Limb edema in patients with advanced disease — a pilot study of compression therapy combined with diuretics
Abstract
Introduction. Management of edema due to advanced disease is seldom recognized in palliative care. The
purpose of this pilot study was to assess the effectiveness and tolerance of conservative edema therapy.
Material and methods. Prospective analysis of limb volumes, edema symptom burden and quality of life
(QoL) in 119 patients diagnosed with edema was performed. Eighteen patients in their last days of life
complaining of edema were treated by limb elevation, supportive (palliative) bandaging, manual lymphatic
drainage, Kinesio Taping and/or controlled subcutaneous needle drainage. Forty-six with longer prognosis
were treated by one-week multilayer short-stretch limb bandaging and then re-evaluated. Twenty-eight
of them with venous congestion resistant to previously given diuretics received additionally furosemide
infusion in hypertonic saline. Subgroups analysis of the patients with diuretic therapy and primary lymphatic
congestion was performed.
Results. Within 46 patients re-evaluated the reduction of limb volume was accompanied by a decrease
of edema symptom intensity and an improvement of QoL. Subgroup analysis revealed both volume and
symptomatic improvement, equally effective in cases with suspected lymphatic congestion or when diuretics
were added.
Conclusion. Edema of advanced disease irrespective of the lymphatic component can be effectively
managed conservatively with short–stretch limb bandaging. In cases resistant to oral diuretic fluid overload,
parenteral hypersaline furosemide addition to the compression may be the safe therapeutic option
enhancing treatment tolerance.
Keywords: advanced diseasediureticsedemafurosemidepalliative carequality of life
References
- Shah MG, Cho S, Atwood JE, et al. Peripheral edema. Am J Med. 2002; 113(7): 580–586.
- Olsson Möller U, Stigmar K, Beck I, et al. Bridging gaps in everyday life - a free-listing approach to explore the variety of activities performed by physiotherapists in specialized palliative care. BMC Palliat Care. 2018; 17(1): 20.
- Cobbe S, Nugent K, Real S. Pilot Study: The Effectiveness of Complex Decongestive Therapy for Lymphedema in Palliative Care Patients with Advanced Cancer. J Palliat Med. 2018; 21(4): 473–478.
- Gradalski T. Edema of Advanced Cancer: Prevalence, Etiology, and Conservative Management-A Single Hospice Cross-Sectional Study. J Pain Symptom Manage. 2019; 57(2): 311–318.
- Reid C, Gibbins J, Burcombe M, et al. The use of the edmonton symptom assessment scale to measure symptoms at the end of life. BMJ Supportive & Palliative Care. 2012; 2(Suppl 1): A29.2–A29.
- URL https://www R-project org. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. (2017).
- Gold Standards Framework. http://www. goldstandardsframework.org.uk/ (15.05.2018).
- Stemmer R. Ein klinisches Zeichen zur Früh- und Differentialdiagnose des Lymphödems. Vasa. 1976; 5: 261–262.
- Real S, Cobbe S, Slattery S. Palliative Care Edema: Patient Population, Causal Factors, and Types of Edema Referred to a Specialist Palliative Care Edema Service. J Palliat Med. 2016; 19(7): 771–777.
- Moffatt CJ, Doherty DC, Franks PJ, et al. Community-Based Treatment for Chronic Edema: An Effective Service Model. Lymphat Res Biol. 2018; 16(1): 92–99.
- Towers A, Hodgson P, Shay C, et al. Care of palliative patients with cancer-related lymphoedema. J Lymphoedema. 2010; 5(1): 72–80.
- Beck M, Wanchai A, Stewart BR, et al. Palliative care for cancer-related lymphedema: a systematic review. J Palliat Med. 2012; 15(7): 821–827.
- Müller M, Klingberg K, Wertli MM, et al. Manual lymphatic drainage and quality of life in patients with lymphoedema and mixed oedema: a systematic review of randomised controlled trials. Qual Life Res. 2018; 27(6): 1403–1414.
- Jacobsen J, Blinderman CD. Subcutaneous lymphatic drainage (lymphcentesis) for palliation of severe refractory lymphedema in cancer patients. J Pain Symptom Manage. 2011; 41(6): 1094–1097.
- Clemens KE, Jaspers B, Klaschik E, et al. Evaluation of the clinical effectiveness of physiotherapeutic management of lymphoedema in palliative care patients. Jpn J Clin Oncol. 2010; 40(11): 1068–1072.
- Gradalski T, Ochalek K, Rybak D. Lymphedema or rather end-of-life edema? J Palliat Med. 2018; 21(5): 585.
- Cheville AL, Andrews K, Kollasch J, et al. Adapting lymphedema treatment to the palliative setting. Am J Hosp Palliat Care. 2014; 31(1): 38–44.
- Gradalski T, Ochalek K, Kurpiewska J. Complex Decongestive Lymphatic Therapy With or Without Vodder II Manual Lymph Drainage in More Severe Chronic Postmastectomy Upper Limb Lymphedema: A Randomized Noninferiority Prospective Study. J Pain Symptom Manage. 2015; 50(6): 750–757.
- Andriessen A, Apelqvist J, Mosti G, et al. Compression therapy for venous leg ulcers: risk factors for adverse events and complications, contraindications - a review of present guidelines. J Eur Acad Dermatol Venereol. 2017; 31(9): 1562–1568.
- Gradalski T. Diuretics Combined With Compression in Resistant Limb Edema of Advanced Disease-A Case Series Report. J Pain Symptom Manage. 2018; 55(4): 1179–1183.
- Won S, Youb S. Loop diuretics in Clinical Practice. Electrolyte Blood Press. 2015; 13: 17–21.
- Tuttolomondo A, Di Raimondo D, Bellia C, et al. Immune-Inflammatory and Metabolic Effects of High Dose Furosemide plus Hypertonic Saline Solution (HSS) Treatment in Cirrhotic Subjects with Refractory Ascites. PLoS One. 2016; 11(12): e0165443.
- De Vecchis R, Esposito C, Ariano C, et al. Hypertonic saline plus i.v. furosemide improve renal safety profile and clinical outcomes in acute decompensated heart failure: A meta-analysis of the literature. Herz. 2015; 40(3): 423–435.
- Palazzuoli A, Ruocco G, Ronco C, et al. Loop diuretics in acute heart failure: beyond the decongestive relief for the kidney. Crit Care. 2015; 19: 296.
- Marenzi G, Lauri G, Grazi M, et al. Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure. J Am Coll Cardiol. 2001; 38(4): 963–968.
