Amputation of multiple limbs caused by use of inotropics

Abstract

Rationale:We present 4 cases of symmetrical peripheral gangrene (SPG) associated with use of inotropic agent to elevate blood pressure. SPG is a relatively rare phenomenon characterized by symmetrical distal ischemic damage that leads to gangrene of 2 or more sites in the absence of large blood vessel obstruction, where vasoconstriction rather than thrombosis is implicated as the underlying pathophysiology. We present 4 SPG cases of the multiple limbs amputation, associated with inevitable use of inotropic agents.Patient concerns:Inotropic agents including dopamine and norepinephrine are used frequently in the treatment of hypotension, and its effectiveness in treating shock is firmly established. However, it can be caused peripheral gangrene by prolonged administration of high dose inotropics, inducing the constant contraction of the peripheral blood vessels.Diagnosis:These 4 patients had different clinical histories and background factors, but each experienced sepsis. The level of amputation is determined by the line of demarcation in concert with considerations of the biomechanics of stump stability, weight bearing, and ambulation.Interventions:After recovering of general conditions and completion of demarcation, these 4 patients underwent the amputation of multiple limbs.(bilateral amputations of upper extremities or bilateral amputations of lower extremities).Outcomes:In each patient, there was no additional amputation caused by extension of SPG, and the rehabilitation with appropriate orthosis was performed. Treatment of underlying disease were continued too.Lessons:It is important to alert the possibility of amputations, according to the use of inevitable inotropics. We recommended the careful use of the inotropic agents to the physicians in treating septic shock.

Incidence and associated risk factors for limb amputation among sepsis survivors in South Korea

“…PG development after treatment for sepsis has been reported in many case reports and, while relatively rare, has serious sequelae [11,17,24,25]. Our study findings highlight the risk factors associated with limb amputation among sepsis survivors; however, they require careful interpretation.…”

“…Therefore, the 0.8% incidence rate of limb amputation among sepsis survivors in our study was not low when compared with that of other diabetic or general populations. Although there have been case reports of limb amputation among sepsis survivors [ 11 , 16 , 17 ], our study was the first to report the incidence of limb amputation for the treatment of PG in sepsis survivors in South Korea.…”

“…Moreover, disseminated intravascular coagulation (DIC), which is also a known complication of sepsis [ 14 ], has been reported to be a factor related to the development of PG [ 15 ]. Therefore, PG is a severe complication for sepsis survivors and several studies have reported treating PG with limb amputation [ 11 , 16 , 17 ]. In South Korea, the incidence rate and associated risk factors for limb amputation in sepsis survivors is not known.…”

Distal Ischemia of the Four Limbs: A Case Report and Literature Review

“…Jung et al reported four cases, all of them related to septic shock. 13 Once again, no references to DIC or hepatic failure presence were made, and amputation was necessary. Tan et al described a case of distal ischemia in a 42-yearold male after collision with his motorbike.…”

Hirudotherapy for neonatal limb ischemia during ECMO support: A word of caution

“…[24][25][26] Multi-limb ischemia, when occurring without the presence of thromboembolic arterial occlusion, is termed symmetric peripheral gangrene (SPG), and often occurs in the presence of disseminated intravascular coagulopathy (DIC), sepsis, or low-flow states. [27][28][29] SPG has been described in pediatric patients on ECMO after cardiac surgery. 28 We performed an extensive literature search of Ovid database with key search terms (hirudotherapy, leech therapy, limb ischemia, children).…”