Digital necrosis: a potential risk of high-dose norepinephrine

Daroca-Pérez, Rafael; Carrascosa, Miguel F

doi:10.1177/2042098617712669

Cited by 22 publications

(20 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…The extremities are particularly vulnerable, and several reports of upper and lower extremity digital malperfusion in patients receiving vasopressor agents have been published. [7][8][9][10][11] Whereas bilateral involvement is most frequent, asymmetric unilateral involvement has been described as was seen in our series. Previous studies have shown pre-existing vascular disease, concomitant use of multiple vasopressor agents, and prolonged periods of hypotension to be risk factors for digital ischemia.…”

Section: Discussionsupporting

confidence: 71%

“…Previous studies have shown pre-existing vascular disease, concomitant use of multiple vasopressor agents, and prolonged periods of hypotension to be risk factors for digital ischemia. 10 Most reports in the medical literature have identified the association between norepinephrine and risk of digital ischemia. [7][8][9][10][11] Norepinephrine was used in almost half the patients in our series and was the vasopressor agent used for the longest duration.…”

Section: Discussionmentioning

confidence: 99%

“…10 Most reports in the medical literature have identified the association between norepinephrine and risk of digital ischemia. [7][8][9][10][11] Norepinephrine was used in almost half the patients in our series and was the vasopressor agent used for the longest duration. Of the five ICU patients who required digital amputation, two were taking norepinephrine and one each was taking phenylephrine, vasopressin, and epinephrine.…”

Section: Discussionmentioning

confidence: 99%

“…Vascular surgeons may be consulted to evaluate patients in the intensive care unit (ICU) with digital ischemia. Several factors can lead to digital ischemia in these patients, including the severity of underlying illness (eg, sepsis, 1,2 heart failure, malignant disease, 3,4 renal failure, 5 and diabetes 6 ), use of vasoactive medications causing peripheral vasoconstriction, [7][8][9][10][11] and use of radial arterial lines for continuous hemodynamic monitoring. 12,13 Finger ischemia can be the source of great anxiety for critically ill patients, families, and care providers.…”

mentioning

confidence: 99%

See 3 more Smart Citations

Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit

Landry

Mostul

Ahn

et al. 2018

Journal of Vascular Surgery

View full text Add to dashboard Cite

Objective: Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. Methods: All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. Results: There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 6 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P ¼ .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P ¼ .05) and hyperlipidemia (42% vs 24%; P ¼ .03) and to undergo finger amputations (16% vs 5%; P ¼ .03). Conclusions: Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.

show abstract

Section: Discussionsupporting

confidence: 71%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

See 2 more Smart Citations

Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit

Landry

Mostul

Ahn

et al. 2018

Journal of Vascular Surgery

View full text Add to dashboard Cite

show abstract

“…If vasopressors actually caused critical limb ischemia, this complication logically should occur right away, not a median of 3 days later. The view that limb ischemic necrosis can be caused by vasopressor use is held by some clinicians, perhaps because of anecdotal reports of patients so treated who were profoundly septic and coagulopathic and where all relevant pathophysiological factors had not been fully considered …”

Section: Discussionmentioning

confidence: 99%