The Epidemiology of Extremity Threat and Amputation after Vasopressor-Dependent Sepsis

Reitz, Katherine M.; Kennedy, Jason; Rieser, Caroline; Hlavin, Callie; Gershengorn, Hayley B.; Neal, Matthew D.; Bensen, Nicole; Linstrum, Kelsey; Prescott, Hallie C.; Rosengart, Matthew R.; Talisa, Victor B.; Hall, Daniel E.; Tzeng, Edith; Wunsch, Hannah; Yende, Sachin; Angus, Derek C.; Seymour, Christopher W.

doi:10.1513/annalsats.202105-547oc

Cited by 9 publications

(11 citation statements)

References 43 publications

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“…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 ).…”

Section: Discussionmentioning

confidence: 99%

“…Predicting which limbs will require amputation is similarly difficult, though may include coagulopathy and weight loss in infants, and long bone injury, coagulopathy, and neurologic disorder in adolescents ( 13 ). In vasopressor-dependent sepsis, amputation risk may increase with higher sequential organ failure assessment scores, INR, lactate, lower platelet count, and culture positive sepsis ( 15 ). It is also likely that loss of venous doppler ultrasonography represents irreversible injury ( 39 ).…”

Section: Discussionmentioning

confidence: 99%

“…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).…”

Section: Introductionmentioning

confidence: 99%

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

et al. 2023

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BackgroundAcute limb ischemia due to microvascular malperfusion may be refractory to initial therapies. Medicinal leech therapy (hirudotherapy) has been attempted in plastic and reconstructive surgery to improve venous congestion in ischemic flaps; however, there are minimal reports related to ischemia secondary to arterial malperfusion. We evaluated a pediatric cohort from an academic intensive care unit with refractory limb ischemia in whom hirudotherapy was attempted to elucidate its use and outcomes.MethodInstitutional patient database was queried to identify pediatric patients (<18 years) who received hirudotherapy in the pediatric critical care unit and met inclusion/exclusion criteria. Patient charts were evaluated for indices including demographics, primary disease, coagulative status, vascular access, vasoactive medication dosing, bleeding, leech use, limb and mortality outcomes. Data was evaluated to identify trends or suspected impact on outcomes.ResultsHirudotherapy was used in 7 patients for limb ischemia, 5 with congenital heart disease, and 2 others with viremic shock. Time to leech application following recognition of ischemia averaged 3 days, with duration of use averaging 3.9 days. Five patients discontinued therapy due to bleeding. Mortality rate was 57%, all secondary to multiorgan failure. In 3 surviving patients, 4 of 5 treated limbs resulted in at minimum partial amputation. Vasoactive-inotropic score tended higher prior to leech application, suggesting a vasoconstrictive pathway for arterial malperfusion. No identifiable trends appeared associated with salvaged limb or adverse effects. Blood loss predictably increased with leech application, as did total transfusion requirement.ConclusionThis case series establishes baseline data for use of hirudotherapy in critically ill children with acute limb ischemia caused by arterial malperfusion. Based on this retrospective cohort, we cannot recommend routine use of hirudotherapy for acute limb ischemia from arterial malperfusion in the pediatric intensive care unit. Application of leeches should be aligned with a protocol defining start and stop parameters, standardized leech utilization, and monitoring for adverse outcomes. Future study would benefit from consensus definitions of study outcomes, including perfusion recovery, tissue/limb salvage and bleeding manifestations. Additional prospective studies are needed prior to any standard or systematic recommendations for use.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

et al. 2023

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“…Conversely, the vasopressors noradrenaline and vasopressin are considered the first- and second-line drugs for patients with septic shock, respectively, as they correct vascular tone depression and improve organ perfusion pressure 17 . However, they also cause peripheral (digital, limb, and mesenteric) ischemia because of PP impairment induced by their vasoconstrictive effects 17 , 18 . Therefore, interventions aimed at reducing or discontinuing these drugs may effectively improve PP especially in cases with abnormal PP, also called cold shock.…”

Section: Discussionmentioning

confidence: 99%

“…However, its effectiveness in reducing mortality is unproven 16 , and its use is not recommended in the guidelines 1 , 2 . Meanwhile, several randomized controlled trials (RCTs) and meta-analyses have confirmed that PMX-DHP indeed increases blood pressure 16 , resulting in reduced doses of vasopressors 15 , which exert adverse effects on PP 17 , 18 . PMX-DHP reportedly induces vasoconstriction in patients with excessively dilated peripheral blood vessels by adsorbing anandamide, 2-arachidonylglycerol, and nitric oxide, thus contributing to improved hemodynamics 15 , 19 .…”

Section: Introductionmentioning

confidence: 99%

Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion

Sekino

Murakami

Sato

et al. 2023

Sci Rep

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Abnormal peripheral perfusion (PP) worsens the prognosis of patients with septic shock. Polymyxin B-direct hemoperfusion (PMX-DHP) increases blood pressure and reduces vasopressor doses. However, the modification of PP following administration of PMX-DHP in patients with vasopressor-dependent septic shock have not yet been elucidated. A retrospective exploratory observational study was conducted in patients with septic shock treated with PMX-DHP. Pulse-amplitude index (PAI), vasoactive inotropic score (VIS), and cumulative fluid balance data were extracted at PMX-DHP initiation (T0) and after 24 (T24) and 48 (T48) h. Changes in these data were analyzed in all patients and two subgroups (abnormal PP [PAI < 1] and normal PP [PAI ≥ 1]) based on the PAI at PMX-DHP initiation. Overall, 122 patients (abnormal PP group, n = 67; normal PP group, n = 55) were evaluated. Overall and in the abnormal PP group, PAI increased significantly at T24 and T48 compared with that at T0, with a significant decrease in VIS. Cumulative 24-h fluid balance after PMX-DHP initiation was significantly higher in the abnormal PP group. PMX-DHP may be an effective intervention to improve PP in patients with abnormal PP; however, caution should be exercised as fluid requirements may differ from that of patients with normal PP.

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Invited commentary on Sepsis

Reitz

Angus

2023

Surgery

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The Epidemiology of Extremity Threat and Amputation after Vasopressor-Dependent Sepsis

Cited by 9 publications

References 43 publications

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

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

Modifications of peripheral perfusion in patients with vasopressor-dependent septic shock treated with polymyxin B-direct hemoperfusion

Invited commentary on Sepsis

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