Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020 May 15. Epub ahead of print.
“Cytokine storm has been implicated in COVID-19 and associated with severe infection , allowing for a focus on cytokine and other proinflammatory markers. It is suspected that the extensive release of cytokines causing a proinflammatory state may play a role in thrombus formation . Tanaka et al. reported that IL-6 could activate the coagulation cascade , increasing the risk of thrombosis and complication. Our patient did have an elevated level of IL-6, in addition to hypertension and elevated CRP, which are all independent risk factors for increased severity of COVID-19 infection .
Helms et al. found that 50 of 57 patients had positive lupus anticoagulant and antiphospholipid (aPL) antibodies , both of which have been associated with thrombotic complications.”
Shackford SR. (2018). Venous Disease. In: Abernathy’s Surgical Secrets, 7th ed.: p. 357.
What is the difference between phlegmasia alba dolens and phlegmasia cerulea dolens?
“These two entities occur following iliofemoral venous thrombosis, 75% of which occur on the left side presumably because of compression of the left common iliac vein by the overlying right common iliac artery (May-Thurner syndrome). Iliofemoral venous thrombosis is characterized by unilateral pain and edema of an entire lower extremity, discoloration, and groin tenderness. In phlegmasia alba dolens (literally, painful white swelling), the leg becomes pale. Arterial pulses remain normal. Progressive thrombosis may occur with propagation proximally or distally and into neighboring tributaries. The entire leg becomes both edematous and mottled or cyanotic. This stage is called phlegmasia cerulea dolens (literally, painful purple swelling). When venous outflow is seriously impeded, arterial inflow may be reduced secondarily by as much as 30%. Limb loss is a serious concern and aggressive management (i.e., venous thrombectomy, catheter-directed lytic therapy, or both) is necessary.”
Hornor MA, Duane TM, Ehlers AP, et al. ACS Guidelines for the Perioperative Management of Antithrombotic Medication. J Am Coll Surg. 2018 Nov;227(5):521-536.e1.
Full-text for Emory users.
Khan S, et al. Incidence, Risk Factors, and Prevention Strategies for Venous Thromboembolism after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol. 2019 Jul;26(7):2276-2284.
Full-text for Emory users.
“A policy change was made in February 2010 to discharge all patients post-CRS/HIPEC with 14 days of additional pharmacothromboprophylaxis, which consisted of low-molecular-weight heparin in 327 of 447 (73%) cases (Supplemental Figure). The 60-day VTE rate decreased from 10.2 to 4.9% after this policy was instituted (p = 0.10, Fig. 2).”
“This policy is in accordance with established guidelines indicating the need for a total of 4 weeks of pharmacothromboprophylaxis in high-risk patients after abdominal or pelvic surgery for cancer. [2,21] Given that patients have an average length of stay of nearly 2 weeks, discharging them on 14 days of pharmacothromboprophylaxis fulfills this duration.”
This continuing education offering is part of Medscape‘s series, Contemporary Topics in Antithrombotic Therapy. (You’ll need a Medscape account to view and/or accrue CME credit.)
Authors: Gary E. Raskob, PhD; Steven B. Deitelzweig, MD; Alex C. Spyropoulos, MD
CME Released: 12/22/2019; Valid for credit through: 12/22/2020
“…[W]e are going to talk about VTE, its importance in the hospital population of patients admitted with medical illness, and how we can work to reduce the burden of disease from this important condition.
About half of all hospitalizations in the United States are for medical illnesses, such as heart failure, pneumonia, stroke, and so on. Of these patients, about half of them are at risk for VTE and about 25% are at high risk for VTE.
Those who develop VTE tend to have pretty severe consequences, and these consequences persist beyond hospitalization.”
One discussion this week involved the effect of abdominal insufflation on deep vein flow.
Reference: Yang C, Zhu L. Coagulation and deep vein flow changes following laparascopic total extraperitoneal inguinal hernia repair: a single-center, prospective cohort study. Surgical Endoscopy. 2019 Feb 11. doi: 10.1007/s00464-019-06700-6.
Summary: The authors observed morphologic change of the iliac vein during TEP procedure. The iliac vein was almost completely collapsed, which not only impaired venous return from the lower extremities but also caused vein distention. The acute distention caused vessel wall damage due to mechanical disruption of the endothelial lining. Vessel wall damage is one of Virchow’s triad in the pathogenesis of thrombosis.
In this study, activated coagulation and impaired deep venous flow implied that the TEP procedure had a certain degree of potential risk for DVT during the early postoperative period.
One discussion this week included the patient safety indicators for pulmonary embolism.
Reference: AHRQ Quality Indicators. PSI #12: Postoperative Pulmonary Embolism or Deep Vein Thrombosis. 2009. Retrieved from https://www.qualityindicators.ahrq.gov on May 17, 2019.