Symmetric peripheral gangrene

Symmetrical peripheral gangrene caused by urosepsis: Case reports and literature review

RATIONALE

Symmetrical peripheral gangrene (SPG) is a serious and rare complication in patients with urosepsis, characterized by distal limb symmetry impairment.

PATIENT CONCERNS

In this study, 3 cases of SPG caused by urosepsis were reported, and the Chinese and English literature on SPG caused by urosepsis was reviewed. The demographic, clinicopathological, treatment, and follow-up data of the patients were summarized and analyzed.

DIAGNOSIS

SPG was diagnosed with clinical symptoms.

INTERVENTIONS

We conducted urological invasive surgery, administered anti-infective therapy, implemented fluid resuscitation and blood product transfusion, provided mechanical ventilation support, optimized myocardial contractility, administered heparin and B vitamins, utilized papaverine for vasodilation, performed hemodialysis and plasma exchange, peripheral skin warming along with other treatment modalities.

OUTCOMES

Two patients died and 1 patient underwent autoamputation.

LESSONS

Our cases and literature review demonstrate that timely and accurate diagnosis, effective infection control, correction of hypoperfusion, organ function support, early management of disseminated intravascular coagulation, avoidance of premature amputation, and multidisciplinary comprehensive treatment are crucial for the successful treatment of SPG caused by urosepsis.

The Epidemiology of Extremity Threat and Amputation after Vasopressor-Dependent Sepsis

Rationale: Extremity threat and amputation after sepsis is a well-publicized and devastating event. However, there is a paucity of data about the epidemiology of extremity threat after sepsis onset. Objectives: To estimate the incidence of extremity threat with or without surgical amputation in community sepsis. Methods: Retrospective cohort study of adults with Sepsis-3 hospitalized at 14 academic and community sites from 2013 to 2017. Vasopressor-dependent sepsis was identified by administration of epinephrine, norepinephrine, phenylephrine, vasopressin, or dopamine for more than 1 hour during the 48 hours before to 24 hours after sepsis onset. Outcomes included the incidence of extremity threat, defined as acute onset ischemia, with or without amputation, in the 90 days after sepsis onset. The association between extremity threat, demographics, comorbid conditions, and time-varying sepsis treatments was evaluated using a Cox proportional hazards model. Results: Among 24,365 adults with sepsis, 12,060 (54%) were vasopressor dependent (mean ± standard deviation age, 64 ± 16 years; male, 6,548 [54%]; sequential organ failure assessment [SOFA], 10 ± 4). Of these, 231 (2%) patients had a threatened extremity with 26 undergoing 37 amputations, a risk of 2.2 (95% confidence interval [CI], 1.4-3.2) per 1,000, and 205 not undergoing amputation, a risk of 17.0 (95% CI, 14.8-19.5) per 1,000. Most amputations occurred in lower extremities (95%), a median (interquartile range) of 16 (6-40) days after sepsis onset. Compared with patients with no extremity threat, patients with threat had a higher SOFA score (11 ± 4 vs. 10 ± 4; P < 0.001), serum lactate (4.6 mmol/L [2.4-8.7] vs. 3.1 [1.7-6.0]; P < 0.001), and more bacteremia (n = 37 [37%] vs. n = 2,087 [26%]; P < 0.001) at sepsis onset. Peripheral vascular disease, congestive heart failure, SOFA score, and norepinephrine equivalents were significantly associated with extremity threat. Conclusions: The evaluation of a threatened extremity resulting in surgical amputation occurred in 2 per 1,000 patients with vasopressor-dependent sepsis.

Change of the Pattern of the Demographic Characteristics of the Patients with Endocarditis: Clinical Case of Infectious Endocarditis in Man with Injectible Drug Dependence, Complicated with Pneumonia and Peripheral Necroses of Feet, Arms, Nose (Own Clinical Observations and Experience of Education in State and English Language)

Infectious endocarditis is multisystem disease, which is the result of the infection (usually bacterial) of endocardial heart surface. Despite of the latest medical achievements in diagnostics and treatment, infectious endocarditis is still a disease with high mortality rate and severe complications. During last decades in developed countries there are obvious changes of demographic characteristics of the patients with infectious endocarditis, namely increasing of aged patients with degenerative valvular diseases, of patients with anamnesis of invasive manipulations and procedures. Beside with well known risk factors (artificial valves and implanted heart devices), there are increasing roles of injectible drug-dependence, human immunodeficiency virus and wide contact with health protection system as predisposing factors for infectious endocarditis. The article contains literature data of the main populational risk groups of infectious endocarditis. Clinical case of severe (fatal) infectious endocarditis in patient with injectible drug dependence is submitted. Special features of the case are peripheral dry necroses of feet, arms, nose, which are very close to the description of symmetrical peripheral gangrene. This rare disorder was first described by Hutchinson in 1891 in 37-year old man, who had gangrene of fingers, hands and ears after shock. Symmetrical peripheral gangrene can be induced by different infection and non-inflection causes. The majority of these cases are connected to the treatment of cardiogenic shock with disseminated intravascular coagulation. Submitted description of the case of symmetrical peripheral gangrene in patient with infectious endocarditis will be useful for different medical care specialists as a reminder of the necessity of constant monitoring of the skin color of the distal parts of the limbs in severe sick patients.

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.

Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia

Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

Symmetrical peripheral gangrene of bilateral feet and unilateral hand after administration of vasopressors during septic shock

We report a case of a 75-year-old Hispanic man treated for septic shock after undergoing surgery for impacted renal stones. He was given vasopressors and later developed symmetrical peripheral gangrene (SPG) on both his feet and left hand. SPG is a serious and rare condition presenting clinically as an acute onset of ischaemia with no vessel occlusion. Vasopressors are identified as a contributing factor in SPG development. The patient ultimately underwent transmetatarsal amputations of both feet and amputation of three digits on his left hand. Early monitoring and swift management of peripheral ischaemia are essential when using vasopressors for the treatment of septic shock.

Complicating Symmetric Peripheral Gangrene after Dopamine Therapy to Patients with Septic Shock

Dopamine is commonly used as a first-line agent in the treatment of patients with septic shock. The use of dopamine rarely causes symmetric peripheral dry gangrene. If the symmetric peripheral dry gangrene occurs in the patient after dopamine injection, it easily leads to disagreement between doctors and patients. A 60-year-old woman who had sudden septic shock was sent to intensive care unit (ICU). She was received dopamine injection according to the routine during treatment. Over the next 3 months, her limbs developed to dry gangrene and required amputation. The result shows that the occurrence of dry gangrene could only be associated with the long-term excessive use of dopamine according to the medical records. Although dopamine is a conventional drug for the treatment of septic shock, the forensic workers and clinicians must realize that vasopressors such as dopamine have been implicated directly or as a contributory cause in dry gangrene cases.