How are phlegmasia alba dolens (PAD) and phlegmasia cerulea dolens (PCD) treated?

Updated: Aug 13, 2018
  • Author: Cassius Iyad Ochoa Chaar, MD, MS, FACS; Chief Editor: Vincent Lopez Rowe, MD  more...
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Answer

Treatment of phlegmasia alba dolens (PAD) or phlegmasia cerulea dolens (PCD) should be initiated as soon as the diagnosis is suspected. The patient is started on anticoagulation, and the involved extremity is elevated. Intravenous (IV) resuscitation is administered if there is significant fluid sequestration and the patient appears to have intravascular fluid depletion, as manifested by tachycardia, hypotension, and decreased urine output.

Heparin administration is initiated with an IV bolus of 80-100 U/kg, followed by continuous infusion at a rate of of 15-18 U/kg/hr.  The activated partial thromboplastin time (aPTT) should be monitored, with a goal in the range of 2.0-2.5 times the laboratory reference range. Platelet counts should be monitored to allow early detection of heparin-induced thrombocytopenia. Heparin drip is preferred because it has a shorter half-life and can be rapidly titrated in the event of bleeding or need for surgical intervention. The goal of early anticoagulation is to halt thrombus propagation and prevent pulmonary embolism (PE).

Low-molecular-weight heparins (LMWHs) have been found to be safe, effective, and convenient for use in PCD and result in shorter hospital stays because they can be used on an outpatient basis. [12, 13]

The oral factor Xa inhibitors rivaroxaban and apixaban are approved for treatment of deep venous thrombosis (DVT) and can potentially be used for treatment of phlegmasia. Alternative anticoagulation agents are longer-acting than heparin and should be started when patient is clinically stable and there is no concern for additional interventions.

If patients improve with elevation and anticoagulation and do not progress to critical limb ischemia, compression therapy with stockings or elastic bandages can help decrease edema and swelling and may be used as tolerated. Many physicians have the patient fitted for a prescription stocking while the limb is still severely edematous. This is inadvisable; instead, the patient may use nonprescription stockings or an elastic bandage, in combination with elevation, to minimize edema before being fitted for a prescription stocking.

Patients are treated with anticoagulation for at least 6 months.


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