Phlegmasia Cerulea Dolens, Massive Iliofemoral DVT, le Mahlaba a Tšohanyetso a Maoto a Boputsoa kapa a Masoeu¶

Phlegmasia cerulea dolens (eo ka ho toba e fetoletsoeng e le "ho ruruha ha buluu e bohloko") ke ts'ohanyetso e matla, e sokelang maoto le e behang bophelo kotsing e bakoang ke a massive deep vein thrombosis (DVT) e thibelang ka ho feletseng karolo ea 100 lekholong ea litsela tse tebileng le tse thibelang likokoana-hloko tse ntšang lesapo le lets'oaneng le lets'oaneng. serope se ka hodimo. Ho fapana le DVT e tloaelehileng ea leoto le ka tlase, moo mali a ntseng a khona ho kheloha ho khutlela pelong ka methapo e menyenyane ea tebeletso, thibelo e felletseng ea "iliofemoral outflow" e ts'oara mali a kenang ka har'a leoto ho se na moo a ka tsoang teng. Ka mor'a lihora tse seng kae, khatello ea hydrostatic ka har'a libethe tsa capillary e phahama ka makhetlo a mahlano, e qobella lithara tsa mokelikeli liseleng tse potolohileng, ho fetola leoto lohle ho tloha groin ho ea menoaneng e thata le e ruruhileng haholo, 'me letlalo le etsa hore letlalo le be le boputsoa bo boputsoa bo boputsoa, ​​ho phahamisa marotholi a mokelikeli o tsoang maling ho ea ho lets'oao le phahameng lefu la compartment, venous gangrene, hypovolemic circulatory shock, le lefu le bolaeang la pulmonary embolism. Haeba motho a e-ba le ho ruruha ha leoto lohle ka tšohanyetso, ho bohloko lefatšeng lohle (ho tloha lethekeng ho ea leotong) ho tsamaeang le bosoeu bo bosoeu (phlegmasia alba dolens, kapa "leoto la lebese") kapa ho fifala ho pherese-putsoa (phlegmasia cerulea dolens), letsetsa sebakeng sa heno. dinomoro tsa tshohanyetso hanghang. Ha u ntse u emetse lipalangoang tsa tšohanyetso, ikopanye le litataiso tse amanang le methapo le ts'oaetso ho pulmonary embolism le deep vein thrombosis (DVT), setho se matla sa ischemic, arterial occlusion, le pulseless extremity, le Cellulitis, erysipelas, lymphangitis le tsoelo-pele ea sepsis.

Hobane leqeba le leholo le lutseng le theohile methapong e pharaletseng ea pelvic hantle monyako oa vena cava e tlase, melao ea hau e 'meli ea bohlokoa ea pele ho sepetlele ke le ka mohla u se ke ua silila, ho pikitla, ho petetsa, kapa ho kenya letsoho la namane leotong le ruruhileng (le ka kutang lesela le leholo le emeng ka har'a sekoti sa pelo). leoto le leka-lekaneng ka holim'a boemo ba pelo** (ho fapana le acute arterial ischemia, moo bophahamo bo mpefatsang tlala, ho phahamisa leoto le koetsoeng ke venous ho sebelisa matla a khoheli ho fokotsa khatello ea mali ea methapo le khatello e tlase ea phaposi).

Etsa sena hona joale¶

1. Letsa nomoro ea hau ea tšohanyetso ea lehae hang-hang 'me u kope sepalangoang ho ea sepetlele se nang le Vascular Surgery and Interventional Radiology. Letsetsa 911 United States le Canada, 112 ho pholletsa le European Union, 999 United Kingdom, 000 Australia, kapa u hlahlobe lethathamo la rona la dinomoro tsa tshohanyetso. Bolela ka ho hlaka: *"Ho belaelloang hore ke phlegmasia cerulea dolens / massive iliofemoral deep vein thrombosis: leoto lohle ho tloha groin ho ea leotong le thata, le ruruhile haholo, le bohloko habohloko, 'me le fetoha pherese-buluu."
2. Beha mokuli a bataletse betheng ha a phomotse ka ho feletseng (U SE KE UA ba lumella ho ea ka kamoreng ea ho hlapela kapa ho tsoa koloing). Ho tsamaea ho kokobetsa mesifa e matla ea serope le pelvic khahlanong le toloana e khōlō ea thrombus e ncha, e sa hokelloang ka har'a methapo e tloaelehileng ea botšehali le ea kaka, e ka ntšang leqeba le leholo ka ho toba pelong le matšoafong**sa matšoafo.
3. O SE KA O SE O TLOHA ho silila, ho pikitla, ho duba, kapa ho kenya setokising kapa ho kenya letsoho ka thata leotong. Hobane phlegmasia e baka mahlaba a tebileng a kang a pere ea charley kapa mesifa ea serope, litho tsa lelapa tse nang le sepheo se setle li atisa ho hohla serope kapa namane kapa leqhoele holim'a letsoho le holimo kapa sethunya sa lipapali. Ho pepeta leha e le efe ka ntle ho ka senya embolus e bolaeang kapa ho senya libethe tse seng li ntse li le ischemic capillary.
4. Tlosa borikhoe bohle, likausi, lieta, lipetja tsa maqaqailana le mehele ea menoana hang-hang, ’me u phahamise leoto hanyenyane holim’a mesamo e bonolo (hoo e ka bang likhato tse 15 ho isa ho tse 30 ho feta tekanyo ea pelo). Khaola li-jeans tse thata kapa li-sweat pants ka lisekere ho e-na le ho hula leoto. Ho phahama ha pelo ka holim'a pelo ho fokotsa khatello ea hydrostatic venous ka har'a marang-rang a capillary 'me ho thusa ho liehisa tsoelo-pele ho ea ho compartment syndrome (ntle le haeba methapo ea methapo e se e nyametse ka ho feletseng le ho phahama ka mokhoa o bonahalang ho eketsa bohloko ba leoto la ischemic, moo ho bolokang leoto le pelo).
5. O SE KE oa itlatsa lintho tse futhumatsang, libotlolo tsa metsi a chesang kapa lipakete tsa leqhoa ka kotloloho letlalong le leputsoa kapa le lesoeu. Letlalo la phlegmasia cerulea dolens le sentse microcirculation le kutlo e sa sebetseng hantle; Lipakete tsa ho futhumatsa li potlakisa tlhoko ea oksijene ea lisele, 'me li baka ho chesoa ke mocheso o mongata, ha lipakete tsa leqhoa li etsa hore reflex arterial vasospasm e potlakisa lefu la venous gangrene.
6. ** Boloka mokuli ka tieo NPO (ho se letho ka molomo) 'me u hlokomele ho phefumoloha ka tšohanyetso, bohloko ba sefuba, kapa ho akheha.** Hobane metsi a mangata ka har'a serope le leoto le le leng le ruruhileng a ka tšoasa 3 ho 5 lilithara (0.8 ho ea ho 1.3 gallons) ea mali le plasma ho tsoa ho potoloha ka kakaretso, ho fokola ha pelo, ho ba le khatello ea maikutlo, bakuli ba fokotseha ka potlako. khatello e tlase ea mali) le ntle le ho tsoa mali ka ntle, 'me ba hloka ho itokisetsa hang-hang bakeng sa thrombolysis ea catheter-directed thrombolysis kapa thrombectomy ea ho buuoa.

Sefate sa qeto: se bohloko haholo, se ruruhile, se khubelu, se tšoeu kapa se pherese-putsoa¶

flowchart TD
    Start["Ho opeloa ha Leoto le Leholo ka Tšohanyetso, ho Ruruha, kapa Phetoho ea 'mala (Bokhubelu, Bosoeu, kapa Bopherese-Boputsoa)"] --> CheckExtent{"Mohato oa 1: Hlahloba ho Ruruha & Kabo ea 'Mala: Na leoto LOHLE le ruruhile ho tloha mokokotlong oa serope ho ea fihla leotong?"}

    CheckExtent -->|"YES: Ho ruruha ho hoholo ha leoto lohle ho tloha groin ho ea menoaneng"| CheckColor{"Mohato oa 2: Leoto le Ruruhileng Haholo ke 'Mala Ofe?"}

    CheckColor -->|"Mottled Cyanotic Purple-Blue kapa Violaceous, Rock-Hard Woody Edema, Agonizing Agonizing, Makhopho a Letlalo (Bullae), Methapo e Fokolang kapa e sa Feleng"| PCD["PHLEGMASIA CERULEA DOLENS (FULMINANT VENOUS OUTFLOW OCLUSION): Letsetsa 911 / 112 / 999 Hang-hang; Fesetere ea Lihora tse 4 ho isa ho tse 6 ho Thibela Leqhubu la Venous Gangrene, Ho khaoloa, le Ho Shoa"]

    CheckColor -->|"Bosoeu bo bosoeu bo bosehla ('Leoto la Lebese'), Edema e Tsitsitseng ho tloha Bokhopong ho ea Leotong, Letlalo le Mofuthu kapa Le phodileng, Maoto a Maoto a ntse a Utloahala."| PAD["PHLEGMASIA ALBA DOLENS (SUBTOTAL ILIOFEMORAL DVT LE ARTERIAL SPASM): Letsetsa Litšebeletso tsa Tšohanyetso Hang-hang; Selelekela sa Phlegmasia Cerulea Dolens"]

    CheckExtent -->|"CHE: Leoto ha le ruruhe (kapa le honyela), Stark Pale/Mottled, Leqhoa-Leqhoele, Ha le Pulseless, le Lerotholi la Leoto / Bohatsu"| AcuteArterial["ACUTE ARTERIAL LIMB ISCHEMIA (ARTERIAL EMBOLISM KAPA THROMBOSIS): Letsetsa Litšebeletso tsa Tšohanyetso Hang-hang; Boloka Leoto le Itšetlehile (Hanyenyane ka tlase ho Pelo), U SE KE UA U Phahamisa"]

    CheckExtent -->|"CHE: Ho ruruha ho lekanyelitsoe leotong le ka tlase / namane feela, KAPA letlalo le khubelu le chesang le nang le feberu."| DiffCellDVT{"Mohato oa 3: Fapanya Namane e Tloaelehileng DVT vs. Acute Cellulitis vs. Necrotizing Fasciitis"}

    DiffCellDVT -->|"Letlalo le lefubelu le chesang le hasana ka potlako, feberu e matla / mohatsela, mofuthu oa lymph node ea inguinal, meeli e hlakileng kapa e sa hlakang."| CheckNecFasc{"Na ho na le bohloko bo sa leka-lekaneng, makhopho a pherese, bohatsu letlalong, kapa crepitus?"}

    CheckNecFasc -->|"EE"| NecFasc["NECROTIZING FASCIITIS (TŠEBELETSO EA HO JA NAMA): Letsetsa Litšebeletso tsa Tšohanyetso Hang-hang bakeng sa Tšebeliso e Hlahang ea Opereishene."]
    CheckNecFasc -->|"NO"| Cellulitis["Acute Limb Cellulitis kapa Erysipelas: Batla Tlhahlobo e Potlakileng ea Bongaka ea Letsatsi le Tšoanang bakeng sa Lithibela-mafu tsa Molomo kapa tsa IV (le Duplex Ultrasound haeba DVT e Co-Exist)"]

    DiffCellDVT -->|"Ho ruruha ha namane ka lehlakoreng le le leng (3 cm kapa ho feta ho feta namane e 'ngoe), bohloko bo tebileng, methapo ea ka holimo e pharalletseng, opereishene ea morao-rao / ho se sisinyehe / mofets'e"| StandardDVT["Ho belaelloang hore Distal kapa Femoropopliteal DVT: U se ke Ua Itšila; E-ea Hang-hang Lefapheng la Tšohanyetso bakeng sa Venous Duplex Ultrasound le Anticoagulation"]

    PCD --> PreHospBundle["Protocol ea Hang-pele ea Pele ho Sepetlele: Phomolo e Felletseng ea Bethe, ZERO Massage, Cut Off Liaparo tse Tight, Boima ba Leoto le Bonolo (15 ho isa ho 30 Degrees), NPO e thata, Heparin e sa Feleng ea IV + Catheter-Directed Mechanical Thrombectomy kapa Surgical Venous Thrombectomy."]
    PAD --> PreHospBundle

Pathophysiology: tsoelo-pele ea mekhahlelo e meraro ho tloha ho DVT e bonolo ho ea ho leoto la lebese, leoto le leputsoa, ​​le venous gangrene.¶

Ho utloisisa hore na ke hobane'ng ha phlegmasia cerulea dolens e itšoara ka tsela e fapaneng le ea tloaelo ea mali ka namane, ho thusa ho hlahloba sebōpeho sa metsi a venous karolong e ka tlaase le pelvis. Ka tloaelo, mali a phunyeletsoang leotong ka mothapo oa botšehali a khutlela pelong ka mekhoa e 'meli e hokahaneng: matla a phahameng deep venous system (anterior tibial, posterior tibial, peroneal, popliteal, deep femoral [profunda femoris], femoral, le iliac veins) le tsamaiso ea* colsuperficial veins mothapo o monyane oa saphenous, le marang-rang a pelvic cross-collateral networks).

Ka mokhoa o tloaelehileng oa thrombosis ea methapo e tebileng ea namane kapa mothapo o ka holimo oa botšehali, profunda femoris (mothapo o tebileng oa serope) le mothapo o moholo oa saphenous o lula o bulehile. Mali a mpa a feta lesela litseleng tsena tse kholo, 'me a baka ho ruruha ha leoto le ka tlase ho isa ho lekanyelitsoeng ntle le ho beha bophelo ba leoto kotsing. Ha lesela le atoloha ho ea holimo ho koala mothapo o tloaelehileng oa botšehali le kantle/tloaelehileng mothapong ka har'a groin le pelvis, leha ho le joalo, litsela tseo tsa bohlokoa tsa ho tsoa li koalehile. Ho senyeha ha kliniki ho tsoela pele ho pholletsa le mekhahlelo e meraro e fapaneng ea hemodynamic:

Mothati oa 1: Phlegmasia Alba Dolens ("Leoto la Lebese" kapa Leoto le Lesoeu le Bohloko)¶

• Ho koaleha ha venous ho na le li-micro-collaterals tsa patent: Thrombus e kholo e thiba kutu e tebileng ea venous, athe karoloana e nyane ea methapo ea letlalo le pelvic e lula e bulehile.
• Ho fetoha ho hoholo ha mokelikeli oa hydrostatic ntle le capillary stasis: Khatello ea venous e nyoloha haholo, e khanna bongata bo boholo ba metsi a plasma a hlakileng ho pholletsa le mabota a capillary ho ea sebakeng sa subcutaneous interstitial (**Starling force force **). Hobane lesela le ka tlas'a letlalo le tlala mokelikeli o hlakileng oa edema o hatellang 'mele o monyane oa subpapillary dermal capillaries ('me o baka vasospasm ea kutlo ea letlalo la arterioles), letlalo holim'a serope le namane kaofela le fetoha strek, chalky, milky white (**phlegmassia)
• Lebitso la histori ("Leoto la Lebese"): Ka makholo a lilemo, lingaka li ile tsa bona ho ruruha hona ha tšohanyetso, ho bohloko ho tšoeu ha leoto lohle le letšehali ho basali qetellong ea trimester ea boraro ea boimana kapa nakoana ka mor'a ho beleha (ha popelo e boima e hatella mothapo o ka letsohong le letšehali khahlanong le lesapo la mokokotlo) 'me ka phoso ba lumela hore lebese le tšetse leoto la letsoele.
• ** Ke hobane'ng ha e le mohato oa bohlokoa oa temoso: ** Sethaleng sa alba, phallo ea mali e ntse e tsitsitse, oksijene e ntse e fihla liseleng tsa mesifa, 'me ischemia ea mesifa ha e e-s'o qale. Leha ho le joalo, ntle le ho thibela mali ho tsoa mali hang-hang le ho senyeha ha venous, ho fihlela ho 40 ho ea ho 50 lekholong ea phlegmasia alba dolens linyeoe li koala methapo ea tsona e menyenyane e setseng 'me li tsoela pele ka ho toba ho fulminant phlegmasia cerulea dolens.

Mothati oa 2: Phlegmasia Cerulea Dolens (Leoto le Leputsoa le Bohloko)¶

• ** karolo ea 100 lekholong e koaletsoeng ka bobeli bo tebileng LE tebeletso / phallo e ka ntle ea venous: ** Ha thrombosis e fetela ka thōko le hoo e batlang e le ho felisa mothapo o mong le o mong o setseng (ho kenyeletsoa le profunda femoris, saphenous junction, le lipompo tse ka hare / tsa ka ntle tsa liliac), ** mali a se nang letho a ka tloha lethekeng le phahameng * ka har'a leoto ka ho otla hohle ha pelo.
• Ho phahama ka makhetlo a mahlano khatellong ea capillary hydrostatic le sebaka se seholo sa boraro: Nakong ea lihora tse 2 ho isa ho tse 6, khatello ea hydrostatic ka har'a li-venule le li-capillaries e nyolohela ho 50 ho 80 mmHg (ka makhetlo a mahlano ka tloaelo). Leoto le kokomoha ho isa tekanyong e kholo, ho nka 3 ho 6 lithara tsa mali le mokelikeli ka hare ho ntlha.
• Deoxygenated stagnation le cyanosis Matšoao a phahameng a hemoglobin e nang le deoxygenated (>5 g/dL betheng ea capillary) fetola ntlha eohle ho tloha mokokotlong oa groin ho ea lintlheng tsa menoana ** e tebileng, ea dusky, ea violaceous pherese-putsoa kapa 'mala o motšo-putsoa **, hangata e tsamaeang le pinpoint dermal hemorrhages (**petechiae ** le purpura) ha li-capillaries li phatloha tlas'a khatello.
• Secondary arterial collapse and venous compartment syndrome: Ha khatello ea methapo e kenang kahare ho likarolo tse koetsoeng tsa mesifa ea namane le serope e nyolohela kaholimo ho 30 ho isa ho 50 mmHg ('me qetellong e feta khatello ea mali ea systolic), lisele tse tsitsitsoeng, tse tletseng mokelikeli li pshatla methapo ea mali e koalehileng le hoja ho se na mali ka ntle methapo ka botsona. Ka nako ena, maqhubu a maoto a distal (* dorsalis pedis ** le ** posterior tibial **) a nyamela, leoto le fetoha leqhoa, 'me methapo ea kutlo e qala ho shoa (ho tsieleha le ho shoa litho).

Mothati oa 3: Venous Gangrene (Irreversible Tissue Necrosis)¶

• **Ka har'a lihora tse 4 ho isa ho tse 12 tsa phlegmasia cerulea dolens tse sa phekoloang , ho tšoaroa ka ho feletseng ha capillary perfusion ho baka necrosis e feletseng ea letlalo, mafura a subcutaneous, le mesifa ea masapo ( venous gangrene **).
• Matšoao a bongaka: Mahlaseli a maholo, a tsitsipano a mokelikeli a tletseng mali a pherese e lefifi kapa a matšo (hemorrhagic bullae) a hlaha ho pholletsa le leoto, leqaqailaneng le leoto le tlase; letlalo lea khoehla; menoana ea maoto le ea pele e fetoha e ntšo 'me e ferekane; ho senyeha ho hoholo ha mesifa ea leoto le shoang ho phalla mali ka potassium (**hyperkalemia **), myoglobin (**rhabdomyolysis le ho hloleha ha liphio tse matla **), le lactic acid (**e matla metabolic acidosis **).
• Lipalo tsa batho ba shoang le ba ho khaoloa litho: Hang ha phlegmasia cerulea dolens e tsoela pele ho ba leqeba la venous, ho hlokahala hore ho khaoloe leoto le leholo ho 20 ho ea ho karolo ea 50 lekholong ea baphonyohi, ’me ka kakaretso lefu la sepetlele le fihla ho 25 ho ea ho karolo ea 40 lekholong.

Hobaneng ha Leoto le letšehali le otloa ka makhetlo a 3 ho isa ho a 4 hangata ho feta ka ho le letona: May-Thurner Syndrome (Iliac Vein Compression)¶

'Nete e tsotehang ea kliniki ea phlegmasia alba dolens le phlegmasia cerulea dolens ke hore **75 ho karolo ea 85 lekholong ea linyeoe tsohle e etsahala ka leoto le letšehali ** ho e-na le leoto le letona. Kotsi ena ea anatomical e bakoa ke May-Thurner syndrome (iliocaval compression syndrome):

1. Sefi sa anatomical scissor pelvis: Anatomy ea motho, ha aorta ea mpa e theoha ka lehlakoreng le letšehali la mokokotlo oa mokokotlo 'me e aroha ka har'a methapo e tloaelehileng ea lesapo le le letšehali, e teteaneng, e thata, e phahameng ** mothapo o nepahetseng oa mokokotlo o tšela ka ho toba ka pele ho lerako le tšesaane le tloaelehileng, le le letšehali le le thata le le letšehali. bony promontory ea ** bohlano lumbar vertebra (L5) **.
2. Ho otla ho sa feleng ha pulsatile hammering le "venous spurs": Ka ho otla ho hong le ho hong ha pelo (ka makhetlo a fetang 100,000 ka letsatsi), mothapo o otlang oa ka ho le letona o hahola mothapo o koaletsoeng ka letsohong le letšehali khahlanong le lesapo la mokokotlo. Ha lilemo li ntse li feta, ho teneha hona ho sa foleng ho etsa hore lesela le ka hare (intima) la mothapo o ka letsohong le letšehali le thehe likhoele tse nang le fibrous webs, synechiae, le makhopho a ka hare ("venous spurs") a fokotsang mocha oa mothapo ka karolo ea 50 ho isa ho 80 lekholong.
3. Sehlahisoa sa tšohanyetso: Ha lets'oao la bobeli la prothrombotic le hlaha, joalo ka lefu le bakoang ke "pancreatic, lung, ovarian, kapa kankere ea mala, e bakang 20 ho karolo ea 40 lekholong ea linyeoe tsa phlegmasia cerulea dolens), bokhachane, tšebeliso ea lithibela-pelehi tsa molomo, opereishene e kholo ea pelvic kapa orthopedic-hedropedic, (HIT), kapa inferior vena cava (IVC) filter thrombosis, lesela le tšesaane le letšehali la iliac le koala hang-hang, le bakang ho phatloha ho hoholo ha thrombosis ho theosa leoto lohle le letšehali.

Phapang ea Phlegmasia Cerulea Dolens, Phlegmasia Alba Dolens, Acute Arterial Ischemia, le Acute Cellulitis¶

Hobane ho fosahetse ho hlahloba phlegmasia cerulea dolens e le baktheria cellulitis e bonolo (le ho romela mokuli hae ka lithibela-mafu tsa molomo) kapa ho e ferekanya ka arterial embolism (le ho leketla leoto fatše betheng) ho lebisa tahlehelong ea maoto kapa lefu, lingaka li sebelisa tafole e thata ea ho bapisa bethe:

Mokhoa oa ho etsa tlhahlobo e sireletsehileng ea matsoho le methapo ea mali le hemodynamic lapeng¶

Ha u ntse u emetse ambulense, bokella lintlha tsa motheo bakeng sa ngaka e buoang ea methapo ntle le ho peta leoto:

1. Hlahloba moeli o ka holimo oa ho ruruha ha groin le mpa: Sheba lekhalo la noka (inguinal ligament), marako, le lebota le ka tlaase la mpa. Haeba 'mala o pherese-putsoa kapa methapo ea bokaholimo e kenelletseng e fetela ka mpeng kapa pelvis, lesela le fetela ho common iliac vein kapa inferior vena cava (IVC).
2. Sheba kutlo ea menoana, motsamao, le machache ("The Venous 6 Ps"):
3. Thetsa monoana o motona habobebe: Botsa hore na letlalo le utloahala le tloaelehile, le tsikinyeha (paresthesia), kapa le le bohatsu (anesthesia).
4. Sheba ho sisinyeha ha menoana e sebetsang: Kopa mokuli hore a tsoka menoana ea hae holimo le tlase ka bonolo (**u se ke ua sutumetsa leoto la bona holimo le uena , kaha mokhoa oa khale oa ho tsamaisa lets'oao la Homans ha o tšepahale ho tsa bongaka 'me o ka ntša leqeba). Ho se khone ho sisinya menoana kapa maqaqailana ( leoto le theoha **) ho bontša hore ho na le ischemia ea bohlokoa.
5. Sheba mahlaseli a letlalo: Hlokomela hore na makhopho a hlakileng (serous bullae) kapa mahlaseli a mali a lefifi (hemorrhagic bullae) a hlahile; makhopho a mali a bolela ketso ea venous e tlang.
6. Lekola matshwao a ho otla ha pelo le ho tshoha: Hobane 3 ho isa ho 5 lithara tsa mokelikeli o ka kopana ka har'a leoto, ho otla ha pelo ho feta 100 ho ea ho 120 ho otla ka motsotso, letlalo le fufuleloa le lerootho, kapa ho tsekela ho bontša hypovolemic shock.
7. Lokisetsa lenane la nalane ea bongaka: Ngola fatše mofetše leha e le ofe o tsejoang, lisebelisoa tsa morao-rao tsa mali (le litekanyetso leha e le life tse fetotsoeng), boteng ba IVC filter, le **ho pepesehela heparin leha e le efe matsatsing a 5 ho isa ho a 14 a fetileng **. Ho pepeseha ha heparin ea sepetlele haufinyane ho ka baka Heparin-Induced Thrombocytopenia (HIT), ts'oaetso ea 'mele ea ho itšireletsa mafung e bakang ho phatloha ho hoholo ha venous le arterial e hlokang hang-hang anticoagulation ea non-heparin (**argatroban ** kapa ** bivalirudin **).

Ho tsosolosa sepetlele le mekhoa e hlakileng ea ho pholosa maoto le matsoho¶

Ha mokuli ea nang le phlegmasia cerulea dolens a fihla lefapheng la tšohanyetso, kalafo e shebana le ho fokotseha ha venous hanghang:

1. Immediate Intravenous Anticoagulation and Fluid Resuscitation: Baoki ba fana ka bolus intravenous le infusion e sa khaotseng ea unfractionated heparin (UFH) (kapa argatroban haeba ho belaelloa HIT) hammoho le aggressive intravenous isotonic crystal crystal fluloids ho tloha ho liphio le ho tsitsisa ha liphio. Leoto le phahamisitsoe holimo (** 30 ho 60 likhato **) ho fokotsa edema.
2. Bedside Duplex Ultrasound and CT Venography (CTV): ultrasound ea khatello ea bethe e tiisa thrombus ka har'a methapo e tloaelehileng ea botšehali le popliteal ka metsotso, ha pelvic CT Venography e etsa 'mapa oa karolo e ka holimo ea leqeba methapong ea pele le ea tlaase ea vena cava le ho khetholla iliac pelion **May-Thurner ea pelvic.
3. Active Clot Removal (Endovascular vs. Open Surgical Thrombectomy): Hobane li-thiners tsa mali feela li ke ke tsa qhala lesela le leholo le thibelang mali ka potlako ho thibela leqeba la venous, Society for Vascular Surgery (SVS) le European Society for Vascular Surgery (ESVS) litataiso tsa ho tlosoa ka potlako:
4. Catheter-Directed Mechanical Thrombectomy (PMT) le Thrombolysis (CDT): Litsebi tsa ho kena lipakeng li ntšetsa pele takatso e kholo kapa li-catheter tsa rheolytic (tse kang ClotTriever, Indigo, kapa AngioJet) kapa li-catheters tsa thrombolysis tse thusoang ke ultrasound (EKOS infusing to *alteplase) ka "valicuteplase" qhala lesela la iliofemoral, le lateloa ke **iliac vein stenting ** haeba May-Thurner compression lesion e fumanoa ka intravascular ultrasound (**IVUS **).
5. Open Surgical Iliofemoral Venous Thrombectomy: Ho bakuli ba nang le lefu la venous gangrene, ho putlama ha methapo e haufi, kapa ho hanana le lithethefatsi tsa thrombolytic, lingaka tse buoang tsa methapo li pepesa mothapo o tloaelehileng oa botšehali ka har'a groin, fetisa Fogarty balloon catheter e nang le lesapo le thibang lenotong. tlamisa** ho ntsha lesela. Haeba khatello ea compartment e ntse e le ho feta 30 mmHg ka mor'a hore venous outflow e tsosolose, ho etsoa four-compartment calf fasciotomy e etsoa.

Linomoro tsa libaka tsa tšohanyetso le liprothokholo tsa mekhatlo¶

Ho belaelloang hore phlegmasia cerulea dolens kapa phlegmasia alba dolens e hloka sepalangoang sa hang-hang sa ambulense ho ea sepetleleng se seholo sa thuto e phahameng se nang le Ho buuoa ka Vascular ea lihora tse 24, Interventional Radiology, le Tlhokomelo e Matla:

• United States le Canada: Letsetsa 911. Kopa lipalangoang ho ea lefapheng la tšohanyetso la sepetlele le nang le bokhoni ba Vascular Surgery le Interventional Radiology (le ka mohla u se ke ua ea tleliniking ea tlhokomelo e potlakileng). E laoloa tlas'a Society for Vascular Surgery (SVS), American Venous Forum (AVF), le American Heart Association (AHA) tataiso.
• United Kingdom: Letsetsa 999 bakeng sa ambulense ea hang-hang ea sepetlele ho ea sepetleleng se seholo se hlobaetsang Lefapha la Tšohanyetso (A&E) le sebeletsang e le Setsi sa Setsi sa Ho Buoa ka Methapo ea Mafu Arterial/Vascular Surgery. E laoloa tlas'a Setsi sa Sechaba sa Bophelo bo Botle le Tlhokomelo e Ntle (NICE NG158) le Vascular Society of Great Britain and Ireland (VSGBI) protocol.
• European Union: Letsetsa 112. E laoloa tlas'a ** European Society for Vascular Surgery (ESVS) Litaelo tsa Boikoetliso ba Tleliniki mabapi le Tsamaiso ea Venous Thrombosis **.
• Australia le New Zealand: Letsetsa 000 Australia kapa 111 New Zealand. E laolwa tlasa Australia le New Zealand Society for Vascular Surgery (ANZSVS) le Thrombosis and Haemostasis Society of Australia and New Zealand (THANZ) ditataiso.
• India le Asia-Pacific: Letsetsa 112 (kapa 108 India), 995 Singapore, 119 Japane le Korea Boroa, kapa 999 Malaysia le Hong Kong. Kopa sepetlele sa thuto e phahameng se nang le lits'ebeletso tsa opereishene ea endovascular le vascular.

Lipotso tse botsoang khafetsa¶

Phapano ke efe lipakeng tsa phlegmasia alba dolens ("leoto la lebese") le phlegmasia cerulea dolens ("leoto le leputsoa")?¶

Maemo ana ka bobeli a bakoa ke sekhahla se seholo sa methapo e tebileng (DVT) e thibelang methapo ea mantlha le ea botšehali ka pelvis le groin, 'me e emela mekhahlelo e' meli ea sekhahla se ts'oanang se sokelang bophelo. Ho phlegmasia alba dolens (sethaleng sa pele sa "leoto la lebese"), methapo e meholo e tebileng e thibiloe ka karolo ea 100 lekholong, empa methapo e menyenyane ea tebeletso e lula e bulehile; mokelikeli o lutlela liseleng ebe o pepeta methapo ea letlalo e le hore leoto lohle le ruruhe ebe le fetoha bosoeu bo hlabang, ha phallo ea mali le methapo ea maoto e ntse e tiile. Ho phlegmasia cerulea dolens (mohato o tsoetseng pele oa "leoto le leputsoa"), methapo e tebileng le methapo e koalang ka botlalo; mali a ka tsoa ka leotong, mali a sa tsitsang a nang le oksijene a fetola setho sohle se boputsoa bo bopherese bo boputsoa bo nang le marotholi a mali, 'me khatello e phahameng ea lerata e pshatla methapo ea mali e koalang methapo, e lebisang ho lefu la venous ka mor'a lihora tse ngata haeba e sa ka ea senyeha hanghang.

Hobaneng o sa tlameha ho sila kapa ho hohla leoto le ruruhileng, le bohloko le ka bang le DVT?¶

Ha lesela le leholo la mali le hlaha ka har'a methapo e tebileng ea namane, serope, kapa pelvis, karolo e ka holimo ea lesela leo e bonolo, ea thetheha, 'me hangata e phaphamala ka mokhoa o hlephileng ka har'a mothapo o pharaletseng oa botšehali kapa oa iliac joalo ka boroso e nang le mohatla o lokolohileng. Haeba u silila, u luba, u pikitla, kapa u sebelisa mochini o hatellang seeta leotong ho kokobetsa bohloko ba mesifa, ho pepeta ho ka senya karolo e kholo ea lesela leo. Ka metsotsoana e seng mekae feela, leqeba leo le robehileng le nyolohela ka tlaase ho vena cava, le feta ka lehlakoreng le letona la pelo, ebe le koala methapo e meholo ea matšoafo matšoafong (ebolism e khōlō ea pulmonary), e ka bakang ho tšoaroa ke pelo ka tšohanyetso.

A na u lokela ho phahamisa leoto kapa ho le boloka fatše haeba motho e mong a e-na le phlegmasia cerulea dolens vs. arterial blockage?¶

Ena ke phapang ea bohlokoa ho thuso ea pele ea vascular. Sebakeng se matla sa arterial blockage (moo lesela le koalang mothapo oa botšehali kapa oa popliteal e le hore mali a se ke a kena leotong le lerootho, le tsinyehileng, le batang ka leqhoa), HA U LOKELA ho phahamisa leoto ka holim'a pelo hobane matla a khoheli a hanyetsana le phallo e fokolang ea mali; boloka boemo ba leoto la ischemic kapa bo itšetlehile hanyane. Ka lehlakoreng le leng, ho phlegmasia alba dolens kapa phlegmasia cerulea dolens, methapo ea mali e pompela mali leotong, empa methapo e thibane ka karolo ea 100 lekholong kahoo mali a ke ke a tsoa leotong le pherese le ruruhileng haholo; ho phahamisa leoto ka bonolo holim'a mesamo (likhato tse 15 ho isa ho tse 30 ka holim'a boemo ba pelo) ho sebelisa matla a khoheli ho theola khatello ea venous hydrostatic le ho fokotsa ho ruruha ha phaposi ha u ntse u emetse thrombectomy ea sepetlele.

Ke hobane'ng ha maqeba a maholo a mali a iliofemoral a etsahala ka makhetlo a 3 ho isa ho a 4 ka leoto le letšehali ho feta leoto le letona?¶

Ka sebōpeho sa pelvic ea motho, mothapo o thata, o nang le khatello e phahameng ka ho le letona, o tšela lesapo la bony bohlano la lesapo la mokokotlo. E tsejoang ka hore ke May-Thurner syndrome (iliac vein compression syndrome), ho otla ha methapo e sa khaotseng ho batalatsa mothapo o ka letsohong le letšehali ebe ho etsa marang-rang a ka hare a fibrous ha nako e ntse e ea. Ha sesosa se kang ho ima, ho buuoa, ho felloa ke metsi 'meleng kapa mofetše ho eketsa ho phalla ha mali, maqeba a ka letsohong le letšehali a koaleha habonolo ho feta mothapo o sa hatellehang oa iliac.

U ka tseba phapang joang lipakeng tsa deep vein thrombosis (DVT) le bacterial cellulitis?¶

DVT e tloaelehileng le bacterial cellulitis li ka shebahala li tšoana hobane ka bobeli li baka leoto le tlase le futhumetseng, le ruruhileng, le lepinki le bofubelu le feberu e bobebe. Leha ho le joalo, cellulitis ke tšoaetso ea letlalo la holim'a letlalo (hangata e qalang ho tsoa letlalong le phatlohileng pakeng tsa menoana ea maoto ho tloha leotong la moatlelete kapa letheba) le bakang letlalo le khubelu la mollo, ho ruruha ha sebaka ka tlas'a lengole, li-lymph nodes tse bonolo, le feberu e matla / mohatsela, ha maoto a maoto a ntse a le matla. DVT e ngata haholo e baka ho ruruha ha leoto lohle ho tloha mokokotlong oa groin ho ea fihla leotong, methapo e hlaheletseng ea bokaholimo, bohloko bo tebileng ba mesifa, 'me e ka ba bosoeu bo bosoeu kapa bo boputsoa bo boputsoa. Hobane tse peli li ka shebahala li tšoana esale pele (kapa tsa etsahala hammoho), "venous duplex ultrasound" e potlakileng ke eona feela tsela e sireletsehileng ea ho li arola.

Na phlegmasia cerulea dolen e ka ba letšoao la pele la mofetše o sa lemoheng kapa karabelo ea heparin?¶

Ee. Lithutong tsa bongaka, karolo ea 20 ho isa ho 40 lekholong ea bakuli ba hlaolelang phlegmasia cerulea dolens ba na le "hypercoagulable malignancy" (joalo ka mofets'e oa pancreatic, matšoafo, mala, ovary, kapa hematologic) e ntšang lintho tse bakang leqeba maling. Hape, bakuli ba ileng ba amohela li-heparin mali tse fokolang mali sepetlele nakong ea matsatsi a 5 ho isa ho a 14 a fetileng ba ka hlahisa Heparin-Induced Thrombocytopenia (HIT), e leng mokhoa oa ho itšireletsa mafung moo li-antibodies li bakang ho phatloha ha mali a venous le arterial blood clots; kamehla bolella ngaka ea tšohanyetso haeba mokuli a sa tsoa kena sepetlele e le hore a ka hlahloba lipalo tsa platelet le ho sebelisa li-non-heparin mali tse fokolang mali ha ho hlokahala.

Mehloli le tataiso ea semmuso¶

• ** 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 *, Karolo ea 4.6: Tsamaiso ea Phlegmasia Ceruela Dolens, unfraction ea leqeba le lengata, leqheka le potlakileng ho tsosolosoa, thrombolysis e tsamaisoang ke catheter, le thrombectomy e bulehileng ea venous).
• Society for Vascular Surgery (SVS) & American Venous Forum (AVF, United States): Early Thrombus Removal Strategies for Acute Deep Venous Thrombosis: Clinical Practice Guidelines (urgent pharmacomechanical or surgical thrombectomy bakeng sa litho tse sokelang litho le iliocerulea DV)
• American Heart Association (AHA, United States): Taolo ea Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, le Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement from the American Heart Association (Circulation, immediate endovascular or surgical de surgery-Thurner iliac vein stenting).
• American College of Chest Physicians (CHEST, United States): Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report (lipontšo tsa thrombolysis e tsamaisoang ke catheter le thrombectomy ea venous ea opereishene ka har'a seso se haufi sa venous).
• Setsi sa Sechaba sa Bophelo bo Botle le Tlhokomelo e Ntle (NICE, United Kingdom): Mafu a Venous Thromboembolic: Tlhahlobo, Tsamaiso le Tlhahlobo ea Thrombophilia (NICE Guideline NG158).

Litataiso tse amanang¶

• Pulmonary embolism le deep vein thrombosis (DVT)
• Acute ischemic occlusion, arterial occlusion, le pulseless extremity
• Cellulitis, erysipelas, lymphangitis, red streaking, le abscess sepsis tsoelo-pele.
• Compartment syndrome ea letsoho, leoto, kapa forearm, ho arohana ho thata, le 6 Ps triage
• Necrotizing fasciitis (tšoaetso e jang nama) le lifolakha tse khubelu tsa cellulitis