Ischemic limb necrosis in septic shock: What is the role of high‐dose vasopressor therapy?

Levy, Jerrold H.; Ghadimi, Kamrouz; Faraoni, David; Diepen, Sean van; Lévy, Bruno; Hotchkiss, Richard S.; Connors, Jean M.; Iba, Toshiaki; Warkentin, Theodore E.

doi:10.1111/jth.14566

Cited by 23 publications

(18 citation statements)

References 38 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…This characteristic gap in time between onset of shock and initiation of vasopressors, and subsequent onset of SPG, which we have noted repeatedly in cases of SPG and PF we have analyzed [1,2,8,40,58,99], has been observed also by others [101]. Skepticism regarding a causal vasopressor role is shared by other experts in thrombosis and hemostasis, given that reports of ischemic limb injury in critically ill patients receiving vasopressor therapy have usually not included information on relevant risk factors such as concurrence of DIC and acute or chronic liver failure [102].…”

Section: Vasopressorsmentioning

confidence: 74%

Symmetrical peripheral gangrene in critical illness

Warkentin

Ning

2021

Transfusion and Apheresis Science

Self Cite

View full text Add to dashboard Cite

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.

show abstract

Section: Vasopressorsmentioning

confidence: 74%

Symmetrical peripheral gangrene in critical illness

Warkentin

Ning

2021

Transfusion and Apheresis Science

Self Cite

View full text Add to dashboard Cite

show abstract

“…In a recent study, Levy et al 11 suggest the distal necrosis may not be due to the vasopressor therapy, but a consequence of disseminated intravascular coagulopathy (DIC) and/or shock liver, a complication which our patient presented. They conducted a systematic review of high dose vasopressors treatment and found no direct link of distal ischemia to the therapy.…”

Section: Discussionmentioning

confidence: 59%

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

Masaragian¹,

Perin²,

Coria³

et al. 2019

Journal of Foot and Ankle Surgery (Asia Pacific)

View full text Add to dashboard Cite

The symmetrical peripheral gangrene syndrome is characterized by ischemic distal lesions in two or more extremities, without the obstruction of large vessels. The ischemia affecting extremities takes place when the arterial blood flow is insufficient to satisfy the metabolic demands of muscles in rest. We present a 22-year-old patient treated with norepinephrine after a septic shock suspicion who presented distal ischemia of fingers, toes, and scalp. There is no consensus about the initial treatment. Improved data gathering is necessary for a better understanding of the mechanisms involved, which could improve treatment and prevent amputation as the final therapeutic option.

show abstract

“…A second issue is the safety profile for vasopressor administration via peripheral intravenous catheters. The guidelines 2008 recommended administration of vasopressors only via a central line [8] based on concerns regarding complications such as tissue necrosis and limb ischemia [12].…”

Section: Discussionmentioning

confidence: 99%