1
|
Falsaperla R, Lo Bianco M, Giugno A, Lena G, Sciuto L, Spata F, Guarneri C, Pavone P, Ruggieri M. Neonatal ischemic limb lesions: From etiology to topical nitroglycerine. A case series analysis. Dermatol Ther 2022; 35:e15426. [PMID: 35261118 PMCID: PMC9286834 DOI: 10.1111/dth.15426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 02/06/2022] [Accepted: 03/05/2022] [Indexed: 11/30/2022]
Abstract
Although rare, ischemic lesions in neonates may occur in Neonatal Intensive Care Units (NICUs) secondary to routine procedures and/or medicaments. We present double-center case series, reporting three preterm neonates with ischemic lesions following cardiac arrest and radial blood sampling. The overall outcome after treatment with 2% nitroglycerine (NTG) ointment showed optimal results with no adverse events. The most frequent causes responsible for the onset of such lesions are peripheral arterial catheterization procedures and dopamine extravasation. Our series describe the cardiac arrest as an underestimated cause of onset. Despite the optimal results emerging from the treatment of such lesions with NTG ointment, both in our experience and in the scientific literature, a defined protocol for its use in NICUs is not currently available, hence the need for further studies.
Collapse
Affiliation(s)
- Raffaele Falsaperla
- General Pediatrics and Pediatric Acute and Emergency Unit, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy.,Neonatal Intensive Care Unit, Policlinico "G. Rodolico-San Marco" University Hospital, University of Catania, Catania, Italy
| | - Manuela Lo Bianco
- Post Graduate Programme in Paediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Andrea Giugno
- Post Graduate Programme in Paediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Germana Lena
- Post Graduate Programme in Paediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura Sciuto
- Post Graduate Programme in Paediatrics, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Francesco Spata
- Neonatal Intensive Care Unit, "Giovanni Paolo II" Hospital, Ragusa, Italy
| | - Claudio Guarneri
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Section of Dermatology, A.O.U.P. "Gaetano Martino", University of Messina, Messina, Italy
| | - Piero Pavone
- Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| | - Martino Ruggieri
- Unit of Rare Diseases of the Nervous System in Childhood, Department of Clinical and Experimental Medicine, Section of Pediatrics and Child Neuropsychiatry, University of Catania, Catania, Italy
| |
Collapse
|
2
|
|
3
|
Oram J, Bodenham A. Hypothesis: is the skin and tissue loss associated with septic purpura fulminans temperature related? Parallels with the anatomical distribution of frostbite. Med Hypotheses 2008; 70:1155-9. [PMID: 18221840 DOI: 10.1016/j.mehy.2007.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Accepted: 11/10/2007] [Indexed: 11/26/2022]
Abstract
Purpura fulminans is a life threatening complication of many septic states, most notably meningococcaemia. It can also occur due to congenital deficiency of anticoagulant proteins. The pathophysiology of purpura fulminans is complex and not fully understood, but involves abnormalities of coagulation pathways, damage to vessel walls, and abnormal vasoconstriction which may lead to ischaemia and organ dysfunction. After the acute illness has resolved purpuric lesions may lead to extensive tissue loss and prolonged morbidity. Although vascular beds throughout the body are affected, and lesions can be seen in all areas of the skin, the distribution of permanent lesions is often confined to the peripheries, resulting in amputation of digits, hands and feet, or even limbs. Many pharmacological strategies have been used in attempts to reduce the tissue loss, but as yet none have proved to be consistently safe and effective. The distribution of this tissue loss is remarkably similar to that seen in frostbite, and raises the hypothesis that local temperature may have some contributing effect on the severity of these lesions. Hypothermia is known to be associated with vasoconstriction (in an attempt to preserve core temperature) and abnormalities of coagulation. This generally leads to an anticoagulated state, however the severe vasoconstriction and hypovolaemia associated with the early (pre-resuscitation) phases of acute sepsis results in peripheral skin temperatures approaching ambient. The effect on coagulation at these temperatures is not as well understood, but recent work has suggested increased platelet aggregation, adverse effects on blood rheology and increased intravascular thrombosis at temperatures of 31-34 degrees C. We hypothesise that low temperature leads to worsening of purpuric lesions and that active warming of the peripheries may reduce the tissue loss associated with resolving purpuric illnesses.
Collapse
Affiliation(s)
- John Oram
- Anaesthesia and Intensive Care, Leeds General Infirmary, Gt George St., Leeds LS1 3EX, United Kingdom.
| | | |
Collapse
|
4
|
Varughese M, Koh TH. Successful use of topical nitroglycerine in ischaemia associated with umbilical arterial line in a neonate. J Perinatol 2001; 21:556-8. [PMID: 11774020 DOI: 10.1038/sj.jp.7210567] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Ischaemic changes associated with umbilical arterial cannulation is an important cause of neonatal morbidity in the NICU. We report successful use of topical nitroglycerine in an infant with ischaemic changes over the right buttock following insertion of an umbilical arterial catheter.
Collapse
Affiliation(s)
- M Varughese
- Neonatal Intensive Care Unit, Kirwan Hospital for Women, Townsville, Queensland 4817, Australia
| | | |
Collapse
|
5
|
MacLennan SE, Kitzmiller WJ, Yakuboff KP. Free-tissue transfer for limb salvage in Purpura fulminans. Plast Reconstr Surg 2001; 107:1437-42. [PMID: 11335814 DOI: 10.1097/00006534-200105000-00019] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the "zone of injury." Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.
Collapse
Affiliation(s)
- S E MacLennan
- Division of Plastic, Reconstructive, and Hand Surgery at the University of Cincinnati College of Medicine and Shriners Hospitals for Children-Cincinnati Burns Hospital, Ohio, USA
| | | | | |
Collapse
|
6
|
Abstract
Acute infectious purpura fulminans is reported in a 16-month-old male with a history of posttraumatic asplenia and complete left brachial plexus palsy. This patient developed peripheral necrosis of both lower extremities and the right upper extremity, whereas the left upper extremity was completely spared from ischemia and tissue damage. Amputation of four digits on the right hand and debridement of both lower extremities were required. This patient demonstrated the protective effect of a traumatic sympathectomy, which suggests the requirement of an intact sympathetic reflex in the development of purpura fulminans.
Collapse
Affiliation(s)
- T M Willis
- Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE 68198-5165, USA
| | | | | | | |
Collapse
|
7
|
Abstract
Purpura fulminans (PF) is a haemorrhagic condition usually associated with sepsis or previous infection. Features include tissue necrosis, small vessel thrombosis and disseminated intravascular coagulation. Gram-negative organisms are the commonest cause of the acute infectious type, which is often associated with multi-organ failure. An idiopathic variety, however, is often confined to the skin. The mortality rate has decreased with better treatment of secondary infections, supportive care and new treatments, but it remains a disabling condition often requiring major amputations. We describe two cases and review the various treatments for this condition.
Collapse
Affiliation(s)
- J Nolan
- Department of Anaesthesia, Treliske Hospital, Truro, Cornwall, UK
| | | |
Collapse
|
8
|
Abstract
Meningococcal disease remains a major cause of death in young children. A decrease in mortality requires recognition and treatment of the disease at a number of stages in the illness. Life-threatening meningococcal disease usually presents as septicaemia rather than meningitis. The cardinal feature of meningococcal septicaemia is the purpuric rash. Many parents recognise the rash and seek medical advice because of it. When primary care physicians recognise the rash, the administration of parenteral penicillin may decrease mortality. However, antibacterials are not given promptly if there is no rash or if the disease presents in an atypical form. In hospital, antibacterial therapy with a third-generation cephalosporin should be given. Disease severity needs to be assessed by a valid method, such as the Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS). This can identify those patients who need intensive care and/or might benefit from new therapies. The 2 life-threatening complications are septic shock and meningoencephalitis with raised intracranial pressure. Despite numerous case reports of success with potential new treatments, none has been proven safe and/or effective by controlled trials. Although it is tempting to focus on new treatments, the early recognition of severe meningococcal disease by parents, primary care physicians and junior hospital doctors is equally, if not more, important as a potential means of decreasing mortality.
Collapse
Affiliation(s)
- F A Riordan
- Birmingham Heartlands and Solihull NHS Trust (Teaching), England
| | | |
Collapse
|
9
|
Abstract
Topical nitroglycerin has been previously described as an adjunctive therapy to increase perfusion to areas of purpura affected in purpura fulminans. We report a case of purpura fulminans in which topical nitroglycerin was found to provide analgesia after its application to purpuric lesions. The broader role for the use of topical nitroglycerin in pain management deserves further study and evaluation.
Collapse
Affiliation(s)
- M T Meyer
- Division of Critical Care, Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | | |
Collapse
|
10
|
Kirsch EA, Barton RP, Kitchen L, Giroir BP. Pathophysiology, treatment and outcome of meningococcemia: a review and recent experience. Pediatr Infect Dis J 1996; 15:967-78; quiz 979. [PMID: 8933544 DOI: 10.1097/00006454-199611000-00009] [Citation(s) in RCA: 169] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- E A Kirsch
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas 75235-9063, USA
| | | | | | | |
Collapse
|
11
|
Abstract
Four neonates had resolution of peripheral tissue ischemia after the application of 2% nitroglycerin ointment. A dosage of 4 mm nitroglycerin ointment per kilogram of body weight was applied to two patients with ischemia caused by vasospasm from indwelling radial artery catheterization and to two patients with ischemia resulting from dopamine extravasation. No adverse effects were noted except mild episodes of decreased blood pressure in two of the patients.
Collapse
Affiliation(s)
- A F Wong
- Division of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco 94143-0622
| | | | | |
Collapse
|