Symmetrical peripheral gangrene

Ghosh, Sudip Kumar; Bandyopadhyay, Debabrata

doi:10.4103/0378-6323.77481

Cited by 56 publications

(131 citation statements)

References 18 publications

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“…It has been suggested that a low flow state contributes to the development of symmetrical peripheral gangrene [9,11]. We sought evidence of low blood flow in these cases.…”

Section: In the Last 3 Years 4 Children At Kosair Children'smentioning

confidence: 99%

Symmetrical Peripheral Gangrene in Four Pediatric Cardiac Surgery Patients Receiving Extracorporeal Membrane Oxygenation

Reed

2012

Pediatr Dev Pathol

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Symmetrical peripheral gangrene (multilimb ischemia without large artery occlusion) is a rare condition usually associated with disseminated intravascular coagulation, hemodynamic compromise, and/or sepsis. However, it has not been described in patients on extracorporal membrane oxygenation (ECMO). Over a 5 year period, four pediatric patients developed symmetrical peripheral gangrene on ECMO after cardiac surgery. They subsequently died and came to autopsy. History, physical examination, and laboratory studies were examined. Gross and microscopic autopsy material was reviewed. Patients were 11 days to 13 years old. Extracorporal membrane oxygenation duration was 11-22 days, and limb ischemia began 2-4 days before death. Three patients had rapid onset, with ischemia developing in <48 hours. In the fourth, ischemic changes began as focal lesions and gradually spread. Two patients were septic. Three had evidence of other end-organ damage. Pressors were used in 3 patients before the limb ischemia. Autopsies disclosed ischemic changes involving all limbs, with confluent ecchymoses. In a detailed examination in 1 case, large arteries of the extremities were patent. Involved skin and soft tissue showed bland fibrin thrombi in the microcirculation, with tissue necrosis and hemorrhage. This report describes the first 4 cases of symmetrical peripheral gangrene complicating ECMO. The 4 pediatric patients all had recent surgery for congenital cardiac disease, and all had significant exposure to ECMO prior to developing limb ischemia. Symmetrical peripheral gangrene is an unusual complication of ECMO that may arise in the setting of disseminated intravascular coagulation, sepsis, or other hemostatic and/or hemodynamic imbalance.

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“…It has been suggested that a low flow state contributes to the development of symmetrical peripheral gangrene [9,11]. We sought evidence of low blood flow in these cases.…”

Section: In the Last 3 Years 4 Children At Kosair Children'smentioning

confidence: 99%

Symmetrical Peripheral Gangrene in Four Pediatric Cardiac Surgery Patients Receiving Extracorporeal Membrane Oxygenation

Reed

2012

Pediatr Dev Pathol

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“…The pathogenesis of SPG may include the Schwartzman reaction, bacterial endotoxin release, and platelet plugging in peripheral arterioles due to vascular collapse and DIC. [1] By exclusion of other possible causes, it is tempting to consider dengue infection as the cause of SPG in this case. Dengue fever is the most important arthropod-borne arboviral infection.…”

Section: Discussionmentioning

confidence: 97%

“…[3] Leukopenia, in particular, is a poor prognostic factor of SPG, reported to be associated with a high mortality rate. [1] Identification and treatment of underlying etiological factors and treatment of DIC have remained the mainstays of management. Other measures that might be helpful are sympathetic blockade (Ganglion block or intravenous trimethaphan therapy), intravenous nitroprusside therapy, topical nitroglycerine ointment, local or intravenous infusion of a α-blocker (phentolamine, chlorpromazine) and intravenous infusion of prostaglandin (epoprostenol), Papaverine, reserpine, streptokinase, dextran, and hyperbaric oxygen therapy have not been shown to be of value.…”

Section: Discussionmentioning

confidence: 99%

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Symmetrical peripheral gangrene: A rare complication of dengue fever

Modak¹,

Guha²

2012

Indian J Med Sci

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Symmetric peripheral gangrene is associated with a variety of infective and non-infective etiologies. SPG is always presented with disseminated intravascular coagulation (DIC) and carries a higher mortality. Herein, we describe a 42-year-old female with dengue fever and rash developed bilateral symmetric dry gangrene of 2 nd and 3 rd toes. There was no history of taking B-blockers, ergot etc. All the peripheral pulses of the affected limbs were palpable. Color Doppler of lower limb vessels was done, which indicated normal flow. Blood was positive for Fibrin degradation products and D dimers. Patient was managed with IV fluids, LMWH, FFP etc. Her general condition improved within 72 hours with no further progression of gangrene.

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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%

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

Cited by 56 publications

References 18 publications

Symmetrical Peripheral Gangrene in Four Pediatric Cardiac Surgery Patients Receiving Extracorporeal Membrane Oxygenation

Symmetrical Peripheral Gangrene in Four Pediatric Cardiac Surgery Patients Receiving Extracorporeal Membrane Oxygenation

Symmetrical peripheral gangrene: A rare complication of dengue fever

Symmetrical Peripheral Gangrene—A Case Report and Brief Review

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