EDEMA

About 20% of terminally ill patients develop ankle edema (excess fluid in tissue spaces).

Ankle swelling reduces mobility, due to:

• Weight gain
• Heavy legs
• Ill-fitting shoes.

There are usually several causes acting together:

• Fluid retention (steroids, NSAIDs)
• Immobility (gravitational)
• Abdominal pressure (hepatomegaly)

• Protein deficiency (low serum albumin)

Other causes include:

• Unilateral deep vein thrombosis
• IVC obstruction (renal cancer)
• Heart failure (raised jugular venous pressure)

Management options:

1. Stop or change drugs if possible
2. Exercise
3. Compression stockings
4. Leg elevation
5. Diuretics
6. Improved nutrition

1. Consider stopping or changing drugs that cause fluid retention (steroids, NSAIDs, estrogens).

2. Exercise reduces edema because the calf muscle acts as a pump (“the second heart”), improves circulation and reduces venous back-pressure. Walking is best but exercises can help. If a patient is either walking or has his legs well-elevated, edema does not occur. Sitting still for long periods worsens edema.

3. Compression stockings will reduce edema. They are worn all day and removed at night. They must be full length to the top of the thigh. (Below-knee stockings cause discomfort and pressure behind the knee.) Compression stockings can be helpful for active patients, especially if diuretics cannot be used (prostatism or frequency due to bladder tumor, for example). They are difficult to put on, however, and should not be used by weak patients or where edema is unimportant.

4. Leg elevation is often recommended, but it is ineffective if it involves “putting your feet up on a stool”. This can worsen gravitational edema by discouraging activity. Leg elevation is effective only when the legs are raised to the level of the right atrium (ankle edema is always improved after sleeping in bed). It can be effective if the patient lies down from 30 to 60 minutes with pillows under his legs.

5. Diuretics are the mainstay of treatment, but diuretics cause a diuresis and for very ill, weak patients the urinary frequency may be very troublesome. (“I’d rather have the swollen ankles.”) Diuretics should be given early in the day to avoid frequency at night, and should be used cautiously in men with prostatic symptoms (poor stream, difficulty starting). (see Diuretics)

6. Increased dietary protein is helpful only if serum albumin levels are low, if the diet has been poor, and if the patient still has a good appetite.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.