Four limb amputations due to peripheral gangrene from inotrope use - Case report and review of the literature

Relationship Between Symmetrical Peripheral Gangrene Patients and Using Vasopressors in the Intensive Care Unit

Symmetrical peripheral gangrene (SPG) is a rare yet severe condition characterized by peripheral ischemic lesions without significant vascular occlusion. Its clinical presentation includes peripheral cyanosis, mottling, and symmetrical ischemia of distal limbs, often progressing to gangrene. Recent years have seen a rise in SPG cases, with mortality rates ranging from 40% to 90%. The condition is associated with systemic diseases, such as sepsis, vasculitis, and coagulopathy. DIC frequently complicates SPG, reflecting a disturbed procoagulant-anticoagulant balance and depletion of natural anticoagulants. While vasopressor therapy, particularly high-dose administration, has been implicated in SPG pathogenesis due to sustained vasoconstriction or idiosyncratic responses, recent evidence suggests it may not be the underlying cause. Studies indicate a low incidence of ischemic limb necrosis associated with high-dose vasopressors, with DIC and shock liver potentially explaining limb ischemia instead. The characteristic temporal interval between the onset of shock liver and limb ischemic necrosis suggests a more complex pathophysiology. The role of infectious agents, such as bacteria and viruses, in SPG pathogenesis is under investigation, with both direct vascular invasion and immune-mediated mechanisms proposed. Diagnosis involves ruling out other causes of acral gangrene through clinical examination, laboratory tests, imaging studies, and biopsy. Treatment strategies aim to halt disease progression, eliminate causative factors, and prevent complications. While anticoagulants, vasodilators, and adjunctive therapies like hyperbaric oxygen show promise, the efficacy of interventions varies, emphasizing the need for individualized management. Notably, hemoadsorption has emerged as a promising treatment, demonstrating significant improvement in SPG cases. Amputation remains a last resort option in irreversible cases. Early recognition and multidisciplinary management are crucial for improving outcomes. Further research is needed to better understand SPG's etiology and develop effective treatments through collaborative efforts.

Endovascular Perfusion Augmentation for Critical Care Decreases Vasopressor Requirements while Maintaining Renal Perfusion

BACKGROUND

Ischemia reperfusion injury causes a profound hyperdynamic distributive shock. Endovascular perfusion augmentation for critical care (EPACC) has emerged as a hemodynamic adjunct to vasopressors and crystalloid. The objective of this study was to examine varying levels of mechanical support for the treatment of ischemiareperfusion injury in swine.

METHODS

Fifteen swine underwent anesthesia and then a controlled 30% blood volume hemorrhage followed by 30 min of supra-celiac aortic occlusion to create an ischemia-reperfusion injury Animals were randomized to standardized critical care (SCC), EPACC with low threshold (EPACC-Low), and EPACC with high threshold (EPACC-High). The intervention phase lasted 270 min after injury Hemodynamic markers and laboratory values of ischemia were recorded.

RESULTS

During the intervention phase, SCC spent 82.4% of the time avoiding proximal hypotension (>60 mm Hg), while EPACC-Low spent 97.6% and EPACC-High spent 99.5% of the time avoiding proximal hypotension, P  < 0.001. Renal artery flow was statistically increased in EPACC-Low compared with SCC (2.29 mL/min/kg vs. 1.77 mL/ min/kg, P  < 0.001), while renal flow for EPACC-High was statistically decreased compared with SCC (1.25 mL/min/kg vs. 1.77 mL/min/kg, P  < 0.001). EPACC animals required less intravenous norepinephrine, (EPACC-Low: 16.23mcg/kg and EPACC-High: 13.72 mcg/kg), compared with SCC (59.45 mcg/kg), P = 0.049 and P = 0.013 respectively.

CONCLUSIONS

Compared with SCC, EPACC-High and EPACC-Low had decreased norepinephrine requirements with decreased frequency of proximal hypotension. EPACC-Low paradoxically had increased renal perfusion despite having a mechanical resistor in the aorta proximal to the renal arteries. This is the first description of low volume mechanical hemodynamic support in the setting of profound shock from ischemia-reperfusion injury in swine demonstrating stabilized proximal hemodynamics and augmented distal perfusion.

Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia

Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.

The effect of topical nitroglycerin on symmetrical peripheral gangrene in a pediatric patient

Symmetrical peripheral gangrene is a rare condition associated with significant morbidity and mortality. The use of topical nitroglycerin may have a role in improving patient outcomes and opens a new area for future research regarding the use of topical nitroglycerin in SPG.

Effects of Norepinephrine Infusion on Cutaneous Surface Temperatures of the Distal Extremities

OBJECTIVES

The etiology of vasopressor-induced digital necrosis is poorly understood, but the skin changes resemble those of frostbite, and it is known from experience that patients taking vasopressors have decreased digital temperatures. We aimed to examine the effects of norepinephrine use on surface temperatures of the distal extremities because there have been no studies examining this relation.

METHODS

Surface temperatures of all digits, palms, and soles were measured using an infrared thermometer in patients receiving different rates of norepinephrine infusion in the intensive care unit and compared with those not receiving any vasopressors.

RESULTS

A total of 101 measurements from 41 unique individuals were obtained. Temperature gradients between the core and the fingertips were consistently more pronounced in those receiving norepinephrine compared with those not receiving norepinephrine and increased with increasing rates of norepinephrine infusion, except with high-dose norepinephrine. Temperature gradients were more pronounced in the toes.

CONCLUSIONS

Norepinephrine use was associated with greater core-to-fingertip temperature gradients and were more pronounced in the toes compared with the fingers.

Reconstruction of Basic Hand Function by a Free Osteocutaneous Spare-Part Flap From the Lower Leg After Septicemia: A Case Report

Background: Spare-part surgery is widely accepted and offers an option in extremely traumatized patients for reconstructive maneuvers. Standardized techniques are lacking, and the therapy needs to fit the patient's clinic. Materials and Methods: In a woman with necrosis of almost all extremities due to septic infection, we used the lower leg as a free osteocutaneous flap to reconstruct a basic hand function after amputation. The fibula segment was buried alongside the remaining first metacarpal bone. On the hand stump, 2 short metacarpals were lengthened using the remaining 2 metacarpals as osteovascular on-top plasties. The flap was microsurgically anastomosed end-to-side to the ulnar artery. After 3 months, the buried fibula was trimmed to the necessary thumb length and fixed to the local metacarpal I stump. Secondary procedures were performed to deepen the first web space. Results: The patient is now able to manage her daily life. Also, she is able to put on her prosthesis on both legs and walk without aids. Conclusions: To our knowledge, this is the first description of successful microvascular transfer of an osteocutaneous free flap from an amputated lower leg of this size and could present a valuable technique for other cases.

Management of vasopressor induced ischemia

Purpose

We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis.

Methods

We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients.

Results

Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases.

Conclusion

Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of "life over limb," and may be safely performed with acceptable outcomes.

Incidence and associated risk factors for limb amputation among sepsis survivors in South Korea

Purpose

Peripheral gangrene (PG) is a known complication requiring limb amputation among sepsis survivors; however, its incidence and associated risk factors remain controversial. We aimed to examine the incidence of limb amputation among sepsis survivors, and to investigate factors independently associated with limb amputation.

Methods

In this population-based cohort study, data obtained from the South Korean national health insurance service database between 2015 and 2016 were analyzed. A sepsis survivor was defined as someone having survived > 90 days after initiation of treatment for sepsis.

Results

Of 19,906 sepsis survivors, 163 (0.8%) had undergone surgical limb amputation. In a multivariable model, male sex (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.26–2.40; P = 0.001), dopamine infusion (OR 1.78, 95% CI 1.22–2.60; P = 0.003), epinephrine infusion (OR 2.04, 95% CI 1.30–3.20; P = 0.002), continuous renal replacement therapy (OR 3.34, 95% CI 2.01–3.20; P < 0.001), diabetes mellitus (DM) without chronic complication (OR 1.73, 95% CI 1.19–2.51; P = 0.004), DM with chronic complication (OR 3.49, 95% CI 2.32–5.26; P < 0.001), and peripheral arterial disease (OR 6.79, 95% CO 3.70–12.46; P < 0.001) were associated with a higher incidence of limb amputation among sepsis survivors.

Conclusions

In South Korea, 0.8% of sepsis survivors underwent limb amputation for the treatment of PG. Furthermore, the incidence of limb amputation was higher among the sepsis survivors having some underlying diseases (DM and peripheral arterial diseases) or receiving certain vasopressor treatments (epinephrine and dopamine).

Electronic supplementary material

The online version of this article (10.1007/s00540-020-02858-9) contains supplementary material, which is available to authorized users.

Endovascular Perfusion Augmentation for Critical Care: Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock

BACKGROUND

The resuscitation of patients in shock is materially intensive and many patients are refractory to maximal therapy. We hypothesized that partial inflation of an intra-aortic balloon, termed Endovascular Perfusion Augmentation for Critical Care (EPACC), would minimize material requirements while improving physiologic metrics.

METHODS

Swine underwent a 25% controlled bleed and 45 min of complete aortic occlusion to create a severe ischemia-reperfusion shock state. Animals received either standardized critical care (SCC) composed of IV fluids and norepinephrine delivered through an algorithmically controlled platform or EPACC in addition to SCC. Physiologic parameters were collected, and blood was sampled for analysis. Primary outcomes were total IV fluids and average MAP during the critical care phase. Differences (P < 0.05) were measured with t test (continuous data) and Wilcoxon rank-sum test (ordinal data).

RESULTS

There were no differences in baseline characteristics. There were no differences in the maximum lactate; however, animals in the EPACC group had a higher average MAP (EPACC 65 mmHg, 95% confidence interval [CI], 65-66; SCC 60 mmHg, 95% CI, 57-63; P < 0.01) and remained within goal MAP for a greater period of time (EPACC 95.3%, 95% CI, 93.2-97.4; SCC 51.0%, 95% CI, 29.5-72.6; P < 0.01). EPACC animals required less IV fluids when compared with the SCC group (EPACC 21 mL/kg, 95% CI, 0-42; SCC 96 mL/kg, 95% CI, 76-117; P < 0.01). There were no differences in final lactate. Animals in the EPACC group had a higher final creatinine (EPACC 2.3 mg/dL, 95% CI, 2.1-2.5; SCC 1.7 mg/dL, 95% CI, 1.4-2.0; P < 0.01), but there were no differences in renal cellular damage on histology (P = 0.16).

CONCLUSION

Using a swine model of severe shock, the addition of EPACC to SCC significantly reduced fluid resuscitation requirements and improved blood pressure. This is the first description of a new therapy for patients in refractory shock or in resource-limited settings.

Terlipressin infusion for prevention of vasoplegic syndrome in patients treated with angiotensin II receptor antagonist undergoing coronary artery bypass graft surgery: a randomized controlled study

Background and objectives

Preoperative use of renin angiotensin system antagonists has been considered an independent risk factor for development of vasoplegic syndrome. The aim of this study was to demonstrate efficacy of prophylactic terlipressin infusion for prevention of vasoplegic syndrome in patients treated with angiotensin receptor blocker undergoing coronary artery bypass graft surgery.

Patients and methods

One hundred patients on angiotensin II receptor antagonist [losartan] scheduled for coronary artery bypass surgery were enrolled into this prospective randomized controlled study. Anesthetic technique, surgical technique, and cardiopulmonary bypass management were standardized for all patients. With the start of rewarming, patients were randomized to receive either terlipressin infusion 1.3 μg.kg−1.hour−1, or normal saline infusion. Incidence of vasoplegic syndrome score was used as primary outcome. Hemodynamic parameters, inotropic score, and vasopressor dependency index were used as secondary outcome.

Results

Incidence of vasoplegic syndrome was significantly lower in terlipressin group compared to placebo group. Norepinephrine was required in 2 patients of terlipressin versus 15 patients of placebo group. Mean arterial blood pressure was significantly higher in terlipressin group compared to placebo group (81.7 ± 18.5 versus 69.3 ± 20.2 at 60 min after weaning from CBP). Cardiac index was significantly lower in terlipressin group compared to placebo group (2.52 ± 1.48 versus 3.2 ± 1.55). Systemic vascular resistance was significantly higher in terlipressin group compared to placebo group (2438.09 ± 735.13 versus 1575.05 ± 753.54). Inotropic score and vasopressor dependency index were significantly lower in terlipressin group compared to placebo group.

Conclusion

Prophylactic terlipressin infusion could prevent development of vasoplegic syndrome in patients treated with angiotensin II receptor antagonist undergoing coronary artery bypass graft surgery.

Trial registration

PACTR, PACTR201804003249274, Registered 25/03/2018—retrospectively registered, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=3249.

Utilization of bone scan and single photon emission computed tomography on amputation planning in acute microvascular injury: Two cases

The use of single photon emission computer tomography (SPECT/CT) in acute vascular injury is not well documented. SPECT/CT combines the anatomic detail of computer tomography with the functional vascular perfusion of photon emission to determine the viability of osseous structures and surrounding soft tissue. The superimposed imaging provides the practitioner with a reliable anatomic image of viability of a specific anatomic area following insult or injury. We present two cases, bilateral lower extremity frostbite, and symmetric peripheral gangrene in which this imaging modality provided guidance for surgical intervention with adequate predictability and results.

Suspected symmetrical peripheral gangrene in a cat

Case summary

An 8-year-old female spayed domestic shorthair cat was presented for evaluation of non-specific lethargy and pain. It was diagnosed with septic shock secondary to wounds on the dorsum and required treatment with multiple vasopressors for circulatory support. During the course of hospitalization, it was weaned from vasopressors but subsequently developed symmetric skin necrosis and sloughing of the paws on the right thoracic and right pelvic limbs leading to a presumptive diagnosis of suspected symmetrical peripheral gangrene (SPG).

Relevance and novel information

This report documents the first case of suspected SPG in a cat that received multiple vasopressors for treatment of septic shock. Early recognition, cessation of vasopressor therapy and surgical management are necessary for treatment of this condition.

Rare case of symmetrical peripheral gangrene due to septic shock, disseminated intravascular coagulation and inotropic use

Introduction

Symmetrical peripheral gangrene (SPG) is a rare syndrome defined by the peripheral ischemic lesion of two or more extremities in the absence of major vascular obstructive disease.

Presentation of case

A 45yo woman, admitted in intensive care unit due to urinary septic shock, in need of high doses of amines, developed cold extremities with acrocyanosis that rapidly progressed to gangrene. Laboratory analysis revealed increased inflammatory parameters, liver shock, thrombocytopenia, prolonged coagulation times, increased D-Dimers and isolation of Acinetobacter baumanni in urine culture. An intravenous vasodilator was initiated with clinical benefits. After improvement and delimitation of the lesions, the patient underwent the amputation of the distal phalanges of the 2nd, 3rd and 4th fingers of the right hand and the toes of both feet.

Discussion/conclusion

Even though there is no consensus regarding SPG treatment, consequences should be mitigated, particularly when vasodilators are used, in order to avoid major amputation.

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Symmetrical Peripheral Gangrene (SPG), although rare, must be immediately recognized because of its harmful consequences.

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SPG has a high mortality rate and a high percentage of the survivors have at least one limb amputated.

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The necessary measures should be taken in a timely manner to mitigate consequences.

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Treatment of the infection, the avoidance of vasopressors, and the use of LMWH and vasodilators, seem to be important to reduce major amputation.

Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene

Symmetrical peripheral gangrene (SPG) is rare but devastating complication which is characterized by symmetrical ischemic change of the distal extremities. In this report, we describe our management protocol for SPG, focusing on surgical approaches. Between January 2007 and February 2016, 10 thoracodorsal artery perforator (TDAP) free flaps were performed in 6 patients with SPG. Three patients were male and mean age was 56 (range, 44-69) years. All the patients were in shock. The causes of shock were sepsis in 4 cases, respiratory arrest in 1 case, and hypovolemia in 1 case. Eight transmetatarsal amputations and 2 Lisfranc amputations were performed. Flap sizes ranged from 7 × 11 cm to 25 × 15 cm. There were 3 cases of partial necrosis of the flap: two healed conservatively with dressings and one required skin graft. Three of the patients were later able to walk independently at Functional Ambulation Classification (FAC) level 6, one patient could walk independently on level surfaces at FAC level 5, and 2 could walk independently using walking aids, classified at FAC level 4. The average follow-up period was 18 (range, 6-54) months. In patients with SPG, minimal bone amputation and foot salvage with TDAP flaps were successful. Separate reconstruction of bone and soft tissue had good outcomes.

Amputation of multiple limbs caused by use of inotropics: Case report, a report of 4 cases

RATIONALE

We present 4 cases of symmetrical peripheral gangrene (SPG) associated with use of inotropic agent to elevate blood pressure. SPG is a relatively rare phenomenon characterized by symmetrical distal ischemic damage that leads to gangrene of 2 or more sites in the absence of large blood vessel obstruction, where vasoconstriction rather than thrombosis is implicated as the underlying pathophysiology. We present 4 SPG cases of the multiple limbs amputation, associated with inevitable use of inotropic agents.

PATIENT CONCERNS

Inotropic agents including dopamine and norepinephrine are used frequently in the treatment of hypotension, and its effectiveness in treating shock is firmly established. However, it can be caused peripheral gangrene by prolonged administration of high dose inotropics, inducing the constant contraction of the peripheral blood vessels.

DIAGNOSIS

These 4 patients had different clinical histories and background factors, but each experienced sepsis. The level of amputation is determined by the line of demarcation in concert with considerations of the biomechanics of stump stability, weight bearing, and ambulation.

INTERVENTIONS

After recovering of general conditions and completion of demarcation, these 4 patients underwent the amputation of multiple limbs.(bilateral amputations of upper extremities or bilateral amputations of lower extremities).

OUTCOMES

In each patient, there was no additional amputation caused by extension of SPG, and the rehabilitation with appropriate orthosis was performed. Treatment of underlying disease were continued too.

LESSONS

It is important to alert the possibility of amputations, according to the use of inevitable inotropics. We recommended the careful use of the inotropic agents to the physicians in treating septic shock.