Severe digital ischaemia treated with phosphodiesterase inhibitors

Kumana, CR; Cheung, Giselle; Lau, Carl

doi:10.1136/ard.2003.015677

Cited by 41 publications

(22 citation statements)

References 4 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Vigorous therapy of sepsis with intravenous antibiotics and anticoagulation for DIC are the other suggested measures [4,12]. Sympathetic blockade, intravenous vasodilators, local injection of alpha-blockers, and phosphodiesterase inhibitors have all been attempted after appearance of digital ischemia, but prevention appears to be the best line of management [8,9,[17][18][19][20][21]. Local debridement and secondary skin grafting have not been shown to be successful, and amputation should be considered only after a clear line of demarcation develops [20].…”

Section: Discussionmentioning

confidence: 99%

Symmetrical Peripheral Gangrene—A Case Report and Brief Review

et al. 2012

View full text Add to dashboard Cite

A 30 year-old gentleman presented to casualty with history of pain abdomen for six days, fever and decreased urine output since two days. He was in a state of septic shock and was diagnosed to have intestinal perforation. His peripheral pulses were not palpable except for the femoral and brachial vessels. Despite fluid resuscitation, he needed infusion of high doses of dopamine and noradrenaline to maintain his blood pressure. He was operated for repair of perforation. On the first postoperative day, in the intensive care unit, vasopressin infusion was added in view of persistent hypotension. Appropriate fluid resuscitation and antibiotic therapy helped to wean him off inotropes and vasopressors by the second postoperative day. On the 3rd postoperative day, however, the patient developed discolouration and blebs on the fingers of left hand, followed by the right hand and then both the lower limbs. Subsequently, over a period of 10 days, this progressed to gangrene formation in the hands despite the patient being haemodynamically stable without any inotropes or vasopressors in this period. We conclude that the septic shock is a systemic derangement affecting all organ systems including coagulation and microcirculation. Early recognition and prompt management of sepsis, optimisation of fluid status to wean off the inotropes and vasopressors at the earliest is necessary to avoid catastrophes such as symmetrical peripheral gangrene.Keywords Symmetrical peripheral gangrene . Sepsis . Vasopressors . Multiple arterial punctures . Resuscitation. Case ReportA 30-year-old man, an agriculturist by occupation, presented to the casualty ward with abdominal pain for 6 days and fever and reduced urine output for 2 days. He was in a state of intense septic shock with absent peripheral pulsations, and the pulse oximeter could not pick up pulsations. Despite fluid resuscitation, he needed high doses of dopamine (20 μg/kg/min) and noradrenaline (0.2-0.3 μg/kg/ min) to maintain normotension. The patient was also found to have altered coagulation parameters which were corrected with fresh frozen plasma. An emergency laparotomy revealed jejunal perforation which was closed. The patient was found to have cirrhotic liver (he was a known chronic alcoholic). Blood pressure remained persistently low, requiring addition of vasopressin infusion in the postoperative period. After multiple failed attempts at cannulation of the radial arteries in both upper limbs, a femoral arterial line was secured in the intensive care unit. By the second postoperative day, all the vasopressors were weaned off. However, cyanosis of the extremities was noted. On the third postoperative day, small blebs/blisters were noticed first in the left hand and subsequently in other limbs also which progressed to gangrene formation over the next 1 week (Figs. 1, 2, 3). Doppler evaluation revealed presence of diminished pulsations in all the vessels supplying the limbs. Echocardiogram revealed absence of any septic foci. While we were waiting for a clear demarca...

show abstract

Section: Discussionmentioning

confidence: 99%

Symmetrical Peripheral Gangrene—A Case Report and Brief Review

et al. 2012

View full text Add to dashboard Cite

show abstract

“…Two case series describe the benefit of sildenafil, a phosphodiesterase inhibitor, in reducing the number and severity of ischemic episodes in 13 patients with secondary Raynaud's disease. 113,114 One double-blinded, placebo-controlled, fixed-dose, crossover study of 16 patients with symptomatic secondary Raynaud's phenomenon resistant to vasodilatory therapy found significant improvements in mean attack rates and duration along with increased nailfold capillary blood flow in the cohort treated with sildenafil at a dose of 50 mg twice daily. 115 Notably, the subjects were able to tell active drug from placebo by the appearance of the pills.…”

Section: Phosphodiesterase Inhibitorsmentioning

confidence: 98%

Raynaud's phenomenon: Pathogenesis and management

Bakst

Merola

Franks

et al. 2008

Journal of the American Academy of Dermatology

160

139

View full text Add to dashboard Cite

“…Suggested doses in various clinical studies (15,25) that exhibit beneficial activity of PDE inhibitors include sildenafil (Viagra) 50 mg twice daily, vardenafil (Levitra) 10 mg twice daily, and tadalafil (Cialis) 20 mg every two to three days, although further studies are needed to delineate optimal dosing suggestions. Other doses that have been examined in clinical human studies include starting doses of sildenafil (Viagra) ranging from 12.5 mg/day to 100 mg/day in single or divided doses (20,(26)(27)(28)(29). The patient described in the present study was weaned to a 50 mg dose every three days, which is the lowest dose and longest interval that seems to be effective in this patient.…”

Section: Pde5 Inhibitors and Peripheral Ischemiamentioning

confidence: 99%

“…Interestingly, in several patients, worsening Raynaud's phenomenon and digital ischemia occurred after the initiation of antituberculosis chemotherapy. It was noted that rifampicin, which enhances sildenafil elimination through induction of P450 enzymes, worsened outcome and led to rapid development of digital gangrene (29), suggesting that PDE5 inhibition did indeed confer a vasodilating effect. Suggested doses in various clinical studies (15,25) that exhibit beneficial activity of PDE inhibitors include sildenafil (Viagra) 50 mg twice daily, vardenafil (Levitra) 10 mg twice daily, and tadalafil (Cialis) 20 mg every two to three days, although further studies are needed to delineate optimal dosing suggestions.…”

Section: Pde5 Inhibitors and Peripheral Ischemiamentioning

confidence: 99%