Management of Anasarca
The treatment of anasarca requires a combination of diuretic therapy and multicomponent compression bandaging, with consideration of ultrafiltration through continuous renal replacement therapy for refractory cases. 1
Diagnosis and Assessment
- Daily weight monitoring under standardized conditions (same time of day, post-void, prior to eating, same clothing, flat surface) to track fluid status 1
- Identify underlying cause:
First-Line Treatment
Diuretic Therapy
- Loop diuretics (furosemide, torsemide, bumetanide) as initial therapy
- Addition of metolazone for enhanced diuresis in resistant cases 5
- Metolazone is specifically indicated for edema accompanying congestive heart failure, renal diseases including nephrotic syndrome, and states of diminished renal function
- Sequential nephron blockade with combination of loop and thiazide diuretics for resistant cases
Fluid and Sodium Restriction
- Limit sodium intake to <2g/day
- Restrict fluid intake in hyponatremic patients
Second-Line Treatments
For Refractory Cases
- Albumin infusion (particularly in patients with severe hypoalbuminemia) followed by loop diuretics 1
- Ultrafiltration or dialysis when diuretics fail, especially in patients with:
- Renal failure
- Severe heart failure
- Diuretic resistance 6
For Specific Etiologies
- Cardiac: Optimize heart failure therapy (ACE inhibitors, beta-blockers, aldosterone antagonists)
- Hepatic: Consider paracentesis for tense ascites
- Inflammatory/Vasculitis: Immunosuppression with glucocorticoids (prednisolone 1 mg/kg/day) 1
- Consider cyclophosphamide or rituximab for vasculitis-related anasarca 1
Monitoring
- Regular assessment of vital signs, especially blood pressure
- Daily weights to track fluid status
- Electrolytes, BUN, and creatinine monitoring (particularly with aggressive diuresis) 1
- Watch for complications:
- Skin breakdown
- Pressure ulcers
- Cellulitis
- Electrolyte abnormalities
Special Considerations
- Discontinue medications potentially contributing to edema (calcium channel blockers, minoxidil, NSAIDs) 2, 3
- Physical therapy and compression bandaging for peripheral edema
- Elevation of extremities when possible
- For patients on immunosuppression: monitor complete blood counts, renal function, and drug-specific toxicities 1
Treatment Pitfalls to Avoid
- Excessive diuresis leading to intravascular volume depletion and prerenal azotemia
- Inadequate monitoring of electrolytes during aggressive diuresis
- Failure to identify and treat the underlying cause
- Relying solely on diuretics without addressing the primary disease process
The management of anasarca requires addressing both the underlying cause and the fluid overload, with careful monitoring to prevent complications from both the condition and its treatment.