A. The patient with any of the following conditions may develop EDEMA.

Differentiate the physiologic explanation/s for edema as well as the characteristics/distribution of the edema, should it develop. (maximum of 20%) Six factors can contribute to the formation of edema: 1. increased hydrostatic pressure; 2. reduced oncotic pressure within blood vessels; 3. increased tissue oncotic pressure; 4. increased blood vessel wall permeability e.g. inflammation; 5. obstruction of fluid clearance via the lymphatic system; 6. changes in the water retaining properties of the tissues themselves. Raised hydrostatic pressure often reflects retention of water and sodium by the kidney. Generation of interstitial fluid is regulated by the forces of the Starling equation . Hydrostatic pressure within blood vessels tends to cause water to filter out into the tissue. This leads to a difference in protein concentration between blood plasma and tissue. As a result the oncotic pressure of the higher level of protein in the plasma tends to suck water back into the blood vessels from the tissue. Starling's equation states that the rate of leakage of fluid is determined by the difference between the two forces and also by the permeability of the v essel wall to water, which determines the rate of flow for a given force imbalance. Most water leakage occurs in capillaries or post capillary venules, which have a semi-permeable membrane wall that allows water to pass more freely than protein. (The protein is said to be reflected and the efficiency of reflection is given by a reflection constant of up to 1.) If the gaps between the cells of the vessel wall open up then permeability to water is increased first, but as the gaps increase in size permeability to protein also increases with a fall in reflection coefficient. Changes in the variables in Starling's equation can contribute to the formation of edema either by an increase in hydrostatic pressure within the blood vessel, a decrease in the oncotic pressure within the blood vessel or an increase in vessel wall permeab ility. The latter has two effects. It allows water to flow more freely and it reduces the oncotic pressure difference by allowing protein to leave the vessel more easily.
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1. Congestive heart failure (5%) A rise in hydrostatic pressure occurs in cardiac failure.CHF happens when the heart cannot pump blood properly to all parts of the body. heart is weakened and its pumping action is impaired If one or both of the lower c hambers of the

heart lose the ability to pump blood effectively, the blood can accumulate in the limbs, causing edema. This serious condition is the result of the heart's inability to pump blood throughout the body, causing a backup that seeps from blood v essels into other tissues. The water-logged cells cause a type of swelling called "edema," which usually pools in the ankles, feet and legs, as gravity pulls the blood down and the heart has trouble pumping it back up. When the right side of the heart star ts to fail, fluid collects in the feet and lower legs. As the heart failure becomes worse, the upper legs swell and eventually the abdomen collects fluid ( ascites). Weight gain accompanies the fluid retention and is an excellent measure of how much fluid is being retained.

2. Renal failure (5%) - patients with kidney disease may not be able to eliminate enough fluid and sodium from the blood. This results in more pressure on the blood vessels, which causes some of the liquid to leak out. Kidney disease patients with edema will generally have swelling around their legs and eyes. The edema of kidney disease can cause swelling in the lower legs and around the eyes. One of the most common problems associated with renal disease is edema, which is when fluid collects in the body and causes swelling. Edema can create discomfort. It can also be an early symptom of renal disease. Therefore, it is important to understand how it relates to kidney function and how it is treated. Features Edema is caused by small blood vessels in the body leaking fluid. The kidney's response to this occurrence is to retain water and sodium. When this happens the small blood vessels get a message from the brain that there is excess fluid in the body, which causes the blood vessels to release even more. The cycle begins and soon the fluid becomes trapped in the body tissue, which causes swelling. Edema can happen anywhere in the body. However, the most common areas are the hands, arms, feet, legs, chest and face Renal Disease and Edema The most common causes of edema in the case of renal disease is an impairment of kidney function or a heavy loss of protein in the urine. Impairment of the kidney's function can be caused by many things including genetic malformation of the kidneys, blockages that can include cancers, benign tumors or scar tissue and loss of function due to disease. When the edema is caused by protein levels in the urine, it is called nephrotic syndrome. This syndrome creates a reduction in albumin (urine proteins). The kidneys receive a message that the body's blood supply is lacking volume, which triggers an attempt to

retain salt to build more volume. The result is excess fluid being stored in tissue which causes swelling. Significance Some cases of edema caused by renal disease create little more than some localized discomfort and temporary tissue deformity, but there are other side effects of edema that that can interfere with daily function or create additional medical problems. Edema can affect the legs and interfere with walking. The skin that is over the swollen tissues can also become itchy and painful. The limbs that swell due to edema can become stiff and uncomfortable In addition to th e physical discomforts of edema, several medical problems can occur. The swelling can create a decrease in blood circulation as well as cause the arteries and veins to lose some of their flexibility and elasticity. Muscles and joints can also become stiff and difficult to use. Edema can also cause a higher risk for skin ulcers due to the skin breaking down.

3. Nephrotic syndrome (3%)

Damage to the capillaries in the kidneys (glomeruli) that filter waste and excess fluids from the blood can result in nephrotic syndrome. Among the many symptoms of nephrotic syndrome is an insufficient level of blood albumin, which leads to edema. A fall in osmotic pressure occurs in nephrotic syndrome. Although a low plasma oncotic pressure is widely cited for the edema of nephrotic syndrome, most physicians note that the edema may occur before there is any significant protein in the urine ( proteinuria) or fall in plasma protein level. Fortunately there is another explanation available. Most forms of nephrotic syndrome are due to biochemical and structural changes in th e basement membrane of capillaries in the kidney glomerulae, and these changes occur, if to a lesser degree, in the vessels of most other tissues of the body. Thus the resulting increase in permeability that leads to protein in the urine can explain the ed ema if all other vessels are more permeable as well. Interstitial oedema is a common clinical expression of nephrotic syndrome. Expansion of the interstitial compartment is secondary to the accumulation of sodium in the extracellular compartment, due to an imbalance between oral or parenteral sodium intake and urinary sodium output, along with alterations of fluid transfer across capillary walls.

Sodium retention and edema are common features of nephrotic syndrome that are classically attributed to hypovole mia and activation of the renin angiotensinaldosterone system. However, numbers of clinical and experimental findings argue against this underfill theory. In this review we analyze data from the literature in both nephrotic patients and experimental model s of nephrotic syndrome that converge to demonstrate that sodium retention is not related to the renin angiotensinaldosterone status and that fluid leakage from capillary to the interstitium does not result from an imbalance of Starling forces, but from c hanges of the intrinsic properties of the capillary endothelial filtration barrier. We also discuss how most recent findings on the cellular and molecular mechanisms of sodium retention has allowed the development of an efficient treatment of edema in neph rotic patients. Most sodium-retaining states are associated with high blood pressure but not with development of edema or ascites. Edema formation in NS results from the asymmetry of extracellular volume expansion brought about by sodium retention: the vas cular volume is not, or only slightly, modified, whereas water and solutes accumulate in the interstitium. Distribution of fluid between vascular and interstitium compartments is governed by fluid exchanges across the capillary wall and by lymphatic draini ng. Capillary filtration capacity is increased almost twofold in nephrotic patients [ 34]. This fluid leakage is governed by several parameters according to Starlings law:

4. Severe burns (3%) the skin reacts to a burn by retaining fluid, causing localized swelling. A layer of protein -rich edema fluid develops between the eschar (zone of coagulation) and the per fused, heat -injured micro vessels as a result of increased (heat and mediator -induced) micro vascular permeability. The leak is most prominent in the first 8 -12 hours but can persist for days. In superficial burns, the edema actually physically separates viable and non-viable tissue, producing blisters, so that mechanical cleaning can remove the dead tissues. In deep second-degree and third -degree burns, the edema occurs throughout the injured tissue. However, the necrotic dermis remains physically adherent to the sub dermal space and requires sharp dissection (debridement) to remove the dead tiss ue or the process of necrolysis must occur. This process is deleterious due to the risk of infection and degree of tissue inflammation, as well as absorption of dead tissue. The degree of tissue edema is dependent on the amount of resuscitation fluid given and the vascular pressures perfusing the area. One of the obvious acute features of cutaneous thermal injury is the swelling of the involved tissue. This swelling is caused by a fluid shift from circulating plasma. Along with the evolution of intravenous fluid therapy in trauma and surgery, the

implementation of such therapy to burn victims has improved survival. Edema generation aggravated by fluid therapy may, however, represent a source of increased morbidity. This paper presents a review of the literat ure on postburn edema generation, focusing mainly on fluid physiology. It is well documented that fluid is lost from the circulation into burned tissue because of a moderate increase in capillary permeability to fluid and macromolecules and a modest increa se in hydrostatic pressure inside the perfusing microvessels. Recently it was discovered that a very negative interstitial pressure develops in thermally injured skin. This pressure constitutes a strong suction adding markedly to the edema

generating effe ct of increased capillary permeability and pressure. Mainly as a result of the systemic inflammatory reaction with liberation of inflammatory cytokines, histamine, complement, and a host of other mediators. These cause a disruption in the normal capillay b arrier by changing vascular membrane permeability locally and systemically. Thus intravascular fluid leaks into the interstitium. This process becomes even more significant when the burned pt is fluid rescusitated and equilibration between intravascular an d interstitial spaces occurs. Edema at the site of burned tissue also occurs as a result of heated and denatured proteins being present that increase the oncotic pressure in the interstitial spacewhich draws more intravascular fluid in. Burns cause what is called the inflammatory reaction, so different cells rush in aid in protection (the immune response) , different things are secreted from various cells types which cause water to rush to 1 - cool area-2-provide a degree of protection 3 etc...so edema is ju st excess fluid and it is protective in nature that why the skin blisters in 2nd degree burns. It has cooling effect etc... Burns are devastating injuries that can cause more than just damaged skin. In fact, damage can extend into your capillaries, or the tiny blood vessels that run throughout your body. These vessels can become porous, allowing blood and other fluid to leak into your tissue. This is called edema. Doctors must battle edema while still keeping patients fully hydrated so that they can recover from their injuries. Explosion accidents can cause internal and external harm as well as property damage. If your explosion accident was caused by a faulty propane tank or another product defect, you may be entitled to financial compensation to help you w ith your medical bills and other expenses. For more information on recovering from a serious burn injury, contact us today for a free information packet.

5. Hepatic failure (3%) A fall in osmotic pressure occurs in nephrotic syndrome and liver failure such as cirrhosis, which causes scarring of the liver. This affects liver function, which causes the secretion of hormones and fluid -regulating chemicals to change. People with cirrhosis of the live r also have increased pressure within the portal vein - a large vein that carries blood from the intestines, spleen and pancreas into the liver. The problems can lead to fluid retention in the legs and ascites (abdominal cavity). Cirrhosis is scarring of the liver from various causes, which can obstruct blood flow through the liver. People with cirrhosis can develop pronounced swelling in the abdomen (ascites) or in the lower legs (peripheral edema). These conditions can change the concentration of protein in the blood, affecting fluid movement in and out of the tissues. In advanced liver disease, the liver is enlarged and fluid may build -up in the abdomen.

6. Pregnancy (3%) during pregnancy the woman releases hormones which encourage the body to retain fluids . Pregnant women tend to retain much more sodium and water than women who are not pregnant. When a woman is pregnant her face will typically swell, as will her hands, lower limbs and feet.

When the woman is resting in a reclined position the enlarged ute rus occasionally compresses the inferior vena cava, causing obstruction of both femoral veins, leading to edema.

A pregnant woman's blood is hypercoaguble (clots more easily), raising the risk of deep venous thrombosis (DVT), a cause of edema. Eclampsia, which results from pregnancy induced hypertension ( high blood pressure ), can also cause edema. Pregnant women retain extra fluid. Swelling commonly develops in the hands, feet, and face, especially near the end of pregnancy. Swelling during pregnancy is not necessarily a sign of preeclampsia It's normal to have a certain amount of swelling during pregnancy because you're reta ining more water. Changes in your blood chemistry also cause some fluid to shift into your tissue.

In addition, your growing uterus puts pressure on your pelvic veins and your vena cava (the large vein on the right side of the body that carries blood from your lower limbs back to the heart). The pressure slows the return of blood from your legs, causing it to pool, which forces fluid from your veins into the tissues of your feet and ankles. During pregnancy, your blood volume increases by about 50 percent. Your body is producing and retaining more fluids when you are pregnant. This can result in fluid retention, which results in swelling.

As your baby grows, more pressure is put on the veins in your legs. The vena cava is the large vein that returns blood to the heart from the limbs. The pressure on the vena cava from the growing uterus slows the flow of blood and this can result in swelling of the feet and legs. As the uterus enlarges, it presses down on the main veins to the legs. This reduces the flow of blood returning to the heart, which pushes the water into the tissues into the legs and feet. If you suffer from high blood pressure, as many women do during pregnancy, additional water can be pushed into the body tissues. If you have high blood pressure, your doctor will closely monitor your condition for signs of preeclampsia. Contributing to your discomfort are increased levels of the hormone progesterone, which cause the kidneys to retain more sodium during pregnancy. The extra salt in your body holds water and leaves you feeling bloated, the same way you feel before your period