Management of vasopressor induced ischemia

Livesey, M. A.; Jauregui, Julio J.; Hamaker, Max C.; Pensy, Raymond A.; Langhammer, Christopher G.; Eglseder, W. Andrew

doi:10.1016/j.jor.2020.10.012

Cited by 13 publications

(13 citation statements)

References 49 publications

(48 reference statements)

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“…Patients should be informed that reconstructive limb salvage can be an arduous course, often requiring multiple revision surgeries, but ultimately it may restore both form and function of their injured limb. 8 In the cases we presented, treatment duration from initial presentation to limb salvage completion lasted several months.…”

Section: Discussionmentioning

confidence: 99%

“…Vasopressors cause significant vasospasm in peripheral arteries, which may lead to irreversible ischemia in multiple areas of the body, including the upper and lower limbs. 7,8 In patients who survive their ICU stay, VIALI is associated with a significant morbidity and a high risk of amputation. 4 Ionotropic and adrenergic medications are commonly used to maintain blood pressure in critically ill patients.…”

Section: Discussionmentioning

confidence: 99%

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

Deldar

Hawa

Haffner

et al. 2022

Plastic and Reconstructive Surgery - Global Open

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Background: 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. Methods: We retrospectively reviewed patients who were treated for septic shock and developed vasopressor-induced limb ischemia at our tertiary referral academic medical center. We reviewed presentation, treatment, surgical outcomes, and long-term functional outcomes. Results: We present three previously healthy patients who developed gangrene of multiple limbs following the use of vasopressors to treat septic shock. Each patient underwent amputations or limb salvage procedures. Conclusions: Limb ischemia is a devastating complication that can occur after prolonged vasopressor use. The decision to proceed with limb salvage versus amputation of ischemic extremities should be tailored to the individual patient. The main objective should be for the patient to obtain optimal function and quality of life, regardless of the type of surgery.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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

Deldar

Hawa

Haffner

et al. 2022

Plastic and Reconstructive Surgery - Global Open

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“…In this case, phentolamine was not considered, as it is more commonly used for ischemia related to local vasopressor extravasation, not complications related to systemic vasopressor administration. 11 …”

Section: Discussionmentioning

confidence: 99%

“… 9 It has also recently been recommended as a treatment option for vasopressor- and trauma-induced digital ischemia. 4 , 10 , 11 We present a case report to highlight the potential use of BT in the treatment of vasopressor-associated SPG.…”

Section: Introductionmentioning

confidence: 99%

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene

Stoehr¹,

Kearney²,

Massie³

et al. 2021

Plastic and Reconstructive Surgery - Global Open

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Summary: Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.

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“…However, SEPSIS-PAM suggests that a bias towards achieving or allowing hypertension through the use of exogenous vasopressor administration does not improve overall outcomes in sepsis (exception of patients with chronic hypertension and association with renal failure) and a meta-analysis did not identify any bene ts to supratherapeutic use of vasopressors with increased risk of new-onset supraventricular tachycardia (11,12). In addition, there are small case series reporting on the rare but limb threatening complication of symmetric peripheral gangrene due to vasopressor use (13).…”

Section: Introductionmentioning

confidence: 99%

Closed Loop Automated Critical Care Concept and Feasibility Study for Resuscitation in A Severe Ischemia-Reperfusion Injury Model of Shock in Swine

Patel

Goenaga‐Díaz

Lane

et al. 2022

Preprint

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BACKGROUNDVolume expansion and vasopressors for the treatment of shock is an intensive process that requires frequent assessments and adjustments. Strict blood pressure goals in multiple physiologic states of shock (TBI, sepsis, and hemorrhagic) have been associated with improved outcomes. The availability of continuous physiologic data is amenable to closed loop automated critical care to improve goal directed resuscitation.METHODS5 adult swine were anesthetized and subjected to a controlled 30% estimated total blood volume hemorrhage followed by 30 minutes of complete supra-celiac aortic occlusion and then auto-transfusion back to euvolemia with removal of aortic balloon. The animals underwent closed loop critical care for 255 minutes after removal of the endovascular aortic balloon. The closed-loop critical care algorithm using proximal aortic pressure and central venous pressure combined with a fully autonomous algorithm providing programmatically control of pumps for titration of vasopressors and weight-based crystalloid boluses (5ml/kg) to maintain a mean arterial pressure between 60 - 70 mmHg.RESULTSDuring the 255 minutes of critical care the animals experienced hypotension (<60 mmHg) 15.29% (8.63% - 16.47% interquartile range), hypertension (>70 mmHg) 7.84% (6.67% - 9.02% interquartile range), and normotension (60 - 70 mmHg) 76.86% (76.86% - 81.18% interquartile range) of the time. Excluding the first 60 minutes of the critical care phase the animals experienced hypotension 1.03% (0.51% - 7.69% interquartile range) of the time. Median intervention rate was 8.47 interventions per hour (interquartile range: 7.76 - 9.18). The proportion of interventions was 61.54% (interquartile range: 61.11%-66.667%) weight-based crystalloid boluses and 38.46% (interquartile range: 33.33%-38.89%) titration of vasopressors.CONCLUSIONThis autonomous critical care platform, utilizing volume expansion and vasopressor titration in a model of ischemia-reperfusion injury, is effective at minimizing hypotension using goal-directed closed loop algorithms and device actuation. This descriptive study highlights the potential for this approach to deliver nuanced critical care in the ICU environment, thereby optimizing resuscitative efforts and expanding capabilities through cognitive offloading. Future efforts will focus on optimizing this platform through comparative studies, specifically evaluating the performance compared to manual critical care.

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Management of vasopressor induced ischemia

Cited by 13 publications

References 49 publications

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

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

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene

Closed Loop Automated Critical Care Concept and Feasibility Study for Resuscitation in A Severe Ischemia-Reperfusion Injury Model of Shock in Swine

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