Good morning, everyone. Let me just get this set up. I am really excited to be here. Let me just figure out my process here. All right. So I'm here today to talk to you about Anasarka. I have no financial disclosures. Whoops. Here we go. We're going to go back and forth. All right. So let's start by talking about what is Anasarka. And it's a condition of extreme generalized edema that affects the whole body. It is unlike peripheral edema where it's very localized. And when you look at the literature, generally there should be at least 2.5 to 3 liters in our interstitial space to be called Anasarka. And for any of those of you that have cared for someone with Anasarka, it's pretty obvious someone who has Anasarka in that it affects the whole body. So the causes are always from an underlying organ system failure, could be a very extreme immune response and anaphylaxis, and also excess fluid administration. So the contributing factors, though, are what really is affecting the variables that affect the transfer of fluid through the body that is because of the disruption of capillary membrane permeability and those microcirculation pressures, along with the low albumin states. So just real quickly, as you look at the normal distribution of body fluids, you can see that most is intracellular fluid, and then one third is the extracellular. But I want to, on the right-hand side, yes. So your intracellular, of course, any fluid that is within the plasma membranes of the cells, but it's this extracellular fluid is where the interstitial and extravascular space lies. And then you have your intravascular blood flow. So fluid travels across the cell membrane and also travels across the capillary membrane. And when you have this permeability and this disruption, now the fluid pressures become extremely disrupted. And it's a balance of the pressures in our microcirculation which is leading to this very extreme case of generalized edema and anasarco. So as you can see, it's your hydrostatic pressures, your osmotic and oncotic pressures that are affecting the pull of fluid into the intravascular space as well as the fluid back and forth. So this is the key to really understanding anasarco. And the challenges of bedside care are things around what is the appropriate choice of fluids to affect those microcirculation factors, your pressures, while treating the underlying condition that is leading to the capillary permeability and disrupting the transfer. So the choice of fluids is really important. And that's not what my talk will be about today, as you're hearing from others on the group that are addressing that and various other talks during the SCCM conference. But from another perspective of critical care in general, and especially from a nursing perspective, it's this need for strict I&O, being able to fully document and assess and calculate the fluid balance in a very accurate way, balancing the hemodynamics between not only the fluids of choice, the vasopressors of choice, as these patients are generally very critically ill. And then there's nutrition. And as we talk about albumin being a protein that affects your oncotic pressures, the underlying way, as you all know, to treat low albumin states is not always by giving albumin, which may help you in a very acute situation. But it's really the nutrition and the stores of your albumin. And then all of these patients will present with obvious edema, increased weight, and very limited mobility. So this is a patient now that you will have great difficulty in moving. So this is where we're going to offshoot a little bit from what you may have thought you were coming to hear today. But we're going to talk about the bedside challenge of the dermatological issues that can occur as I'm putting a nursing focus on this. And although this is not just a nursing problem of assessment, it's really an interdisciplinary team. But these are giving you just an overall balance of your patient with anisarka and what you may be presented with. So pressure ulcer risk assessment. Just as an example, I use the Braden score, which is a very standard tool that is used as a high validity, high reliability. And in general, a score of 18 says you are at very high risk of skin damage. You can see it's sensory perception, moisture activity, mobility, nutrition, friction, and shear. All of these patients get the highest scores for all of those. And it wouldn't matter which score you would use. This is just the Braden. But when you look at multiple other, there would be no doubt that this patient is at very high risk. But there's other factors. It's their length of stay, their map, the vasopressors, the sedatives, the postural changes are all contributing to this risk of pressure ulcer development. So what's really important in a patient with anisarka is medical device friction and pressure ulcer development that can occur. And most commonly, it would be through your ET tubes, trach ties. They show retention sutures here, but it could be any type of suture. NG tubes, oxygen tubing, CPAP masks, BiPAP masks, O2 sat probes, even tubing. And because of the extreme edema, the skin is much more fragile and much more likely to break down, even from very short times of pressure. So in general, and these guidelines are all coming from the National Pressure Injury Advisory Panel in general, and you can surely read them, but it's making sure the device is needed. And it's giving such a meticulous attention because, like I said, the time of pressure for pressure injury to develop is much quicker than with someone who would not have this more fragile skin. And rotating. Even something as simple as an O2 sat probe on a finger or an ear has to be rotated. And some would say every shift, or at a minimum daily. And looking to have some type of cushioning under all of these devices to prevent these types of injury. So then there's eye care. And you can see that there is a high risk for corneal damage, infection, vision loss. And as a standard in critical care, we all pay attention to this. But again, in someone who has anosarca, you could have where the, gosh, I say this incorrectly every time, but the laga pathalmos is when you can actually see it's the middle picture, seeing that scleral type edema and the eye can't even close. So the key here is you need to keep the eyes moist. You need to use the ointment, the artificial tears every four hours. And you may need to do passive closure of the eyelid by using a special gel. You could use a polyethylene film. You could use a paper MedPort tape. But eye protection is really critical. Then there's the lips. And the lips, especially in someone who is intubated, and the pressure from the ET tube, as you saw. And there's many devices where the ET tube may rotate very easily. Whereas we're all probably using tape also very frequently. But the key is you have to lift that ET tube up in some way so that it's not directly putting pressure, because these patients will have significant damage. And then there's extremity care. And of course, it's elevate. So I say elastic bandages or compression as appropriate, because it can be appropriate, but it would have to be done in a very good way that you're not actually creating more pressure by uneven distribution of a wrap or a compression. And getting help from physical occupational therapy may be needed in extreme cases for that. And offloading the heels is also really important. And through the guidelines, the recommendation is you put vertical pillows on each leg, and then you put a horizontal under both of them so you really get that full lift of the heel. And then sacrum care. And these patients are at risk for not only pressure injury, but moisture injury, fungal infection. And there can be a constant oozing of fluid in all of the body areas. So, and we'll talk a little bit here at the end, the specialty mattresses that may be appropriate, but moisture barrier creams, anti-fungal creams, anti-yeast creams, incontinent management, incontinent management, and turning schedules are extremely important. As we said, that the immobility is very common in these patients also. And then there's skinfold moisture management, which is really prevalent. This is showing you an example of a knee where you have edema, makes the skin taut and fragile. It makes a very inflammatory rash environment for possible bacterial growth. So the idea is to pad the area, not rub. And again, it's the antibacterial creams, fungal, yeast creams, moisture barrier creams. And again, going back to the specialty mattresses, which I believe is the next. So I'm not here to advocate for any one brand of a specialty bed, but there really is, if resources are available, these patients above probably any patient need some type of specialty support. And the support can be for pressure redistribution, but it's also this continuous low air loss fluidized air, which is really the key to causing water evaporation and actually removing moisture from the patient. And that would really be the key for this type of patient. And they come in various bed mattress overlays, cushions, pads, all of that, and have many, many features. So I know my time is up, and I'll just conclude with that anisarc is a condition of extreme generalized edema. You have to identify and treat the underlying causes and the contributing factors. And meticulous skin and eye care is critical as a priority care. So thank you so much.

Anasarca

generalized edema

fluid balance

critical care

nursing strategies