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Nakamura K, Nakano H, Ikechi D, Mochizuki M, Takahashi Y, Koyama Y, Hashimoto H, Abe T, Hayakawa M, Yamakawa K. The Vasopressin Loading for Refractory septic shock (VALOR) study: a prospective observational study. Crit Care 2023; 27:294. [PMID: 37480126 PMCID: PMC10362561 DOI: 10.1186/s13054-023-04583-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 07/17/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Vasopressin is a second-line vasoactive agent for refractory septic shock. Vasopressin loading is not generally performed because of the lack of evidence for its effects and safety. However, based on our previous findings, we hypothesized it can predict the responsibility to vasopressin infusion with safety, and prospectively examined it in the present study. METHODS Vasopressin loading was performed via the intravenous administration of a bolus of 1 U, followed by its continuous infusion at 1U/h in patients with septic shock treated with ≥ 0.2 μg/kg/min noradrenaline. An arterial pressure wave analysis was conducted, and endocrinological tests were performed immediately prior to vasopressin loading. We classified patients into responders/non-responders based on mean arterial pressure (MAP) changes after vasopressin loading. Based on our previous findings, the lower tertile of MAP changes was selected as the cut-off. The change in the catecholamine index (CAI) after 6 h was assigned as the primary outcome. Digital ischemia, mesenteric ischemia, and myocardial ischemia during the admission period were prospectively and systematically recorded as adverse events. RESULTS Ninety-two patients were registered during the study period and examined. Sixty-two patients with a MAP change > 22 mmHg were assigned as responders and the others as non-responders. Blood adrenocorticotropic hormone levels were significantly higher in non-responders. Stroke volume variations were higher in responders before loading, while stroke volume and dP/dtmax were higher in responders after loading. Median CAI changes were - 10 in responders and 0 in non-responders, which was significantly lower in the former (p < 0.0001). AUROC of MAP change with vasopressin loading to predict CAI change < 0 after continuous infusion was 0.843 with sensitivity of 0.92 and specificity of 0.77. Ischemia events were observed in 5 cases (5.4%). CONCLUSIONS Vasopressin loading may be safely introduced for septic shock. Vasopressin loading may be used to predict responses to its continuous infusion and select appropriate strategies to increase blood pressure.
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Affiliation(s)
- Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Daisuke Ikechi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Yasuaki Koyama
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, 2-1-1, Jonan-cho, Hitachi, Ibaraki 317-0077 Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, 1187-299, Kaname, Tsukuba, Ibaraki 300-2622 Japan
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, 1-1-1, Tennodai, Tsukuba, Ibaraki 305-8575 Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Kita 14-jo Nishi 5-chome, Kita-ku, Sapporo-shi, Hokkaido 060-8648 Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College Hospital, 2-7, Daigakumachi, Takatsuki, Osaka 569-8686 Japan
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Achieving Functional Outcomes after Surgical Management of Catastrophic Vasopressor-induced Limb Ischemia. Plast Reconstr Surg Glob Open 2022; 10:e4175. [PMID: 35265449 PMCID: PMC8901208 DOI: 10.1097/gox.0000000000004175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 01/06/2022] [Indexed: 12/02/2022]
Abstract
Vasopressor-induced limb ischemia is an unfortunate complication that can occur in patients treated for septic shock. Current literature lacks surgical treatment recommendations for this condition, besides amputation. We describe various reconstructive surgeries and functional outcomes in patients treated surgically for vasopressor-induced limb ischemia.
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The Epidemiology of Extremity Threat and Amputation Following Vasopressor-dependent Sepsis. Ann Am Thorac Soc 2021; 19:625-632. [PMID: 34644242 DOI: 10.1513/annalsats.202105-547oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Extremity threat and amputation following sepsis is a well-publicized and devastating event. However, there is a paucity of data exists surrounding theabout the epidemiology of extmreityextremity threat following sepsis onset. OBJECTIVES We aim toTo estimate the incidence of extremity threat with or without surgical amputation in community sepsis. METHODS Multihospital Rretrospective cohort study of adults with Sepsis-3 hospitalized at XX14 academic and community sites from 2013 to 2017. Vasopressor-dependent sepsis was identified by administration epinephrine, norepinephrine, phenylephrine, vasopressin, or dopamine for >1 hour during the 48 hours before to 24 hours following sepsis onset. Outcomes included the incidence of extremity threat, defined as acute onset ischemia, with or without amputation in the 90 days following sepsis onset. The association between extremity threat, and demographics, comorbid conditions, and, and time-varying sepsis treatment factorss were evaluated using a Cox-proportional hazards model. RESULTS Among 24,365 adults with sepsis, 12,060 (54%) were vasopressor-dependent (mean±standard deviation SD age, 64±16 years; male, 6,548 [54%]; sequential organ failure assessment (SOFA), 10±4). Of these, 231 (2%) patients had a threatened extremity with 26 undergoing 37 amputations, a risk of 2.2 (95% CI: 1.4-3.2) per 1,000, and 205 not undergoing amputation, a risk of 17.0 (95% CI: 14.8-19.5) per 1,000. 95% of the total 37Most amputations occurred in lower extremities (95%), a median (interquartile range) of 16 (6.3-4039.9) days after sepsis onset. Compared to patients with no extremity threat, patients with threat had a higher sequential organ failure assessmentSOFA score (11±4 vs 10±4; P < 0.001), serum lactate (4.6 mmol/L [2.4-8.7] vs 3.1 [1.7-6.0]; P < 0.001), and more bacteremia (n = 37 [37%??] vs n = 2,087 [26%]; P < 0.001) at sepsis onset. Peripheral vascular disease, congestive heart failure, sequential organ failure assessmentSOFA score, and norepinephrine equivalents were significantly associated with the risk of extremity threat. CONCLUSIONS The evaluation of a threatened extremity resulting in surgical amputation occurred in 2 per 1,000 patients with vasopressor-dependent sepsis.
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Hussein AA, Sabry NA, Abdalla MS, Farid SF. A prospective, randomised clinical study comparing triple therapy regimen to hydrocortisone monotherapy in reducing mortality in septic shock patients. Int J Clin Pract 2021; 75:e14376. [PMID: 34003568 DOI: 10.1111/ijcp.14376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/09/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES This prospective, comparative and randomised clinical study evaluated the effectiveness of triple therapy regimen (hydrocortisone, thiamine and vitamin C) versus hydrocortisone alone in reducing the mortality rate and preventing progressive organ dysfunction in septic shock patients. METHODS A total of 94 patients were randomly assigned to one of two groups: the first group received hydrocortisone 50 mg/6-h IV for 7 days or till intensive care unit (ICU) discharge, if sooner, followed by tapering. The second group received hydrocortisone 50 mg/6-h IV for 7 days or ICU discharge followed by tapering, vitamin C 1.5 g/6-h IV for 4 days or till ICU discharge and thiamine 200 mg/12-h IV for 4 days or till ICU discharge. RESULTS The triple therapy regimen showed a non-significant reduction in 28-day mortality compared to hydrocortisone alone (17 [36.2%] vs. 21 [44.7%]; P = .4005), but it was significantly lower than the control group regarding shock time and the duration of vasopressor use in days (4.000 [3.000-7.000]; 5.000 [4.000-8.000], [P = .0100]). The patients in the control group were likely to get 0.59 more in SCr level than those in the intervention group by a linear regression model which was significant (P < .05). Also, the number of patients who developed a fever after 216 hours was significantly higher in the control group (P value = .0299). CONCLUSION Vitamin C, thiamine, and hydrocortisone regimen for septic shock management showed non-significant efficacy in decreasing 28-day mortality when compared to hydrocortisone monotherapy. On the other hand, it showed significant efficacy in decreasing the shock time and duration on vasopressors.
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Affiliation(s)
| | - Nirmeen A Sabry
- Clinical pharmacy department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Maged S Abdalla
- Anaesthesia and Critical Care department, Faculty of Medicine (Kasr-el Ainy), Cairo University, Cairo, Egypt
| | - Samar F Farid
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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Change of the Pattern of the Demographic Characteristics of the Patients with Endocarditis: Clinical Case of Infectious Endocarditis in Man with Injectible Drug Dependence, Complicated with Pneumonia and Peripheral Necroses of Feet, Arms, Nose (Own Clinical Observations and Experience of Education in State and English Language). Fam Med 2021. [DOI: 10.30841/2307-5112.2-3.2021.240770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Infectious endocarditis is multisystem disease, which is the result of the infection (usually bacterial) of endocardial heart surface. Despite of the latest medical achievements in diagnostics and treatment, infectious endocarditis is still a disease with high mortality rate and severe complications. During last decades in developed countries there are obvious changes of demographic characteristics of the patients with infectious endocarditis, namely increasing of aged patients with degenerative valvular diseases, of patients with anamnesis of invasive manipulations and procedures. Beside with well known risk factors (artificial valves and implanted heart devices), there are increasing roles of injectible drug-dependence, human immunodeficiency virus and wide contact with health protection system as predisposing factors for infectious endocarditis. The article contains literature data of the main populational risk groups of infectious endocarditis.
Clinical case of severe (fatal) infectious endocarditis in patient with injectible drug dependence is submitted. Special features of the case are peripheral dry necroses of feet, arms, nose, which are very close to the description of symmetrical peripheral gangrene. This rare disorder was first described by Hutchinson in 1891 in 37-year old man, who had gangrene of fingers, hands and ears after shock. Symmetrical peripheral gangrene can be induced by different infection and non-inflection causes. The majority of these cases are connected to the treatment of cardiogenic shock with disseminated intravascular coagulation.
Submitted description of the case of symmetrical peripheral gangrene in patient with infectious endocarditis will be useful for different medical care specialists as a reminder of the necessity of constant monitoring of the skin color of the distal parts of the limbs in severe sick patients.
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Magnin M, Amson H, Vacheron CH, Thiollière F, Piriou V, Junot S, Bonnet Garin JM, Allaouchiche B. Associations between peripheral perfusion disorders, mean arterial pressure and dose of norepinephrine administrated in the early phase of septic shock. Clin Exp Pharmacol Physiol 2021; 48:1327-1335. [PMID: 34133795 DOI: 10.1111/1440-1681.13540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 09/11/2020] [Accepted: 06/14/2021] [Indexed: 11/27/2022]
Abstract
The aim of the study was to explore the correlations between peripheral perfusion, mean arterial pressure and the dose-rate of norepinephrine (NE) infused for the treatment of septic shock. The study is retrospective analysis of data acquired prospectively on 57 patients during the first 24 hours after the occurrence of the shock. Clinical and haemodynamic characteristics, skin perfusion parameters (capillary refill time [CRT], mottling score and temperature gradients) and the dose rate of NE infusion were collected. Negative correlations between mean arterial pressure (MAP) and temperature gradients (core-to-toe: P = .03, core-to-index: P = .04) were found and abnormal CRT was associated with lower MAP (P = .02). The dose rate of NE was negatively correlated with temperature gradients (core-to-toe: P = .02, core-to-index: P = .01, forearm-to-index: P = .008) in the overall population. In patients receiving NE for at least 12 hours, the NE dose rate positively was correlated with the mottling score (P = .006), temperature gradients (core-to-toe: P = .04, forearm-to-index: P = .02, core-to-index: P = .005) and CRT (P = .001). The dose of NE administrated was associated with 14-days mortality (odds ration [OR] = 1.21 [1.06-1.38], P = .006) and with 28-days mortality (OR = 1.17 [1.01-1.36], P = 0.04). In conclusion, the study described the presence of correlations between peripheral perfusion and MAP and between peripheral perfusion and the dose rate of NE infusion.
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Affiliation(s)
- Mathieu Magnin
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Physiology, University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Harry Amson
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France.,PHE3ID, Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS UMR 5308, Université Claude Bernard Lyon 1, Lyon, France.,Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Charles-Hervé Vacheron
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France.,PHE3ID, Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, CNRS UMR 5308, Université Claude Bernard Lyon 1, Lyon, France.,Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Fabrice Thiollière
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France
| | - Vincent Piriou
- Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France
| | - Stéphane Junot
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Anesthesiology, University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Jeanne-Marie Bonnet Garin
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Physiology, University of Lyon, VetAgro Sup, Marcy l'Etoile, France
| | - Bernard Allaouchiche
- University of Lyon, APCSe Agressions Pulmonaires et Circulatoires dans le Sepsis (Pulmonary and circulatory disorders in sepsis), VetAgro Sup, Marcy l'Etoile, France.,Intensive care unit, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, University of Lyon, Pierre-Bénite, France
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Nakamura K, Nakano H, Naraba H, Mochizuki M, Takahashi Y, Sonoo T, Hashimoto H, Abe T, Hayakawa M, Yamakawa K. Vasopressin Loading for Refractory Septic Shock: A Preliminary Analysis of a Case Series. Front Med (Lausanne) 2021; 8:644195. [PMID: 34017842 PMCID: PMC8129171 DOI: 10.3389/fmed.2021.644195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Vasopressin is one of the strong vasopressor agents associated with ischemic events. Responses to the administration of vasopressin differ among patients with septic shock. Although the administration of a high dose of vasopressin needs to be avoided, the effects of bolus loading have not yet been examined. Since the half-life of vasopressin is longer than that of catecholamines, we hypothesized that vasopressin loading may be effective for predicting responses to its continuous administration. Methods: We retrospectively analyzed consecutive cases of septic shock for which vasopressin was introduced with loading under noradrenaline at >0.2 μg/kg/min during the study period. Vasopressin was administered in a 1 U bolus followed by its continuous administration at 1 U/h. The proportion of patients with a negative catecholamine index (CAI) change 6 h after the introduction of vasopressin was set as the primary outcome. We defined non-responders for exploration as those with a mean arterial pressure change <18 mmHg 1 min after vasopressin loading, among whom none had a change in CAI <0. Results: Twenty-one consecutive cases were examined in the present study, and included 14 responders and 7 non-responders. The primary outcome accounted for 71.4% of responders and 0% of non-responders, with a significant difference (p = 0.0039). Median CAI changes 2, 4, and 6 h after the administration of vasopressin were 0, -5, and -10 in responders and +20, +10, and +10 in non-responders, respectively. CAI was not reduced in any non-responder. Outcomes including mortality were not significantly different between responders and non-responders. Digital ischemia (1/21) and mesenteric ischemia (1/21) were observed. Conclusions: Vasopressin loading may predict responses to its continuous administration in septic shock patients. Further investigations involving a safety analysis are needed.
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Affiliation(s)
- Kensuke Nakamura
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Hidehiko Nakano
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Hiromu Naraba
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan.,TXP Medical Co., Ltd., Tokyo, Japan
| | - Masaki Mochizuki
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Yuji Takahashi
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Tomohiro Sonoo
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan.,TXP Medical Co., Ltd., Tokyo, Japan
| | - Hideki Hashimoto
- Department of Emergency and Critical Care Medicine, Hitachi General Hospital, Ibaraki, Japan
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo-shi, Japan
| | - Kazuma Yamakawa
- Department of Emergency Medicine, Osaka Medical College Hospital, Takatsuki, Japan
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8
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Nakamoto K, Skaff PR, McCully BH, Gress TW, Mozaffari FB, Denning DA. Effects of Norepinephrine Infusion on Cutaneous Surface Temperatures of the Distal Extremities. South Med J 2021; 114:180-185. [PMID: 33655313 DOI: 10.14423/smj.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The etiology of vasopressor-induced digital necrosis is poorly understood, but the skin changes resemble those of frostbite, and it is known from experience that patients taking vasopressors have decreased digital temperatures. We aimed to examine the effects of norepinephrine use on surface temperatures of the distal extremities because there have been no studies examining this relation. METHODS Surface temperatures of all digits, palms, and soles were measured using an infrared thermometer in patients receiving different rates of norepinephrine infusion in the intensive care unit and compared with those not receiving any vasopressors. RESULTS A total of 101 measurements from 41 unique individuals were obtained. Temperature gradients between the core and the fingertips were consistently more pronounced in those receiving norepinephrine compared with those not receiving norepinephrine and increased with increasing rates of norepinephrine infusion, except with high-dose norepinephrine. Temperature gradients were more pronounced in the toes. CONCLUSIONS Norepinephrine use was associated with greater core-to-fingertip temperature gradients and were more pronounced in the toes compared with the fingers.
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Affiliation(s)
- Keitaro Nakamoto
- From the Department of Surgery and Clinical and Translational Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Paulina R Skaff
- From the Department of Surgery and Clinical and Translational Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Brian H McCully
- From the Department of Surgery and Clinical and Translational Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Todd W Gress
- From the Department of Surgery and Clinical and Translational Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Farid B Mozaffari
- From the Department of Surgery and Clinical and Translational Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - David A Denning
- From the Department of Surgery and Clinical and Translational Sciences, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
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9
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Abstract
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.
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Affiliation(s)
- Theodore E Warkentin
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; Service of Clinical Hematology, Hamilton General Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada.
| | - Shuoyan Ning
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Pathology and Molecular Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada; McMaster Centre for Transfusion Research, Canada; Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada; St. Joseph's Healthcare, Hamilton, Ontario, Canada
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10
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Vogt PM, Mett TR, Bingoel AS, Jokuszies A, Krezdorn N. Reconstruction of Basic Hand Function by a Free Osteocutaneous Spare-Part Flap From the Lower Leg After Septicemia: A Case Report. Hand (N Y) 2021; 16:NP5-NP9. [PMID: 32100571 PMCID: PMC7818030 DOI: 10.1177/1558944720906499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Spare-part surgery is widely accepted and offers an option in extremely traumatized patients for reconstructive maneuvers. Standardized techniques are lacking, and the therapy needs to fit the patient's clinic. Materials and Methods: In a woman with necrosis of almost all extremities due to septic infection, we used the lower leg as a free osteocutaneous flap to reconstruct a basic hand function after amputation. The fibula segment was buried alongside the remaining first metacarpal bone. On the hand stump, 2 short metacarpals were lengthened using the remaining 2 metacarpals as osteovascular on-top plasties. The flap was microsurgically anastomosed end-to-side to the ulnar artery. After 3 months, the buried fibula was trimmed to the necessary thumb length and fixed to the local metacarpal I stump. Secondary procedures were performed to deepen the first web space. Results: The patient is now able to manage her daily life. Also, she is able to put on her prosthesis on both legs and walk without aids. Conclusions: To our knowledge, this is the first description of successful microvascular transfer of an osteocutaneous free flap from an amputated lower leg of this size and could present a valuable technique for other cases.
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Affiliation(s)
- Peter Maria Vogt
- Hannover Medical School, Germany,Peter Maria Vogt, Department of Plastic, Aesthetic,
Hand and Reconstructive Surgery, Burn Centre, Hannover Medical School, Carl-Neuberg-Str.
1, Hannover 30625, Germany.
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11
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Macheka KT, Masamha T, Mungani H, Kumirayi L. Symmetrical peripheral gangrene: A rare clinical entity. Clin Case Rep 2020; 8:2914-2917. [PMID: 33363850 PMCID: PMC7752447 DOI: 10.1002/ccr3.3300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/08/2020] [Accepted: 08/09/2020] [Indexed: 11/18/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) may present initially with septicemia. Prompt identification and management of the underlying cause of SPG is central for the best outcome. Good management incorporates delaying early surgical intervention, suitable antibiotic therapy, judicious debridement, and skin grafting.
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Affiliation(s)
- Kudzai T. Macheka
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
| | - Tasimbanashe Masamha
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
| | - Hopewell Mungani
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
| | - Linda Kumirayi
- Department of SurgeryCollege of Health SciencesParirenyatwa HospitalHarareZimbabwe
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12
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Livesey M, Jauregui JJ, Hamaker MC, Pensy RA, Langhammer CG, Eglseder WA. Management of vasopressor induced ischemia. J Orthop 2020; 22:497-502. [PMID: 33100742 DOI: 10.1016/j.jor.2020.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/06/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis. Methods We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients. Results Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases. Conclusion Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of "life over limb," and may be safely performed with acceptable outcomes.
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Affiliation(s)
- Michael Livesey
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Julio J Jauregui
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Max C Hamaker
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Raymond A Pensy
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Christopher G Langhammer
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - W Andrew Eglseder
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
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Oh TK, Song IA. Incidence and associated risk factors for limb amputation among sepsis survivors in South Korea. J Anesth 2020; 35:51-58. [PMID: 33025150 PMCID: PMC7538278 DOI: 10.1007/s00540-020-02858-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 09/19/2020] [Indexed: 11/29/2022]
Abstract
Purpose Peripheral gangrene (PG) is a known complication requiring limb amputation among sepsis survivors; however, its incidence and associated risk factors remain controversial. We aimed to examine the incidence of limb amputation among sepsis survivors, and to investigate factors independently associated with limb amputation. Methods In this population-based cohort study, data obtained from the South Korean national health insurance service database between 2015 and 2016 were analyzed. A sepsis survivor was defined as someone having survived > 90 days after initiation of treatment for sepsis. Results Of 19,906 sepsis survivors, 163 (0.8%) had undergone surgical limb amputation. In a multivariable model, male sex (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.26–2.40; P = 0.001), dopamine infusion (OR 1.78, 95% CI 1.22–2.60; P = 0.003), epinephrine infusion (OR 2.04, 95% CI 1.30–3.20; P = 0.002), continuous renal replacement therapy (OR 3.34, 95% CI 2.01–3.20; P < 0.001), diabetes mellitus (DM) without chronic complication (OR 1.73, 95% CI 1.19–2.51; P = 0.004), DM with chronic complication (OR 3.49, 95% CI 2.32–5.26; P < 0.001), and peripheral arterial disease (OR 6.79, 95% CO 3.70–12.46; P < 0.001) were associated with a higher incidence of limb amputation among sepsis survivors. Conclusions In South Korea, 0.8% of sepsis survivors underwent limb amputation for the treatment of PG. Furthermore, the incidence of limb amputation was higher among the sepsis survivors having some underlying diseases (DM and peripheral arterial diseases) or receiving certain vasopressor treatments (epinephrine and dopamine). Electronic supplementary material The online version of this article (10.1007/s00540-020-02858-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tak Kyu Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, Korea
| | - In-Ae Song
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, 166 Gumi-ro, Bundang-gu, Seongnam, 463-707, Korea.
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Distribution and relative expression of vasoactive receptors on arteries. Sci Rep 2020; 10:15383. [PMID: 32958803 PMCID: PMC7505843 DOI: 10.1038/s41598-020-72352-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 08/31/2020] [Indexed: 02/05/2023] Open
Abstract
Arterial tone is regulated by multiple ligand-receptor interactions, and its dysregulation is involved in ischemic conditions such as acute coronary spasm or syndrome. Understanding the distribution of vasoactive receptors on different arteries may help guide the development of tissue-specific vasoactive treatments against arterial dysfunction. Tissues were harvested from coronary, mesenteric, pulmonary, renal and peripheral human artery (n = 6 samples of each) and examined using a human antibody array to determine the expression of 29 vasoactive receptors and 3 endothelin ligands. Across all types of arteries, outer diameter ranged from 2.24 ± 0.63 to 3.65 ± 0.40 mm, and AVPR1A was the most abundant receptor. The expression level of AVPR1A in pulmonary artery was similar to that in renal artery, 2.2 times that in mesenteric artery, 1.9 times that in peripheral artery, and 2.2 times that in coronary artery. Endothelin-1 was expressed at significantly higher levels in pulmonary artery than peripheral artery (8.8 times), mesenteric artery (5.3 times), renal artery (7.9 times), and coronary artery (2.4 times). Expression of ADRA2B was significantly higher in coronary artery than peripheral artery. Immunohistochemistry revealed abundant ADRA2B in coronary artery, especially vessels with diameters below 50 μm, but not in myocardium. ADRA2C, in contrast, was expressed in both myocardium and blood vessels. The high expression of ADRA2B in coronary artery but not myocardium highlights the need to further characterize its function. Our results help establish the distribution and relative levels of tone-related receptors in different types of arteries, which may guide artery-specific treatments.
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Ennis J, Ahmed O, Khalid M, Boland PA, Allen M. Meningococcal Sepsis Complicated by Symmetrical Peripheral Gangrene: A Case Report. Cureus 2020; 12:e9470. [PMID: 32874799 PMCID: PMC7455390 DOI: 10.7759/cureus.9470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare complication of septicaemia and disseminated intravascular coagulation (DIC) characterised by distal ischaemia in two or more extremities without large vessel obstruction. SPG has high mortality and morbidity rates, though consensus guidelines for management have yet to be produced. We herein present the case of a 28-year-old woman with meningococcal septicaemia complicated with extensive bilateral upper and lower limb SPG. We discuss the various management options of SPG. While reported cases are scarce in the literature, early recognition of sepsis and prompt withdrawal of vasoconstrictors in an intensive care setting, combined with timely heparinisation, appear to be the most common management strategy thus far.
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Affiliation(s)
- Jessica Ennis
- General Surgery, Connolly Hospital Blanchardstown, Dublin, IRL
| | - Ola Ahmed
- General Surgery, Connolly Hospital Blanchardstown, Dublin, IRL
| | - Muhammad Khalid
- Medicine, The Mater Misericordiae University Hospital, Dublin, IRL.,Medicine, Connolly Hospital Blanchardstown, Dublin, IRL
| | | | - Michael Allen
- General Surgery, Connolly Hospital Blanchardstown, Dublin, IRL
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Endovascular Perfusion Augmentation for Critical Care: Partial Aortic Occlusion for Treatment of Severe Ischemia-Reperfusion Shock. Shock 2020; 51:659-666. [PMID: 29877961 DOI: 10.1097/shk.0000000000001199] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The resuscitation of patients in shock is materially intensive and many patients are refractory to maximal therapy. We hypothesized that partial inflation of an intra-aortic balloon, termed Endovascular Perfusion Augmentation for Critical Care (EPACC), would minimize material requirements while improving physiologic metrics. METHODS Swine underwent a 25% controlled bleed and 45 min of complete aortic occlusion to create a severe ischemia-reperfusion shock state. Animals received either standardized critical care (SCC) composed of IV fluids and norepinephrine delivered through an algorithmically controlled platform or EPACC in addition to SCC. Physiologic parameters were collected, and blood was sampled for analysis. Primary outcomes were total IV fluids and average MAP during the critical care phase. Differences (P < 0.05) were measured with t test (continuous data) and Wilcoxon rank-sum test (ordinal data). RESULTS There were no differences in baseline characteristics. There were no differences in the maximum lactate; however, animals in the EPACC group had a higher average MAP (EPACC 65 mmHg, 95% confidence interval [CI], 65-66; SCC 60 mmHg, 95% CI, 57-63; P < 0.01) and remained within goal MAP for a greater period of time (EPACC 95.3%, 95% CI, 93.2-97.4; SCC 51.0%, 95% CI, 29.5-72.6; P < 0.01). EPACC animals required less IV fluids when compared with the SCC group (EPACC 21 mL/kg, 95% CI, 0-42; SCC 96 mL/kg, 95% CI, 76-117; P < 0.01). There were no differences in final lactate. Animals in the EPACC group had a higher final creatinine (EPACC 2.3 mg/dL, 95% CI, 2.1-2.5; SCC 1.7 mg/dL, 95% CI, 1.4-2.0; P < 0.01), but there were no differences in renal cellular damage on histology (P = 0.16). CONCLUSION Using a swine model of severe shock, the addition of EPACC to SCC significantly reduced fluid resuscitation requirements and improved blood pressure. This is the first description of a new therapy for patients in refractory shock or in resource-limited settings.
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Newbury A, Harper KD, Trionfo A, Ramsey FV, Thoder JJ. Why Not Life and Limb? Vasopressor Use in Intensive Care Unit Patients the Cause of Acute Limb Ischemia. Hand (N Y) 2020; 15:177-184. [PMID: 30073871 PMCID: PMC7076614 DOI: 10.1177/1558944718791189] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Acute limb ischemia (ALI) of the upper extremity is a rare yet severe condition in intensive care unit (ICU) patients that generally leads to amputation. The aim of this study is to determine risk factors for development of upper extremity limb ischemia in ICU patients requiring vasopressor support. Methods: This is a retrospective study conducted from 2010 to 2015. Patients who received vasopressors during ICU admission were considered for the study. Patients were identified via Current Procedural Terminology (CPT) billing codes. ALI patients were matched to control patients based on diagnosis and Acute Physiology and Chronic Health Evaluation II score. Days on pressors, number of pressors, total doses, and level of ischemia were recorded. Primary end point was doses, types, and days on vasopressors. Secondary end point was level of ALI. Results: Patients in the ALI group were more likely to be started on a higher number of different types of pressors (2.6 vs 1.3 pressors). ALI patients received pressors for 8.5 days compared with 1.6 days in control patients, and received 12.8 doses compared with 3.0 doses in control patients. In addition, vasopressors with alpha-adrenergic activity were more likely to be used in the ALI group. Level of ischemia was not linked to any of the tested variables. Conclusion: 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.
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Affiliation(s)
| | - Katharine D. Harper
- Temple University Hospital, Philadelphia, PA, USA,Katharine D. Harper, Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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Kurup V, Simpson RS. Sepsis-induced digital ischaemia in a professional pianist, in the absence of vasopressors. BMJ Case Rep 2019; 12:e229659. [PMID: 31653621 PMCID: PMC6827789 DOI: 10.1136/bcr-2019-229659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2019] [Indexed: 11/04/2022] Open
Abstract
Peripheral limb ischaemia and gangrene are devastating complications of pneumococcal sepsis. We report a 43-year-old professional pianist who presented with early sepsis and rapid development of this syndrome. No vasopressor medication was ever administered. We urgently reviewed the medical literature on a range of therapies recommended by consulting teams, to ensure he received optimal care. Based on our review and on feedback from the patient himself, we gained valuable insights into this illness and the merits of selected treatment options. His fingers ultimately recovered their function, intact, although several toes were later amputated. More recently published reviews postulate that imbalances in coagulation factors and natural anticoagulants occur as a result of disseminated intravascular coagulopathy and 'shock liver' in the sepsis syndrome, leading to microcirculatory thromboses. We submit this report as we believe it supports this hypothesis and adds further valuable information. We hope our observations will assist other critical care clinicians confronting this serious condition.
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Affiliation(s)
- Vishnu Kurup
- Intensive Care, Barwon Health, Geelong, Victoria, Australia
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Taylor D, Wyncoll D. Mottling reduction in the early phases of profound septic shock. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:268. [PMID: 31375126 PMCID: PMC6676589 DOI: 10.1186/s13054-019-2558-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/25/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Daniel Taylor
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK.
| | - Duncan Wyncoll
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
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20
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Guirguis E, Grace Y, Maarsingh H, Tran TC, Tkachuk E. Vitamin C, Thiamine, and Steroids in the Sepsis Conquest: Replete to Defeat. J Pharm Pract 2019; 33:682-695. [PMID: 31238773 DOI: 10.1177/0897190019851923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Sepsis and septic shock are significant health issues in the United States. Novel treatment options focusing on mitigating the dysregulated host response while reducing the need for vasopressor support are needed. This review discusses ascorbic acid, thiamine, and steroids as monotherapy and in combination for the treatment of sepsis and septic shock. SUMMARY The results of clinical studies using ascorbic acid, thiamine, and steroids as monotherapy or in combination are reviewed. High doses of IV ascorbic acid improved organ failure evidenced by changes in SOFA scores, declining CRP and PCT levels, and reduced vasopressor use. Thiamine initiation improved lactate levels in thiamine deficient patients in one study and demonstrated quicker lactate clearance and lower 28-day mortality in another study. Steroid studies demonstrated greatest benefit when initiating hydrocortisone and fludrocortisone early in septic shock. Combination therapy with ascorbic acid, thiamine and steroids reduced hospital mortality and vasopressor use in sepsis and septic shock in a small single-center study. CONCLUSION Initial studies in patients with sepsis and septic shock demonstrated beneficial effects of ascorbic acid, thiamine, and steroids as monotherapy or in combination without safety concerns. However, the efficacy and safety of these therapies warrant further validation in larger clinical studies.
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Affiliation(s)
- Erenie Guirguis
- Lloyd L. Gregory School of Pharmacy, 15482Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Yasmin Grace
- Lloyd L. Gregory School of Pharmacy, 15482Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Harm Maarsingh
- Lloyd L. Gregory School of Pharmacy, 15482Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Thi Ca Tran
- Lloyd L. Gregory School of Pharmacy, 15482Palm Beach Atlantic University, West Palm Beach, FL, USA
| | - Elena Tkachuk
- Lloyd L. Gregory School of Pharmacy, 15482Palm Beach Atlantic University, West Palm Beach, FL, USA
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Casey K, Dickinson A. Suspected symmetrical peripheral gangrene in a cat. JFMS Open Rep 2019; 5:2055116919855539. [PMID: 31245021 PMCID: PMC6582298 DOI: 10.1177/2055116919855539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Case summary An 8-year-old female spayed domestic shorthair cat was presented for evaluation of non-specific lethargy and pain. It was diagnosed with septic shock secondary to wounds on the dorsum and required treatment with multiple vasopressors for circulatory support. During the course of hospitalization, it was weaned from vasopressors but subsequently developed symmetric skin necrosis and sloughing of the paws on the right thoracic and right pelvic limbs leading to a presumptive diagnosis of suspected symmetrical peripheral gangrene (SPG). Relevance and novel information This report documents the first case of suspected SPG in a cat that received multiple vasopressors for treatment of septic shock. Early recognition, cessation of vasopressor therapy and surgical management are necessary for treatment of this condition.
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Affiliation(s)
- Kelsey Casey
- Department of Emergency and Critical Care, Pittsburgh Veterinary Specialty and Emergency Center, Pittsburgh, PA, USA
| | - Amy Dickinson
- Department of Emergency and Critical Care, Pittsburgh Veterinary Specialty and Emergency Center, Pittsburgh, PA, USA
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Abstract
Background Symmetrical peripheral gangrene (SPG) is an uncommon syndrome showing symmetrical gangrene in acral regions without evidence of large-vessel occlusion or vasculitis. Intravenous vasopressors are frequently used to manage hemodynamically unstable patients. There have been few reports about SPG after using inotropics. However, risk factors for SPG have not been extensively studied. Therefore, the objective of this study was to analyze several cases of SPG and identify risk factors for SPG. Methods From October 2013 to October 2016, 36 patients with SPG after using vasopressors were included in this study. SPG is an extremely rare disease entity. Therefore, this work was designed as a matched case-control study. For the control group, 42 patients (25 men and 17 women) with similar age, admission department, sex, and vasopressor usage in intensive care unit patients during the same period were selected. Retrospective chart review was performed to identify risk factors within the following categories: medical conditions, vasopressor-related factors, and Sequential Organ Failure Assessment scores. Results Differences between the 2 groups concerning medical condition-related variables did not exist. Statistically significant differences were found in intensive care unit duration (P = 0.0011) and survival. All vasopressor-related factors were adjusted according to weights of patients. Weight-compensated mean dose of dopamin significantly (P = 0.028) affected the occurrence of SPG. Weight-compensated peak dose of norpin, dopamin, and epinephrine also significantly contributed to SPG. Conclusions Symmetrical peripheral gangrene is a rare clinical syndrome related with a high mortality and up to 70% of patients who survive require amputation. Several studies have mentioned that there are several factors affecting the result of SPG. Few studies on SPG have been reported and most of them are case reports. In this study, we revealed the influence of vasopressors to the occurrence of SPG, and this was the first matched case-control study based on the analysis of multiple risk factors.
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Nandhabalan P, Ioannou N, Meadows C, Wyncoll D. Refractory septic shock: our pragmatic approach. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:215. [PMID: 30231909 PMCID: PMC6145185 DOI: 10.1186/s13054-018-2144-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 07/30/2018] [Indexed: 02/08/2023]
Abstract
Despite timely intervention, there exists a small subgroup of patients with septic shock who develop progressive multi-organ failure. Seemingly refractory to conventional therapy, they exhibit a very high mortality. Such patients are often poorly represented in large clinical trials. Consequently, good evidence for effective treatment strategies is lacking. In this article, we describe a pragmatic, multi-faceted approach to managing patients with refractory septic shock based on our experience of toxin-mediated sepsis in a specialist referral centre. Many components of this strategy are inexpensive and widely accessible, and so may offer an opportunity to improve outcomes in these critically ill patients.
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Affiliation(s)
- Prashanth Nandhabalan
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK.
| | - Nicholas Ioannou
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
| | - Christopher Meadows
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
| | - Duncan Wyncoll
- Department of Critical Care, St Thomas' Hospital, Westminster Bridge Rd., Lambeth, London, SE1 7EH, UK
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Lower Extremity Salvage with Thoracodorsal Artery Perforator Free Flap in Condition of Symmetrical Peripheral Gangrene. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6508607. [PMID: 29854775 PMCID: PMC5964422 DOI: 10.1155/2018/6508607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 02/28/2018] [Accepted: 03/27/2018] [Indexed: 11/18/2022]
Abstract
Symmetrical peripheral gangrene (SPG) is rare but devastating complication which is characterized by symmetrical ischemic change of the distal extremities. In this report, we describe our management protocol for SPG, focusing on surgical approaches. Between January 2007 and February 2016, 10 thoracodorsal artery perforator (TDAP) free flaps were performed in 6 patients with SPG. Three patients were male and mean age was 56 (range, 44-69) years. All the patients were in shock. The causes of shock were sepsis in 4 cases, respiratory arrest in 1 case, and hypovolemia in 1 case. Eight transmetatarsal amputations and 2 Lisfranc amputations were performed. Flap sizes ranged from 7 × 11 cm to 25 × 15 cm. There were 3 cases of partial necrosis of the flap: two healed conservatively with dressings and one required skin graft. Three of the patients were later able to walk independently at Functional Ambulation Classification (FAC) level 6, one patient could walk independently on level surfaces at FAC level 5, and 2 could walk independently using walking aids, classified at FAC level 4. The average follow-up period was 18 (range, 6-54) months. In patients with SPG, minimal bone amputation and foot salvage with TDAP flaps were successful. Separate reconstruction of bone and soft tissue had good outcomes.
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Symmetrical Peripheral Gangrene: Mechanisms for Limb Loss in the ICU in Patients With Retained Pulses. ACTA ACUST UNITED AC 2018. [DOI: 10.1097/cpm.0000000000000253] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ruffin N, Vasa CV, Breakstone S, Axman W. Symmetrical peripheral gangrene of bilateral feet and unilateral hand after administration of vasopressors during septic shock. BMJ Case Rep 2018; 2018:bcr-2017-223602. [PMID: 29437714 PMCID: PMC5836706 DOI: 10.1136/bcr-2017-223602] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We report a case of a 75-year-old Hispanic man treated for septic shock after undergoing surgery for impacted renal stones. He was given vasopressors and later developed symmetrical peripheral gangrene (SPG) on both his feet and left hand. SPG is a serious and rare condition presenting clinically as an acute onset of ischaemia with no vessel occlusion. Vasopressors are identified as a contributing factor in SPG development. The patient ultimately underwent transmetatarsal amputations of both feet and amputation of three digits on his left hand. Early monitoring and swift management of peripheral ischaemia are essential when using vasopressors for the treatment of septic shock.
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Affiliation(s)
- Naeemah Ruffin
- Orthopedics, Division of Podiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Chirag V Vasa
- Infectious Diseases, Mount Sinai Queens Hospital, Astoria, New York, USA
| | - Sarah Breakstone
- Orthopedics, Division of Podiatry, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Wayne Axman
- Orthopedics, Division of Podiatry, Mount Sinai Queens Hospital, Astoria, New York, USA
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Jung KJ, Nho JH, Cho HK, Hong S, Won SH, Chun DI, Kim B. Amputation of multiple limbs caused by use of inotropics: Case report, a report of 4 cases. Medicine (Baltimore) 2018; 97:e9800. [PMID: 29384879 PMCID: PMC5805451 DOI: 10.1097/md.0000000000009800] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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.
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Affiliation(s)
- Ki Jin Jung
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan-si
| | - Jae-Hwi Nho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Hyeung-Kyu Cho
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Sijohn Hong
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Cheonan, Cheonan-si
| | - Sung Hun Won
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Dong-Il Chun
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
| | - Byungsung Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Seoul, Yongsan-gu, Seoul, South Korea
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Chou HC, Huang HL, Chen CY, Wang CL, Shu CC, Hsu NC, Lin YF, Chen JS, Sheng WH. Receipt of Vasopressors Is Positively Associated With the Length of the Actively Dying Process in Hospitalization. Am J Hosp Palliat Care 2018; 35:1043-1049. [PMID: 29378423 DOI: 10.1177/1049909117754040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND End-of-life care is important in general hospitalization care. However, the clinical impact of using vasopressors on the length of the actively dying process is still controversial. METHODS We reviewed patients who were hospitalized in general wards and died before discharge. We classified the patients into 2 groups: those who received vasopressors (RVs) and those who did not receive vasopressors (NRV). We analyzed the factors associated with the length of hospital stay (LOS) and the length of the actively dying process. RESULTS In all, 745 participants, 10.01% of all admitted patients, were analyzed. Of them, 225 patients were RV group, and the remaining 520 were NRV group. Age and gender were comparable in the 2 groups. The use of vasopressors was associated with an admission diagnosis of sepsis and absence of Do-Not-Resuscitate consent and parenteral use of morphine. In multivariable analysis, a high Barthel index score, the absence of cancer and cardiopulmonary resuscitation (CPR), and no receipt of vasopressors were independent factors for LOS. For the length of the actively dying process, a longer duration of inotropic agent, the receipt of vasopressors, and the absence of CPR were independent factors. CONCLUSION In-hospital mortality is not uncommon during hospitalization in a general ward. The length of the actively dying process is extended by the use of vasopressors. Further prospective study is required for cautious evaluation of the pros and cons of using vasopressors at the end of life during hospitalization.
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Affiliation(s)
- Hsiao-Chen Chou
- 1 Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsien-Liang Huang
- 2 Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chiang-Yi Chen
- 1 Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chuan-Lan Wang
- 1 Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan
| | - Chin-Chung Shu
- 3 Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nin-Chieh Hsu
- 3 Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Feng Lin
- 3 Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jin-Shing Chen
- 4 Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wang-Huei Sheng
- 3 Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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Foead AI, Mathialagan A, Varadarajan R, Larvin M. Management of Symmetrical Peripheral Gangrene. Indian J Crit Care Med 2018; 22:870-874. [PMID: 30662227 PMCID: PMC6311972 DOI: 10.4103/ijccm.ijccm_379_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a rare, debilitating disease that deserves more widespread concern among the medical fraternities. The objective of this review is to outline the etiology, pathology findings, and management practices of SPG. About 18%–40% mortality rate was reported, and survivors have high frequency of multiple limb amputations. SPG is the hallmark of disseminated intravascular coagulation (DIC). The main pathogenesis theory, to date, is microthrombosis associated with disturbed procoagulant–anticoagulant balance. The treatment of SPG is largely anecdotal and theoretically involves heparin-based anticoagulation and substitution of natural anticoagulants. Early recognition, prompt management of DIC, and underlying conditions may halt the progression of the disease. The multicenter randomized controlled trial should be set up to formulate the proper treatment guidelines.
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Affiliation(s)
- Agus Iwan Foead
- Department of Orthopedics, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Amuthaganesh Mathialagan
- Department of Pharmacology, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Raghu Varadarajan
- Department of Surgery, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
| | - Michael Larvin
- Department of Surgery, School of Medicine, Perdana University-Royal College of Surgeons Ireland Selangor, Malaysia
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Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest 2017; 151:1229-1238. [PMID: 27940189 DOI: 10.1016/j.chest.2016.11.036] [Citation(s) in RCA: 593] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The global burden of sepsis is estimated as 15 to 19 million cases annually, with a mortality rate approaching 60% in low-income countries. METHODS In this retrospective before-after clinical study, we compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone, and thiamine during a 7-month period (treatment group) with a control group treated in our ICU during the preceding 7 months. The primary outcome was hospital survival. A propensity score was generated to adjust the primary outcome. RESULTS There were 47 patients in both treatment and control groups, with no significant differences in baseline characteristics between the two groups. The hospital mortality was 8.5% (4 of 47) in the treatment group compared with 40.4% (19 of 47) in the control group (P < .001). The propensity adjusted odds of mortality in the patients treated with the vitamin C protocol was 0.13 (95% CI, 0.04-0.48; P = .002). The Sepsis-Related Organ Failure Assessment score decreased in all patients in the treatment group, with none developing progressive organ failure. All patients in the treatment group were weaned off vasopressors, a mean of 18.3 ± 9.8 h after starting treatment with the vitamin C protocol. The mean duration of vasopressor use was 54.9 ± 28.4 h in the control group (P < .001). CONCLUSIONS Our results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, are effective in preventing progressive organ dysfunction, including acute kidney injury, and in reducing the mortality of patients with severe sepsis and septic shock. Additional studies are required to confirm these preliminary findings.
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Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA.
| | - Vikramjit Khangoora
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - Racquel Rivera
- Department of Pharmacy, Sentara Norfolk General Hospital, Norfolk, VA
| | - Michael H Hooper
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, Norfolk, VA
| | - John Catravas
- School of Medical Diagnostic & Translational Sciences, College of Health Sciences, Old Dominion University, Norfolk, VA; Department of Medicine and Department of Physiological Sciences, Eastern Virginia Medical School, Norfolk, VA
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Adverse Drug Reactions in the Intensive Care Unit. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7153447 DOI: 10.1007/978-3-319-17900-1_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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Warkentin TE, Pai M. Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis: reply. J Thromb Haemost 2016; 14:2317-2319. [PMID: 27608440 DOI: 10.1111/jth.13498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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Affiliation(s)
- Rajinder Singh Rawat
- Department of Cardiac Anaesthesiology, Max Devki Devi Heart and vascular institute, Saket, Delhi, India
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Warkentin TE, Pai M. Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis? J Thromb Haemost 2016; 14:231-5. [PMID: 26662371 DOI: 10.1111/jth.13219] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/25/2015] [Indexed: 11/29/2022]
Abstract
For unknown reasons, a small minority of critically ill patients with septic or cardiogenic shock, multiorgan failure, and disseminated intravascular coagulation develop symmetrical acral (distal extremity) limb loss due to microvascular thrombosis ('limb gangrene with pulses'). Case reports have described preceding 'shock liver' in some critically ill patients who developed such a picture of ischemic limb necrosis. This suggests that profoundly disturbed procoagulant-anticoagulant balance featuring uncontrolled generation of thrombin-resulting from failure of the protein C and antithrombin natural anticoagulant systems due to insufficient hepatic synthesis of these crucial proteins-could explain the microvascular thrombosis and associated limb loss. We hypothesize that shock liver is the key predisposing risk factor underlying ischemic limb necrosis in the majority of patients who develop this complication in the setting of acute disseminated intravascular coagulation complicating septic or cardiogenic shock. As shock liver precedes onset of limb ischemia by several days, therapeutic intervention may be possible.
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Affiliation(s)
- T E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Pai
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
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Abstract
Aggressive fluid resuscitation to achieve a central venous pressure (CVP) greater than 8 mm Hg has been promoted as the standard of care, in the management of patients with severe sepsis and septic shock. However recent clinical trials have demonstrated that this approach does not improve the outcome of patients with severe sepsis and septic shock. Pathophysiologically, sepsis is characterized by vasoplegia with loss of arterial tone, venodilation with sequestration of blood in the unstressed blood compartment and changes in ventricular function with reduced compliance and reduced preload responsiveness. These data suggest that sepsis is primarily not a volume-depleted state and recent evidence demonstrates that most septic patients are poorly responsive to fluids. Furthermore, almost all of the administered fluid is sequestered in the tissues, resulting in severe oedema in vital organs and, thereby, increasing the risk of organ dysfunction. These data suggest that a physiologic, haemodynamically guided conservative approach to fluid therapy in patients with sepsis would be prudent and would likely reduce the morbidity and improve the outcome of this disease.
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Affiliation(s)
- P Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA 23507, USA
| | - R Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
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Phan PN, Acharya V, Parikh D, Shad A. A rare case of symmetrical four limb gangrene following emergency neurosurgery. Int J Surg Case Rep 2015; 16:15-8. [PMID: 26406313 PMCID: PMC4643340 DOI: 10.1016/j.ijscr.2015.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 09/08/2015] [Accepted: 09/11/2015] [Indexed: 11/24/2022] Open
Abstract
Postoperative sepsis and limb gangrene are uncommon but important complications of neurosurgery. Peripheral gangrene should be suspected at the first signs of distal ischaemia. Early diagnosis and intervention is crucial. Early specialist and multi-disciplinary team input with close monitoring ensures better outcomes.
Introduction The authors report a case of symmetrical peripheral gangrene (SPG) following emergency neurosurgery. Presentation of case A 35-year-old female presented to hospital in Thailand with nausea, headache, and subsequent seizures. She was found to have a large intracranial space-occupying lesion with mass effect. Following emergency surgical debulking and decompression, she suffered from severe sepsis with multiple organ failure, treated with high dose intravenous vasopressors and developed secondary gangrene in all four limbs. She was repatriated to the UK with a baseline GCS of 8 and multiple postoperative medical complications. With initial conservative management, the patient made a prolonged but satisfactory progression to recovery prior to semi-elective debridement and selected digit amputation of the gangrene. Discussion This is the first reported case of four limb symmetrical peripheral gangrene following an emergency craniotomy. Conclusion Although rare, SPG is a substantial complication with high mortality and morbidity and therefore should be especially taken into account for emergency intracranial pathologies in neurosurgical patients, particularly if they require emergency surgery.
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Affiliation(s)
- Pho Nh Phan
- University of Warwick Medical School, Gibbet Hill Road, Coventry, West Midlands CV4 7AL, United Kingdom.
| | - Vikas Acharya
- Department of Neurosurgery, University Hospital of Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, United Kingdom.
| | - Dhruv Parikh
- Department of Neurosurgery, University Hospital of Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, United Kingdom.
| | - Amjad Shad
- Department of Neurosurgery, University Hospital of Coventry and Warwickshire, Clifford Bridge Road, Coventry, West Midlands CV2 2DX, United Kingdom.
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Liao CY, Huang SC, Lin CH, Wang CC, Liu MY, Ben RJ, Kuo WH, Lee CC. Successful resolution of symmetrical peripheral gangrene after severe acute pancreatitis: a case report. J Med Case Rep 2015; 9:213. [PMID: 26376919 PMCID: PMC4573942 DOI: 10.1186/s13256-015-0688-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 08/21/2015] [Indexed: 12/28/2022] Open
Abstract
Introduction Symmetrical peripheral gangrene is an uncommon but devastating complication in critically ill patients, and it has a high mortality. It is seen in a wide variety of medical conditions, presenting as symmetrical gangrene of two or more extremities without large blood vessel obstruction. Case presentation We report a case of a 44-year-old Chinese man who was diagnosed with alcohol-related severe acute pancreatitis and presented with systemic inflammatory response syndrome and intractable vomiting. On the fourth day of admission, the patient developed cyanosis and gangrene of the fingers bilaterally. His cyanosis and gangrene did not resolve despite tapering of the vasopressor treatment. Gradually, his digital gangrene improved after administration of anti-platelet medication and pentoxifylline. Conclusions To the best of our knowledge, this is the first case report of symmetrical peripheral gangrene occurring after acute pancreatitis with successful resolution. We highlight the importance of prompt and aggressive fluid resuscitation and consideration of multiple treatment options to prevent a hypovolemic state caused by acute pancreatitis.
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Affiliation(s)
- Chen-Yi Liao
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Shih-Chung Huang
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Cheng-Hui Lin
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Chih-Chiang Wang
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Mei-Yu Liu
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Ren-Jy Ben
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Wu-Hsien Kuo
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
| | - Ching-Chang Lee
- Department of Internal Medicine, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan.
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Four limb amputations due to peripheral gangrene from inotrope use - Case report and review of the literature. Int J Surg Case Rep 2015; 14:63-5. [PMID: 26232740 PMCID: PMC4573421 DOI: 10.1016/j.ijscr.2015.07.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/17/2015] [Accepted: 07/17/2015] [Indexed: 12/03/2022] Open
Abstract
Rare case of 4 limb amputations due to peripheral gangrene from inotrope use. Contributing factors include disseminated intravascular coagulation and septic shock. Differential diagnoses include symmetrical peripheral gangrene and purpura fulminans. Some therapeutic agents are beneficial for peripheral ischemia with dopamine use. Single-stage elective amputations led to satisfactory rehabilitation with prosthesis.
INTRODUCTION We present a rare case of 4 limb amputations due to peripheral gangrene which resulted from the use of inotropes for septic shock. PRESENTATION OF CASE A 72-year-old woman with no past medical history presented with fever and pain in bilateral big toes. She was diagnosed with Streptococcal pneumoniae septicaemia and was started on broad spectrum antibiotics, dopamine and noradrenaline in the medical intensive care unit. She developed peripheral gangrene of all 4 extremities due to microvascular spasm from inotrope use and 4 limb amputations were performed electively in a single stage. DISCUSSION The gangrene was contributed by the presence of disseminated intravascular coagulation and septic shock. There was no evidence of an autoimmune disorder or vasculitis on laboratory investigations and tissue histology. CONCLUSION Microvascular spasm is a rare complication of inotrope use which may lead to extensive peripheral gangrene. Anecdotal reports of reversal agents have been discussed. Four limb amputations are a reasonable option especially if done in an elective setting after the gangrene has demarcated itself. Rehabilitation with prosthesis after 4 limb amputations can result in good functional outcome.
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Farkas DT, Rahnemai-Azar AA, Kunhammed SS, Greenbaum A, Bibi S, John MM. Realistic Survival Outcomes After Vasopressor Use in the Intensive Care Unit. Am J Hosp Palliat Care 2015; 33:871-874. [PMID: 26113743 DOI: 10.1177/1049909115593065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM Patients in the intensive care unit (ICU) have significantly increased mortality rates. Frequently, clinicians are called upon to help families make decisions regarding aggressiveness of care. Having a realistic expectation of outcome is critical for these discussions. This article looked at survival and outcomes following initiation of vasopressors. METHODS All patients admitted to the ICU between January and June 2011were included. Patients were classified into those who had been started on vasopressors (VP+) and those who had not (VP-). Outcomes of these groups including survival were calculated and compared. RESULTS A total of 1023 patients were included: 169 in the VP+ group and 854 in the VP- group. The survival rate in the VP+ group was 29.6% compared to 92.0% in the VP- group. This was both clinically and statistically significant (P < .001). CONCLUSION Patients started on vasopressors in the ICU have very poor outcomes. Being able to quantify this accurately is important to clinicians having discussions with family members.
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Affiliation(s)
- Daniel T Farkas
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amir A Rahnemai-Azar
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shameem Shah Kunhammed
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Arieh Greenbaum
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Shahida Bibi
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohan Mathew John
- Department of Surgery, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Srinivasan NM, Chaudhuri S. Arterial cannulation can hasten the onset of symmetrical peripheral gangrene. Anesth Essays Res 2015; 5:102-4. [PMID: 25885311 PMCID: PMC4173375 DOI: 10.4103/0259-1162.84187] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Symmetrical peripheral gangrene (SPG) is a devastating complication seen in critical care settings due to several contributory factors like low perfusion, high dose of vasopressors, disseminated intravascular coagulation, etc. Arterial cannulation is commonly done in critical patients for monitoring. We report a case of patient who developed early features of SPG which recovered in one hand, although it progressed in the hand which had the arterial cannula.
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Affiliation(s)
- Nataraj M Srinivasan
- Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
| | - Souvik Chaudhuri
- Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
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Lerolle N, Carlotti A, Melican K, Aubey F, Pierrot M, Diehl JL, Caille V, Hékimian G, Gandrille S, Mandet C, Bruneval P, Dumenil G, Borgel D. Assessment of the interplay between blood and skin vascular abnormalities in adult purpura fulminans. Am J Respir Crit Care Med 2013; 188:684-92. [PMID: 23924269 DOI: 10.1164/rccm.201302-0228oc] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Purpura fulminans in adults is a rare but devastating disease. Its pathophysiology is not well known. OBJECTIVES To understand the pathophysiology of skin lesions in purpura fulminans, the interplay between circulating blood and vascular alterations was assessed. METHODS Prospective multicenter study in four intensive care units. Patients with severe sepsis without skin lesions were recruited as control subjects. MEASUREMENTS AND MAIN RESULTS Twenty patients with severe sepsis and purpura fulminans were recruited for blood sampling, and skin biopsy was performed in deceased patients. High severity of disease and mortality rates (80%) was observed. Skin biopsies in purpura fulminans lesions revealed thrombosis and extensive vascular damage: vascular congestion and dilation, endothelial necrosis, alteration of markers of endothelial integrity (CD31) and of the protein C pathway receptors (endothelial protein C receptor, thrombomodulin). Elevated plasminogen activating inhibitor-1 mRNA was also observed. Comparison with control patients showed that these lesions were specific to purpura fulminans. By contrast, no difference was observed for blood hemostasis parameters, including soluble thrombomodulin, activated protein C, and disseminated intravascular coagulation markers. Bacterial presence at the vascular wall was observed specifically in areas of vascular damage in eight of nine patients tested (including patients with Streptococcus pneumoniae, Neisseria meningitidis, Escherichia coli, and Pseudomonas aeruginosa infection). CONCLUSIONS Thrombi and extensive vascular damage with multifaceted prothrombotic local imbalance are characteristics of purpura fulminans. A "vascular wall infection" hypothesis, responsible for endothelial damage and subsequent skin lesions, can be put forward.
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Affiliation(s)
- Nicolas Lerolle
- 1 Département de Réanimation Médicale et Médicine Hyperbare, Centre Hospitalier Universitaire Angers, and Faculté de Médecine, Université d'Angers, Angers, France
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Warkentin TE. Anticoagulant failure in coagulopathic patients: PTT confounding and other pitfalls. Expert Opin Drug Saf 2013; 13:25-43. [DOI: 10.1517/14740338.2013.823946] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Theodore E Warkentin
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton Regional Laboratory Medicine Program, Hamilton General Hospital, Hamilton Health Sciences, 237 Barton St. E, Hamilton, Ontario L8L 2X2, Canada
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Stewart S. Symmetrical peripheral gangrene and the use of systemic hyperbaric oxygen therapy. J Wound Care 2013; 21:615-6, 618-9. [PMID: 23299273 DOI: 10.12968/jowc.2012.21.12.615] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Symmetrical peripheral gangrene (SPG) is a rare but devastating condition when two or more distal sites become gangrenous, as the result of severe illness and treatment in critical care. The striking factor in SPG is that there is no occlusion of the major blood vessels to the affected limbs; the pathogenesis of the condition is not well understood and there are high reported mortality and amputation rates. Here we report the chronological progress report of a case of SPG, which affected both forefeet. This case report supports the view that early amputation should be avoided allowing for stabilisation of the gangrene so that no viable tissue is sacrificed. Further research is necessary to establish the pathogenesis and suitable treatment pathways.
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Affiliation(s)
- S Stewart
- Department of Podiatry and Foot Health, Newton Abbot Hospital, Newton Abbot, Devon, UK.
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Gordon AC, Wang N, Walley KR, Ashby D, Russell JA. The cardiopulmonary effects of vasopressin compared with norepinephrine in septic shock. Chest 2013; 142:593-605. [PMID: 22518026 DOI: 10.1378/chest.11-2604] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Vasopressin is known to be an effective vasopressor in the treatment of septic shock, but uncertainty remains about its effect on other hemodynamic parameters. METHODS We examined the cardiopulmonary effects of vasopressin compared with norepinephrine in 779 adult patients with septic shock recruited to the Vasopressin and Septic Shock Trial. More detailed cardiac output data were analyzed for a subset of 241 patients managed with a pulmonary artery catheter, and data were collected for the first 96 h after randomization. We compared the effects of vasopressin vs norepinephrine in all patients and according to severity of shock (< 15 or ≥ 15 μg/min of norepinephrine) and cardiac output at baseline. RESULTS Equal BPs were maintained in both treatment groups, with a significant reduction in norepinephrine requirements in the patients treated with vasopressin. The major hemodynamic difference between the two groups was a significant reduction in heart rate in the patients treated with vasopressin (P <.0001), and this was most pronounced in the less severe shock stratum (treatment × shock stratum interaction, P =.03). There were no other major cardiopulmonary differences between treatment groups, including no difference in cardiac index or stroke volume index between patients treated with vasopressin and those treated with norepinephrine. There was significantly greater use of inotropic drugs in the vasopressin group than in the norepinephrine group. CONCLUSIONS Vasopressin treatment in septic shock is associated with a significant reduction in heart rate but no change in cardiac output or other measures of perfusion. TRIAL REGISTRY ISRCTN Register; No.: ISRCTN94845869; URL: www.isrctn.org
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Affiliation(s)
- Anthony C Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, School of Public Health, Faculty of Medicine, Imperial College London, England.
| | - Nan Wang
- Imperial Clinical Trials Unit, School of Public Health, Faculty of Medicine, Imperial College London, England
| | - Keith R Walley
- Critical Care Research Laboratories, Institute for Heart and Lung Health, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
| | - Deborah Ashby
- Imperial Clinical Trials Unit, School of Public Health, Faculty of Medicine, Imperial College London, England
| | - James A Russell
- Critical Care Research Laboratories, Institute for Heart and Lung Health, St. Paul's Hospital and University of British Columbia, Vancouver, BC, Canada
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Shenoy R, Agarwal N, Goneppanavar U, Shenoy A, Sharma A. Symmetrical peripheral gangrene-a case report and brief review. Indian J Surg 2012; 75:163-5. [PMID: 24426551 DOI: 10.1007/s12262-012-0576-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 06/04/2012] [Indexed: 10/28/2022] Open
Abstract
A 30 year-old gentleman presented to casualty with history of pain abdomen for six days, fever and decreased urine output since two days. He was in a state of septic shock and was diagnosed to have intestinal perforation. His peripheral pulses were not palpable except for the femoral and brachial vessels. Despite fluid resuscitation, he needed infusion of high doses of dopamine and noradrenaline to maintain his blood pressure. He was operated for repair of perforation. On the first postoperative day, in the intensive care unit, vasopressin infusion was added in view of persistent hypotension. Appropriate fluid resuscitation and antibiotic therapy helped to wean him off inotropes and vasopressors by the second postoperative day. On the 3rd postoperative day, however, the patient developed discolouration and blebs on the fingers of left hand, followed by the right hand and then both the lower limbs. Subsequently, over a period of 10 days, this progressed to gangrene formation in the hands despite the patient being haemodynamically stable without any inotropes or vasopressors in this period. We conclude that the septic shock is a systemic derangement affecting all organ systems including coagulation and microcirculation. Early recognition and prompt management of sepsis, optimisation of fluid status to wean off the inotropes and vasopressors at the earliest is necessary to avoid catastrophes such as symmetrical peripheral gangrene.
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Affiliation(s)
- Rajgopal Shenoy
- Department of Surgery, Kasturba Hospital, Manipal, India ; Department of general surgery, Kasturba medical college, Manipal, 576104 Karnataka India
| | | | | | - Anitha Shenoy
- Department of Anaesthesiology, Kasturba Hospital, Manipal, India
| | - Ankur Sharma
- Department of Surgery, Kasturba Hospital, Manipal, India
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Cho AR, Kim JI, Kim EJ, Son SM. Skin Necrosis after High Dose Vasopressor Infusion in Septic Shock - Two Case Reports -. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.3.182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ah-Reum Cho
- Department of Anesthesia and Pain Medicine, Pusan National University Hospital, Busan, Korea
| | - Jeung-Il Kim
- Department of Orthopedic Surgery, Pusan National University Hospital, Busan, Korea
- Department of Orthopedic Surgery, School of Medicine, Pusan National University, Busan, Korea
| | - Eun-Jung Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Hospital, Busan, Korea
| | - Seung-Min Son
- Department of Orthopedic Surgery, Pusan National University Hospital, Busan, Korea
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Abstract
Necrotizing myositis is a severe and very rare streptococcal soft tissue infection involving the superficial fascia and muscle. Its clinical symptoms are nonspecific until the appearance of a fulminant clinical course with soft tissue destruction and septic shock. A high mortality and morbidity rate has been reported in the few cases over the last century. Despite several attempts to better define the different entities causing this necrotizing soft tissue infection, no clear treatment has been outlined. We present the case of a 47-year-old woman who had an acute necrotizing myositis after a stab wound. The diagnosis of necrotizing myositis was only established after surgical treatment with a pathology report. We reviewed the literature to highlight the clinical difficulty of a preoperative diagnosis and surgical treatment.
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