Use of continuous caudal block to relieve lower-extremity ischemia caused by vasculitis in a child with meningococcemia

Hypothesis: is the skin and tissue loss associated with septic purpura fulminans temperature related? Parallels with the anatomical distribution of frostbite

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.

Free-tissue transfer for limb salvage in Purpura fulminans

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.

The protective effect of brachial plexus palsy in purpura fulminans

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.

Recognition, treatment and complications of meningococcal disease

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.

Topical nitroglycerin and pain in purpura fulminans

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.

Continuous axillary nerve block for chronic pain

Continuous axillary nerve block was used to relieve pain after a chemical burn to the arm in a child on mechanical ventilation after liver transplantation. The analgesia was sufficient to replace parenteral analgesia and allow extubation.

Indications and application of epidural anesthesia in a pediatric population outside the perioperative period

The techniques of spinal and epidural anesthesia have been key components of anesthetic care for the past 100 years. Although commonly used in the operating room, their use in children outside the perioperative period has been limited. The author presents his experience with the use of epidural anesthesia to provide analgesia in five children when parenteral narcotics were ineffective in treating pain associated with burns, sickle cell crisis, trauma, and malignancies. Additionally, the principles and adverse effects of epidural anesthesia are discussed.

Update on anesthesia management for infants and children

This review aims at providing the pediatric surgeon with an update on the most important issues in pediatric anesthesia and the changes that have taken place over the last few years. Many practices, entrenched in tradition, are being modified in the light of research that has provided new knowledge, drugs, and techniques. Pediatric anesthesia requires dedication, a sense of anticipation, meticulous attention to detail, and an individual who derives enormous satisfaction from the pleasure to be had from dealing with these small patients and their families.