Management and Treatment of Anasarca
The management of anasarca requires aggressive diuretic therapy combined with multicomponent compression bandaging, with consideration of ultrafiltration through continuous renal replacement therapy for refractory cases. 1
Definition and Pathophysiology
Anasarca is generalized, massive edema characterized by widespread swelling of the skin and subcutaneous tissues, affecting the entire body including extremities, abdomen (ascites), and sometimes causing pleural and pericardial effusions. It represents the most severe form of edema and indicates significant fluid retention.
Diagnostic Assessment
- Daily weight monitoring: Perform under standardized conditions (same time of day, post-void, before eating, same clothing, flat surface) 1
- Laboratory evaluation:
- Serum albumin, total protein
- Renal function (BUN, creatinine)
- Liver function tests
- Urinalysis for proteinuria
- Electrolytes
- Identify underlying cause:
- Cardiac (heart failure)
- Renal (nephrotic syndrome, acute kidney injury)
- Hepatic (cirrhosis, liver failure)
- Nutritional (severe hypoalbuminemia)
- Inflammatory/immune (vasculitis)
- Medication-induced (e.g., gemcitabine) 2
Treatment Algorithm
Step 1: Address the Underlying Cause
- Cardiac: Optimize heart failure treatment
- Renal: Treat nephrotic syndrome or kidney disease
- Hepatic: Manage liver disease
- Inflammatory: Consider immunosuppression for vasculitis-related anasarca 1
Step 2: Diuretic Therapy
- Loop diuretics: First-line treatment
- Furosemide: Start with 40-80mg IV twice daily, titrate as needed
- Consider continuous infusion (5-10mg/hour) for resistant cases
- Add thiazide diuretics for synergistic effect in resistant cases
- Metolazone 2.5-10mg daily
- Potassium-sparing diuretics may be added
- Spironolactone 25-100mg daily
Step 3: Albumin Replacement (for severe hypoalbuminemia)
- Indications: Serum albumin <2.5 g/dL with poor response to diuretics 3
- Administration:
- Combined approach: Administer albumin followed by loop diuretics to enhance diuresis
Step 4: Physical Measures
- Multicomponent compression bandaging for extremities 1
- Elevation of affected limbs
- Salt restriction: <2g sodium daily
Step 5: For Refractory Cases
- Ultrafiltration/dialysis:
- Consider continuous renal replacement therapy
- Continuous flow peritoneal dialysis has shown efficacy in pediatric patients with anasarca and ARDS 4
- Paracentesis for tense ascites
- Thoracentesis for symptomatic pleural effusions
Special Considerations
Cardiac Anasarca
- Optimize preload and afterload reduction
- Consider inotropic support for low cardiac output
- Monitor for pulmonary edema during albumin administration
Renal Anasarca
- Careful monitoring of renal function during diuresis
- Adjust diuretic dosing based on response and renal function
- Consider nephrologist consultation for severe or refractory cases
Hepatic Anasarca
- Monitor for hepatorenal syndrome during diuresis
- Careful sodium and fluid restriction
- Consider transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites
Nutritional Support
- Optimize protein intake while maintaining appropriate fluid and sodium restrictions
- Consider nutritional supplementation for malnourished patients
Monitoring
- Daily weights to assess fluid status
- Intake and output measurements
- Regular electrolyte monitoring (especially potassium, sodium, magnesium)
- Renal function tests
- Blood pressure monitoring (risk of hypotension with aggressive diuresis)
Complications and Pitfalls
- Electrolyte abnormalities: Hypokalemia, hyponatremia, hypomagnesemia
- Acute kidney injury: From excessive diuresis or underlying disease progression
- Hypotension: Particularly with aggressive diuresis or albumin administration
- Skin breakdown: Due to severe edema, requires meticulous skin care
- Thrombotic events: Increased risk due to immobility and underlying conditions
Prognosis
Prognosis depends largely on the underlying cause and response to therapy. Postoperative anasarca is associated with poor outcomes, with studies showing higher Clavien-Dindo complication grades in affected patients 5. Risk factors for poor outcomes include age >60 years, low albumin levels, and elevated leukocyte counts 5.