by David G. Hicks
Treating cases that have edema is a challenge routinely encountered by today’s embalmer. It is not unusual to have a person whose features are grossly distorted by the presence of edema, while other cases exhibit edema only in the extremities. In either circumstance edema can cause a lot of problems, but with some basic techniques it is manageable.
There are basically two types of edema with which the embalmer will be faced: intercellular (pitting) and intracellular (hard). According to Taber’s Cyclopedic Medical Dictionary, edema is defined as a “localized or generalized condition in which the body tissue contains an excessive amount of tissue fluid”. Both types cause swelling of the tissue. According to Mayer, edema is said to be present when more than a 10% increase in overall body moisture has occurred. Causes for edema can include increased permeability of the capillary walls, increased capillary pressure, and retention of sodium, venous obstruction and heart failure.
Intercellular edema, or pitting edema as it is more commonly referred to, is the most frequent type encountered by the embalmer. Pitting edema can be gravitated out of the area and usually responds well to specialized arterial injection techniques and solutions, while intracellular or hard edema is not as common and does not respond well to arterial injection.
I would recommend that both common carotids be used (Restricted Cervical Injection or RCI) if the person has not been autopsied. The RCI involves raising both the right and left common carotid arteries. Arterial tubes are then inserted superiorly on the right and left, and inferiorly on the right (some embalmers insert a tube down the left as well and then use a “Y” injector). Typically, the left common carotid artery is clamped or tied on the inferior portion thus restricting the cervical region from receiving fluid. The cannulae directed superiorly are left open so that any fluid reaching the head via the vertebral or costo-cervical arteries can drain.
The embalmer has greater control over the amount and strength of the fluid used in embalming the torso and head if both the right and left common carotids are used. If the embalmer thinks that it is necessary, the left internal jugular vein can be raised as well. The RCI technique is especially useful if the head does not have any edema. It allows a very strong solution to be injected into the torso and extremities, while a weaker solution can be used for the head.
When edema is present only in the legs, the femoral arteries and veins can be raised and the proper solution injected into that localized area.
When the body has been autopsied each area – legs, arms and head – can be injected with an appropriate solution. The key to success on autopsied cases is delaying suturing for as long as possible. By doing this, the embalming fluid has time to pull the edema out of the interstitial spaces. The drainage will continue to collect in the open cavity where it can be aspirated later. I have witnessed the thoracic/ abdominal cavity fill up with drainage at least twice in the course of an 8 to 10 hour time frame. This was fluid that was able to be removed by delaying the suturing. It would have continued to collect whether the body had been sutured closed or not.
Intermittent injection is another method I recommend on cases with edema. Intermittent injection is achieved by injecting a half of a gallon of embalming fluid into the body and then the embalming machine is turned off. As the edema moves into the venous system, due to osmosis, blood will continue to drain from the deceased. After twenty minutes, injection is resumed and the process is repeated. Intermittent injection will take longer but the results will be worth the extra effort and time.
In addition, the embalmer may also find it beneficial to elevate the extremities (legs and arms) above the heart allowing gravity to do the rest. I have done this on numerous occasions with good results. If the body is autopsied, the fluid will collect in the cavity as mentioned before. If the case is not autopsied, the embalmer can create channels in the lower extremities by inserting the trocar through the obturator foramen. This channeling allows the edema to gravitate out of the legs and into the abdominal region where it can be aspirated out.
Arterial solution is another area of focus. It is important to remember that to remove the edema a strong solution must be mixed in the tank. We often mix fluid based on the strength of the primary solution and do not factor in the secondary dilution of the embalming fluid mixed with the added fluid from the edema present in the body. I would suggest a 25 index arterial fluid mixed at a minimum strength of 2%. In extreme cases a 2.5% to 3 % strength solution would not be too strong. A chart depicting the various indexes and ounces per gallon can be found in Mayer’s Embalming History, Theory and Practice. Also, check the bottles of arterial fluid as certain manufacturers have printed the percentage strength dilutions on the bottle.
I also believe that specialized edema-eliminating fluids (usually composed of some inorganic salt) help to reduce edema. Most fluid manufacturers suggest that 8 to 16 ounces per gallon be used in addition to the arterial fluid. I know of embalmers who use Epsom salts (Magnesium Sulfate) in place of edema fluids, but from my experience I have found it to be very hard on embalming machines and for that reason I do not recommend it.
Cases exhibiting extreme edema are challenging. As professional embalmers we need to remember that time is a key element in determining how much edema is removed. It will take time to raise other vessels and it will take time to position the body with the extremities elevated, but as professionals we must give our time to each and every embalming case. Whatever type of case you may encounter I challenge you to try something different or vary a technique because you never know when you might learn something new. FBA
David G. Hicks is Regional Sales Representative for Pierce with over twenty-one years of industry experience. A licensed funeral director and embalmer, David also was Chair of Embalming Sciences at Cincinnati College of Mortuary Science and taught at Mid-America College of Funeral Service. David can be reached at 513.384.7846 or [email protected].