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Classification of Edema.

Discussion in 'Internal Medicine and IM Subspecialties' started by RussianJoo, Dec 16, 2008.

  1. RussianJoo

    RussianJoo Useless Member 10+ Year Member

    Jun 7, 2004
    Rock City
    Can someone list the guidelines or classifications for classifying edema as +1, +2,+3, or +4. I tried using Bates guide to physical exam, I tried using uptodate, wikipedia and google and couldn't find anything. Does anyone know this? can you list a source of where you got this information as well?

    thank you for your help.
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  3. drjitsu

    drjitsu 2+ Year Member

    Aug 31, 2008
    As far as I know, this is a subjective scale as to the severity of the pitting. That being said, I've seen it listed as follows:

    1+ Mild pitting, slight indentation, no perceptable swelling of the leg
    2+ Moderate pitting, indentation subsides rapidly
    3+ Deep pitting, indentation remains for a short time, leg looks swollen
    4+ Very deep pitting, indentation lasts a long time, leg is very swollen

    So, in general, you'll hear some say that this is a scale of how deep this pitting is, and others will say this is how long the pitting remains. I've even seen some time scales such as 3-4 sec = 1+, etc... Either way, the important points are: it's subjective and only used for pitting edema. (Yes, I've seen a chart say "1+ nonpitting edema")
  4. RussianJoo

    RussianJoo Useless Member 10+ Year Member

    Jun 7, 2004
    Rock City
    thank you. I know that this scale is only used for pitting edema. however just like other scales there should be a standard cut off ie everyone who reads 2+ pitting edema should think the same thing, right? that's the whole point of a scale like that. Also there must have been a paper published or this mentioned in a text book. Sure most of us have heard this classification being used but it couldn't have just spread by word of mouth.

    What I saw someon mention on a nursing forum, so I don't know of accurate this is and they didn't list a source but.

    1+ is if the pitting lasts 0 to 15 sec
    2+ is if the pitting lasts 16 to 30sec
    3+ is if the pitting lasts 31 to 60sec
    4+ is if the pitting lasts >60sec

    what do you guys think? it sounds good but a source would be nice to have..
  5. obiwan

    obiwan Junior Member 10+ Year Member

    Mar 26, 2006
    while we're on the subject of edema, can someone clarify the difference betn pitting and non-pitting edema. i've never really read anything so far in med school that differentiates betn the 2.
  6. drjitsu

    drjitsu 2+ Year Member

    Aug 31, 2008
    So, in a very basic sense, pitting edema will indent when pressure is applied to the edematous area, usually over the tibia when talking about the lower extremity. Nonpitting edema will not indent.

    That being said, classic causes of pitting edema, ie lymphedema, is soft and will pit early in the course. It is not until the chronic stages in which the area gets that woody feel from the tissues becoming fibrotic that the edema becomes nonpitting.

    The other main cause of nonpitting edema is myxedema. This does not pit because it's not fluid being displaced into the interstitial space, rather it's an accumulation of increased amounts of mucopolysaccharides in the dermis, and thus will not pit.

    So, I hope that answers your question. I think the most important thing here is that although pitting vs nonpitting certainly may speak as to etiology, the early stages of nonpitting etiologies will indeed pit. (Except for myxedema, but it's relatively rare, and the other stigmata of thyroid dz should be apparent at this stage.) So, instead of making a differential based on pitting vs nonpitting, I think it's a good idea to base a differential on bilateral vs. unilateral distribution, in conjunction with , as always, a good history. (Obviously a history of CHF, renal dz, or thyroid pathology will influence your differential.)

    Hope that helps.
  7. phassett74

    phassett74 New Member 5+ Year Member

    Apr 18, 2005
    Personally, I think Sapira's has the best description and rationale for this:

    Here's another for you:

    Hope this helps. Seems as though nurses and paramedics seem to put a great deal of stock into the "alchemy" of grading pitting edema, but until I see some guidelines or normalization, I will defer to the far more insightful approach of Sapira's.

    Ultimately, I really don't believe grading it matters, as much as accurately appreciating and assessing the patient in the context of their disease process.
  8. dragonfly99

    dragonfly99 5+ Year Member

    May 15, 2008
    that is a good question
    I agree most with phasset.
    What's most important is that you examine the patient well enough to find the edema and be able to describe it and generate a differential diagnosis. Typically you'll have the ability to follow the patient (i.e. in clinic or the hospital ward) and one of the important things is whether the edema changes/improves with your treatment. You'll find that there are a lot of things on physical exam that are not able to be made totally "objective", such as describing skin rashes, edema and other things. There are a lot of gray areas in internal medicine and classifying edema by whether it takes 8 seconds vs. 10.5 seconds to go away isn't something I'd ever really do on the wards. It's just not very practical. Typically, I'd describe 1+ edema as "Trace"/barely able to be seen. 4+ is when the legs are really, really visibly swollen and it leaves a huge mark when you put your finger there that lasts a long time (like half a minute or something?). Nobody really times it. 2+ and 3+ are somewhere in between. If you want to be sure how you're doing on fixing the edema, you could measure the leg daily (I mean circumference) ....usually only do that with massive edema though.
  9. RussianJoo

    RussianJoo Useless Member 10+ Year Member

    Jun 7, 2004
    Rock City
    thanks guys. after chatting with my program director about this i'll have to agree with drjitsu, phasset and Dragon, and my program director. he said that basically it's subjective and there are some guidlines, he has heard the guidline that has both deepth and time in it to be most accurate. there's one i read that head 4mm, 6mm, 8mm and more than 8mm quoted with other discriptions with it for 1+, 2+, 3+, 4+ edema. but what he basically said no one really pays attention to the number but the discription is more important, like what location it covers and anything else that will describe it.

    thanks I just thought there would be something more objective but i guess there isn't.
  10. lord_jeebus

    lord_jeebus 和魂洋才 Moderator Physician 10+ Year Member

    Jul 12, 2003
    If your goal is to really record what you're observing, it's better to record how many mm of pitting you get, and where you see it.

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