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- Publisher
- Wolters Kluwer Health
- Copyright
- Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc.
- ISSN
- 0025-7974
- eISSN
- 1536-5964
- DOI
- 10.1097/MD.0000000000009800
- pmid
- 29384879
- Publisher site
- See Article on Publisher Site
Abstract
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. Abbreviations: DIC = disseminated intravascular coagulation, ICU = intensive care unit, SPG = symmetrical peripheral gangrene. Keywords: amputation, dry gangrene, inotropics, symmetrical peripheral gangrene (SPG) feet, penis, and ear lobes. The common causes of dry gangrene are 1. Introduction large vessel diseases such as diabetes mellitus, atherosclerosis, Dry gangrene is common as a result of arterial occlusion. [1] and long-term smoking. Less frequently, microvessel angiop- Typically affected parts of the body include toes, fingers, hands, athy associated with autoimmune vasculitis and connective tissue diseases, such a scleroderma, infections, trauma, severe burns, Editor: N/A. [2] and frostbite, cause gangrene. Funding/support: This work was supported by the Soonchunhyang University Symmetrical peripheral gangrene (SPG), also termed Research Fund. purpura fulminant, is uncommon but not rare in critically ill This article does not contain any studies with human participants or animals patients. SPG is a clinical syndrome characterized by bilateral performed by any of the authors. distal ischemic damage leading to gangrene in the absence No benefits in any form have been received or will be received from a [3,4] of major vascular occlusive disease. Peripheral pulses commercial party related directly or indirectly to the subject of this article. All are palpable as a result of sparing of larger vessels. The authors of this article declare that we have no conflict of interest. mechanism of vascular occlusion is disseminated intravascular Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan-si, Department of Orthopaedic Surgery, Soonchunhyang coagulation (DIC). Various infective and noninfective [5] University Hospital Seoul, Yongsan-gu, Seoul, South Korea. etiological factors have been demonstrated with SPG. It Correspondence: Jae-Hwi Nho, Department of Orthopaedic Surgery, has been described in conditions associated with sepsis, Soonchunhyang University Hospital Seoul, 59, Daesagwan-ro, Yongsan-gu, low-flow states, vasospastic conditions, myeloproliferative Seoul, 04401, South Korea (e-mail: huuy@schmc.ac.kr). [6,7] disorders, and hyperviscosity syndromes. SPG related Copyright © 2018 the Author(s). Published by Wolters Kluwer Health, Inc. to inappropriate use of vasoactive drugs has been also This is an open access article distributed under the Creative Commons [8–11] described. Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial Dopamine and norepinephrine have positive inotropic effects, and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. and so are frequently used in the management of severe ill patients with cardiogenic or septic shock. SPG can occur with Medicine (2018) 97:5(e9800) prolonged administration, especially at high infusion rates. While Received: 29 November 2017 / Received in final form: 6 January 2018 / Accepted: 16 January 2018 rare, SPG may lead to a catastrophic complications with high mortality rate and high frequency of multiple limb amputations http://dx.doi.org/10.1097/MD.0000000000009800 1 Jung et al. Medicine (2018) 97:5 Medicine Figure 1. Ischemic changes in 4 limbs after use of the inotropic agent. [6] in up to 70% of surviving patients. We present 4 cases of SPG unstable and her general condition made her unfit for surgery. associated with use of vasoactive drugs. After 3 months treatment in the nephrology department, her general condition was recovered, but gangrene had advanced to the wrists and ankles. Amputation surgery was done 4 weeks 2. Case 1 later to remove the septic sources. After demarcation, disarticu- A 46-year-old woman came to our hospital because of high fever. lation of both wrists and 2 below knee amputations were done In the emergency room, she was diagnosed with urinary tract (Figs. 2 and 3). She was recovered 8 weeks of surgery. She was infection and was admitted to our nephrology department. On observed in our out-patient department and participated in a the admission day, septic shock, hypotension (80/40), and rehabilitation program using orthosis. tachycardia of 120 beats per min developed. Our nephrologist decided to use inotropic therapy comprising norepinephrine 32 3. Case 2 mg every 24hours in the intensive care unit (ICU). On day 8 following admission, multiple bullae formation was found. A A 28-year-old man came to our hospital because of abdominal pain. dermatology consultation was done initially for clinical evalua- He was diagnosed with colitis and known end stage renal disease, tion. On day 11 following admission, necrotic gangrene and was admitted to our gastroenterology department. On the day advanced in the hands and feet (Fig. 1) necessitating consultation of admission, he had fever (38.8 C) and hypotension (80/60mm with the orthopedic department. In ICU care, vital signs were Hg); the hospital gastroenterologist decided to transfer the patient to 2 Jung et al. Medicine (2018) 97:5 www.md-journal.com Figure 2. Postoperative radiographs of both wrists. ICU because of septic condition and to use inotropic therapy pressure. On day 3 following admission, necrotic gangrene was consisting of norephinephrine (32mg every 24h). On post- found on the distal end of the extremities (Fig. 6) and the admission day 3, necrotic gangrene was found on the distal end orthopedic department was consulted for management of the of the extremities. On day 12 following admission, the patient had infection. Seven days after admission, wound curettage and anti- recovered from the septic condition, but the necrotic gangrene had bead insertion surgery was done for management of the infection. advanced in both feet (Fig. 4). The orthopedic department was However, the necrotic gangrene advanced. After a 3-week consulted. After 2 months treatment in the gastroenterology and treatment in the pulmonology department, below the knee and nephrology department, both legs were operated on using below the ray amputation surgeries were done (Fig. 7). She was carefully knee amputation (Fig. 5). He was observed in our outpatient treated in the pulmonology department, but her general condition department and underwent a rehabilitation program using orthosis. worsened because of pneumonia. Two months after admission, she expired due to acute respiratory distress syndrome. 4. Case 3 5. Case 4 A 72-year-old woman came to our hospital because of dyspnea and tachycardia. She was diagnosed with sepsis and admitted to our A 76-year-old woman came to our hospital because of fever and pulmonology department. On the day of admission, she was metabolic acidosis. She was diagnosed with sepsis and admitted moved to the ICU and inotropic therapy involving norephinephr- to the nephrology department. Before transfer to our hospital, she ine (32mg every 24hours) was begun to maintain her blood was treated for traumatic intracerebral hemorrhage and 3 Jung et al. Medicine (2018) 97:5 Medicine Figure 3. Postoperative radiographs of both knees. traumatic subarachnoid hemorrhage, and was bedridden. On the 6. Discussion day of admission, she was moved to the ICU and received continuous renal replacement therapy because of anuria, and SPG is a relatively rare phenomenon characterized by symmetri- inotropic therapy with norephinephrine (80mg every 24hours) cal distal ischemic damage that leads to gangrene of 2 or more was initiated to maintain her blood pressure. On day 3 following sites in the absence of large blood vessel obstruction, where admission, necrotic gangrene was found on the distal end of the vasoconstriction rather than thrombosis is implicated as the [4,12] extremities and the orthopedic department was consulted for underlying pathophysiology. management of the infection (Fig. 8). Surgery was recommended Inotropic drugs including dopamine and norepinephrine are but was opposed by a family member. Instead, the wounds were frequently used in the treatment of hypotension, and its dressed. After 3 months of treatment in the nephrology effectiveness in treating shock is firmly established. However, department, amputation surgery was done. This involved it can cause peripheral gangrene with prolonged administration disarticulation of both wrists and below the knee amputation of high doses and was first reported as a complication about 25 [5] (Fig. 9). She was observed in the physical medicine and years ago. rehabilitation department and participated in a rehabilitation Dopamine and norepinephrine are also frequently used in program using orthosis. septic shock because of their positive inotropic effects. When Figure 4. Ischemic changes in both fee after use of the inotropic agent. 4 Jung et al. Medicine (2018) 97:5 www.md-journal.com Figure 5. Postoperative radiographs of both knees. dopamine is administered in low doses of 2 to 5mg/kg/min, it phenylpropanolamine from tissue storage sites. However,in higher causes vasodilatation of the coronary, renal, and mesenteric doses of up to 20 to 50mg/kg/min, vasoconstriction may occur due vessels. In moderate doses of 5 to 20mg/kg/min, it brings about to alpha-receptor stimulation. The use of the alpha-receptor the desired outcome of enhanced cardiac contractility caused by a stimulator noradrenaline is frequent in patients with septic shock, direct action on beta-adrenergic receptors and by the release of but their vasospastic effects may be more intense in the digital vascular beds. As a result, peripheral gangrene is not unexpected [3] following high doses of dopamine or noradrenaline. The 4 cases presented here had different clinical histories and background factors, but each experienced sepsis; about 80% of [13] SPG is related to sepsis. Inotropics were applied to maintain blood pressure. After a few days of inotropic therapy, necrotic gangrene was evident at the distal end of the extremities where the blood supply was poor. In internal medicine, epoprostenol sodium, tissue plasminogen activator, aspirin, vasodilators, and sympathetic blockade have [14] been suggested as treatment modalities for SPG. These options were unsuccessful for our patients. After medical treatment, we decided on surgical intervention when gangrene had demarcated, as suppuration is rarely complicated and the outcome of surgery [14] is usually good. The 4 cases of SPG within 6 months indicate to us that SPG may not be as rare as assumed. The possibility of SPG should be considered during inotropic therapy; proper dosage and duration Figure 6. Ischemic changes in foot after use of the inotropic agent. Figure 7. Postoperative radiographs of both knees. 5 Jung et al. Medicine (2018) 97:5 Medicine Figure 8. Ischemic changes in hand after use of the inotropic agent. Figure 9. Postoperative radiographs of 4 limbs. of inotropics in patients with sepsis are important to treat shock according to the use of inevitable inotropic agents, and we effectively and prevent SPG. recommended the careful use of the inotropic agents. Suggestedfirst-line measures when SPG isidentified earlyinclude discontinuation of vasopressors, reversal of DIC by cautious References anticoagulation, and aggressive treatment of shock and sepsis. [1] O’Connor DJ, Gargiulo NJ 3rd, Jang J. Hemoglobin A1c as a measure of Adjuvant therapy with tissue plasminogen activator, plasmaphe- disease severity and outcome in limb threatening ischemia. J Surg Res 2012;174:29–32. resis, sympathetic blockade, and aspirin has been recognized to [2] Waseda K, Tanimoto Y, Hasegawa K, et al. Churg-Strauss syndrome contribute to a favorable outcome. Amputation remains the final with necrosis of toe tips. Acta Med Okayama 2011;65:215–8. treatment option available to the patient for established gangrene. [3] Ang CH, Koo OT, Howe TS. Four limb amputations due to peripheral The level of amputation is determined by the line of demarcation in gangrene from inotrope use: case report and review of the literature. 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Journal
Medicine – Wolters Kluwer Health
Published: Feb 1, 2018