki ʻana, a me ka 6 Ps triage
• Necrotizing fasciitis (ka maʻi ʻai ʻiʻo) a me nā hae ʻulaʻula cellulitis