Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia

Abstract

Patients admitted to the ICU are more likely to sustain an acute ischemic event of an upper extremity with more vasopressor usage. Patients who received alpha-adrenergic activating vasopressors were more likely to sustain limb ischemia. When discoloration of an extremity is detected, patients should receive counteractive treatments in an effort to salvage the extremity and prevent function loss.

Vasopressor-induced ischemia of bilateral feet in a previously healthy 34-year-old female

“…The prevalence and incidence of digital necrosis is difficult to establish because it is a secondary diagnosis that may not be accurately recorded in patients' electronic medical records. 9 In addition, as was the case with our patient, referral to the appropriate surgical specialty is often delayed after onset of ischemic changes. Oftentimes digital ischemia is viewed as a tolerable outcome due to the medical adage "life over limb."…”

“…Oftentimes digital ischemia is viewed as a tolerable outcome due to the medical adage "life over limb." 9 Although sustainment of life undoubtedly takes priority over limb preservation, we should not depreciate the treatment of ischemic limbs solely because we feel we have to choose one over the other. This raises the question of whether prophylactic vasodilatory therapy to prevent ischemia and eventual amputation of peripheral structures should be initiated when beginning a critically ill patient on vasopressors.…”

“…Newbury et al recommends the use of nitrogen paste to the affected digits at first presentation of abnormal color, as well as the use of calcium channel blockers to assist with peripheral vasodilation, and temperature regulation with indirect heat or warming blankets on the affected limbs. 9 Additionally, anticoagulation therapy in a hemodynamically stable patient should be considered if not already being administered. 9 Various other case studies have shown that use of topical nitroglycerin patch with meticulous monitoring successfully alleviates impending peripheral gangrene in neonates.…”

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene

“…BT may reduce the risk of disfigurement and amputation from SPG, and it could be useful when a patient is developing SPG and may remain on vasopressor support for a prolonged period. 4 High-quality studies are warranted to investigate this potential use, although conducting such studies is difficult due to the low incidence and high mortality of the condition.…”

“… 9 It has also recently been recommended as a treatment option for vasopressor- and trauma-induced digital ischemia. 4 , 10 , 11 We present a case report to highlight the potential use of BT in the treatment of vasopressor-associated SPG.…”