Symmetrical peripheral gangrene in critical illness

Abstract

Symmetrical peripheral gangrene (SPG) is a disabling complication that affects a small proportion of patients who survive critical illness. Its pathogenesis reflects profoundly disturbed procoagulant-anticoagulant balance in susceptible tissue beds secondary to circulatory shock (cardiogenic, septic). There is a characteristic SPG triad: (a) shock (hypotension, lactic acidemia, normoblastemia, multiple organ dysfunction), (b) disseminated intravascular coagulation (DIC), and (c) natural anticoagulant depletion (protein C, antithrombin). In recent years, risk factors for natural anticoagulant depletion have been identified, most notably acute ischemic hepatitis ("shock liver"), which is seen in at least 90% of patients who develop SPG. Moreover, there is a characteristic time interval (2-5 days, median 3 days) between the onset of shock/shock liver and the beginning of ischemic injury secondary to peripheral microthrombosis ("limb ischemia with pulses"), reflecting the time required to develop severe depletion in hepatically-synthesized natural anticoagulants. Other risk factors for natural anticoagulant depletion include chronic liver disease (e.g., cirrhosis) and, possibly, transfusion of colloids (albumin, high-dose immunoglobulin) lacking coagulation factors. A causal role for vasopressor therapy is unproven and is unlikely; this is because critically ill patients who develop SPG do so usually after at least 36-48 hours of vasopressor therapy, implicating a time-dependent pathophysiological mechanism. The most plausible explanation is a progressive time-dependent decline in key natural anticoagulant factors, reflecting ongoing DIC ("consumption"), proximate liver disease whether acute or chronic ("impaired production"), and colloid administration ("hemodilution"). Given these evolving concepts of pathogenesis, a rationale approach to prevention/treatment of SPG can be developed.

Hirudotherapy for limb ischemia in the pediatric intensive care unit: A retrospective observational cohort

“…Further complicating leech assessment was the overall death rate in an already small cohort (4/7). Acute limb ischemia has high morbidity and mortality in adults, with fatality in 15%–33% and major amputation rates ∼10%–30% ( 15 , 16 , 39 , 40 ). The addition of COVID-19 infection or ECMO requirement may increase mortality to 30%–60% ( 37 , 41 ).…”

“…This contrasts with adults, where the majority of cases are secondary to peripheral artery disease (14). Within the context of critical disease, ischemia may be encountered simultaneously in multiple limbs, with proposed contributions from sepsis, disseminated intravascular coagulopathy (DIC), low blood flow states, and vasopressor use (15)(16)(17)(18)(19). Diffuse or bilateral ischemia isolated to acral limbs is termed symmetric peripheral gangrene (SPG), and may be difficult to treat without surgical intervention (16,19).…”

Gangrena Simétrica Periférica (Gsp): Relato De Caso E Revisão Narrativa Da Literatura

“…Em trabalhos descritivos de casos de GSP na literatura, os pacientes nem chegaram a fazer uso de DVA para estabelecer correlação entre causa e efeito 16,17 . Uma revisão sobre o assunto não encontrou diferença das doses e a duração de uso de DVA entre pacientes sem e com GSP 18 . Esperar-se-ia que, se o papel das DVA na síndrome fosse predominante, os pacientes que evoluíssem com isquemia acral deveriam usar doses maiores, o que não aconteceu de fato.…”

Symmetrical peripheral gangrene in a patient with septic shock due to Serratia marcescens

“…The current paradigm of SPG focuses on the triad of circulatory shock, disseminated intravascular coagulation (DIC), and natural anticoagulant depletion. 1,2 Roughly more than half of patients recovering from SPG require limb amputation. 3,4 In our case, the patient presented with DIC associated with septic shock and was being treated with catecholamines.…”