Symmetrical peripheral gangrene: association with noradrenaline administration

Hayes, Michelle; Yau, E.H.S.; Hinds, C. J.; Watson, Joe

doi:10.1007/bf01694349

Cited by 90 publications

(66 citation statements)

References 12 publications

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“…10,11 High-dose vasoconstrictor therapy also may lead to the development of ischemia of the distal portions of the upper and lower extremities and mesenteric ischemia. 12,13 For these reasons, perioperative identification of patients at high risk of developing vasoplegia is an appealing concept that could be of clinical benefit. We hypothesized that the severity and duration of the decline in mean arterial pressure (MAP) immediately after CPB is started, as quantified by the area above the MAP curve (AAC), can be used to identify patients likely to experience post-CPB vasoplegia.…”

Section: Clinical Perspective On P 1671mentioning

confidence: 99%

Early On–Cardiopulmonary Bypass Hypotension and Other Factors Associated With Vasoplegic Syndrome

et al. 2009

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Background-Vasoplegic syndrome is a form of vasodilatory shock that can occur after cardiopulmonary bypass (CPB).We hypothesized that the severity and duration of the decline in mean arterial pressure immediately after CPB is begun can be used as a predictor of patients will develop vasoplegia in the immediate post-CPB period and of poor clinical outcome. We quantified the decline in mean arterial pressure by calculating an area above the mean arterial blood pressure curve. Methods and Results-We retrospectively analyzed 2823 adult cardiac surgery cases performed between July 2002 and December 2006. Of these 2823, 577 (20.4%) were vasoplegic after separation from CPB. We found that 1645 patients (58.3%) had a clinically significant decline in mean arterial pressure after starting CPB (area above the mean arterial blood pressure curve Ͼ0) and were significantly more likely to become vasoplegic (23.0% versus 16.9%; odds ratio, 1.26; 95% confidence interval, 1.12 to 1.43; PϽ0.001). These patients were also far more likely either to die in hospital or to have a length of stay Ͼ10 days (odds ratio, 3.30; 95% confidence interval, 1.44 to 7.57; Pϭ0.005). Additional risk factors for developing vasoplegia that were identified included the additive euroSCORE, procedure type, prebypass mean arterial pressure, length of bypass, administration of pre-CPB vasopressors, core temperature on CPB, pre-and post-CPB hematocrit, the preoperative use of ␤-blockers or angiotensin-converting enzyme inhibitors, and the intraoperative use of aprotinin. Conclusions-The results of this investigation suggest that it is possible to predict vasoplegia intraoperatively before separation from CPB and that the presence of a clinically significant area above the mean arterial blood pressure curve serves as a predictor of poor clinical outcome. (Circulation. 2009;120:1664-1671.)

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Section: Clinical Perspective On P 1671mentioning

confidence: 99%

Early On–Cardiopulmonary Bypass Hypotension and Other Factors Associated With Vasoplegic Syndrome

et al. 2009

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“…Symmetrical peripheral gangrene is characterized by distal ischemic damage in 2 or more extremities, without large vessel obstruction. This syndrome has been reported in several conditions such as infections, disseminated intravascular coagulation (DIC), low cardiac output states, and rarely associated with falciparum malaria (Alexander et al, 1975;Mohantly et al, 1985;Chittichai et al, 1991;Hayes et al, 1992;Kochar et al, 1998;Davis et al, 2001;Sharma and Gupta, 2002;Liechti et al, 2003). We report 3 cases of severe falciparum malaria with peripheral gangrene and their treatments.…”

Section: Introductionmentioning

confidence: 72%

Peripheral gangrene in patients with severe falciparum malaria: report of 3 cases

et al. 2006

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Peripheral gangrene, characterized by distal ischemia of the extremities, is a rare complication in patients with falciparum malaria. Patients with this complication have generally undergone early amputation of the affected areas. In this report, we describe 3 adult Thai patients presented at the Hospital for Tropical Diseases, Bangkok, with high grade of fever ranged 6-9 days, jaundice, acute renal failure, respiratory failure, alteration of consciousness and shock. Two patients had gangrene developed at the lower extremities on day 1 of hospitalization and 1 patient had gangrene developed on day 3. Blood smears revealed hyperparasitemia with Plasmodium falciparum. These patients were diagnosed as having severe malaria with peripheral gangrene. The resolution of gangrene was successfully achieved by treatment with artesunate and conservative treatment in 2 of 3 cases.

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“…Symmetrical peripheral gangrene is described as multiple extremity ischemia at two or more sites in the absence of large vessel obstruction [1,2]. Possible etiological factors cited in literature include obstructive intracardiac lesions [3], sepsis [4], vasospastic conditions [5,6], small vessel obstruction [1], protein C deficiency [7], use of vasopressor agents [8,9], low cardiac output states [10,11], disseminated intravascular coagulation (DIC) [12,13], factor V Leiden mutation [14], and parenteral abuse of the sublingually available form of buprenorphine [15]. It is well established that the digital perfusion will drop to zero in presence of persistently low perfusion pressures of 35-60 mmHg [16].…”

Section: Discussionmentioning

confidence: 99%

“…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%

“…Low flow states result in occlusion of the microcirculation of the affected parts [1][2][3][4][5]. This could be aggravated by the use of vasopressors to treat profound hypotension before optimization of fluid status as it would result in even more sluggish flow in the microcirculation [8,9]. Thus, the symmetric peripheral gangrene occurs due to ischemia caused by a combination of vasospasm and thrombosis.…”

Section: Discussionmentioning

confidence: 99%

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Symmetrical Peripheral Gangrene—A Case Report and Brief Review

et al. 2012

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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...

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Symmetrical peripheral gangrene: association with noradrenaline administration

Cited by 90 publications

References 12 publications

Early On–Cardiopulmonary Bypass Hypotension and Other Factors Associated With Vasoplegic Syndrome

Early On–Cardiopulmonary Bypass Hypotension and Other Factors Associated With Vasoplegic Syndrome

Peripheral gangrene in patients with severe falciparum malaria: report of 3 cases

Symmetrical Peripheral Gangrene—A Case Report and Brief Review

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