RESUMEN
A spectrum of dermatologic manifestations has been reported in multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection. We report 2 patients with multisystem inflammatory syndrome in children and severe cardiovascular dysfunction who developed acral gangrene. Both responded well to therapy and recovered in the follow-up.
Asunto(s)
COVID-19/patología , Gangrena/virología , Síndrome de Respuesta Inflamatoria Sistémica/patología , COVID-19/diagnóstico por imagen , COVID-19/fisiopatología , COVID-19/virología , Niño , Familia , Gangrena/diagnóstico por imagen , Gangrena/patología , Gangrena/fisiopatología , Humanos , Masculino , SARS-CoV-2/aislamiento & purificación , Síndrome de Respuesta Inflamatoria Sistémica/diagnóstico por imagen , Síndrome de Respuesta Inflamatoria Sistémica/fisiopatología , Síndrome de Respuesta Inflamatoria Sistémica/virologíaRESUMEN
OBJECTIVE: The purpose of this article was to review our clinical experience with COVID-19 patients observed in the Cardiovascular Division of Pompidou Hospital (University of Paris, France) and the Department of Neurology of the Eastern Piedmont University (Novara, Italy), related to the impact on the cardiovascular, hematological, and neurologic systems and sense organs. PATIENTS AND METHODS: We sought to characterize cardiovascular, hematological, and neurosensory manifestations in patients with COVID-19 and variants. Special attention was given to initial signs and symptoms to facilitate early diagnosis and therapy. Indications of ECMO (extracorporeal membrane oxygenation) for cardiorespiratory support were evaluated. RESULTS: Preliminary neurosensorial symptoms, such as anosmia and dysgeusia, are useful for diagnosis, patient isolation, and treatment. Early angiohematological acro-ischemic syndrome includes hand and foot cyanosis, Raynaud digital ischemia phenomenon, skin bullae, and dry gangrene. This was associated with neoangiogenesis, vasculitis, and vessel thrombosis related to immune dysregulation, resulting from "cytokine storm syndrome". The most dangerous complication is disseminated intravascular coagulation, with mortality risks for both children and adults. CONCLUSIONS: COVID-19 is a prothrombotic disease with unique global lethality. A strong inflammatory response to viral infection severely affects cardiovascular and neurological systems, as well as respiratory, immune, and hematological systems. Rapid identification of acro-ischemic syndrome permits the treatment of disseminated intravascular coagulation complications. Early sensorial symptoms, such as gustatory and olfactory loss, are useful for COVID-19 diagnosis. New variants of SARS-CoV-2 are emerging, principally from United Kingdom, South Africa, and Brazil. These variants seem to spread more easily and quickly, which may lead to more cases of COVID.
Asunto(s)
Anosmia/fisiopatología , COVID-19/fisiopatología , Cianosis/fisiopatología , Coagulación Intravascular Diseminada/fisiopatología , Disgeusia/fisiopatología , Miocarditis/fisiopatología , Enfermedad de Raynaud/fisiopatología , Vasculitis/fisiopatología , COVID-19/patología , COVID-19/terapia , COVID-19/virología , Proteasas 3C de Coronavirus/ultraestructura , Síndrome de Liberación de Citoquinas , Coagulación Intravascular Diseminada/patología , Oxigenación por Membrana Extracorpórea , Pie/irrigación sanguínea , Francia , Gangrena/patología , Gangrena/fisiopatología , Mano/irrigación sanguínea , Humanos , Isquemia/patología , Isquemia/fisiopatología , Ventilación no Invasiva , Intercambio Plasmático , Enfermedad de Raynaud/patología , SARS-CoV-2 , Glicoproteína de la Espiga del Coronavirus/ultraestructura , Sincrotrones , Vasculitis/patologíaRESUMEN
ABSTRACT: Norepinephrine is used in the acute care setting to establish and maintain hemodynamic stability in patients with hypotension. Although it is often a lifesaving medication, norepinephrine may lead to profound vascular insufficiency in the extremities, resulting in dry gangrene and skin necrosis. The purpose of this article is to present a case series of skin complications related to treatment with norepinephrine and review the pathophysiology behind these complications. The authors also explore risk stratification as it relates to history and clinical presentation with subsequent focus on contingencies to mitigate the adverse effects of vasoconstriction on peripheral tissues.
Asunto(s)
Gangrena/etiología , Isquemia/etiología , Norepinefrina/efectos adversos , Anciano , Estudios de Casos y Controles , Femenino , Gangrena/fisiopatología , Humanos , Isquemia/complicaciones , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Norepinefrina/farmacología , Enfermedades Vasculares Periféricas/etiología , Vasoconstrictores/efectos adversos , Vasoconstrictores/farmacologíaRESUMEN
BACKGROUND Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, in late 2019 and has led to an ongoing pandemic. COVID-19 typically affects the respiratory tract and mucous membranes, leading to pathological involvement of various organ systems. Although patients usually present with fever, cough, and fatigue, less common manifestations have been reported including symptoms arising from thrombosis and thromboembolism. A spectrum of dermatologic changes is becoming recognized in patients with COVID-19 who initially present with respiratory symptoms. The mechanism behind these manifestations remains unclear. This report presents the case of a 47-year-old Hispanic man who developed cutaneous vasculitic lesions and gangrene of the toes following admission to hospital with COVID-19 pneumonia. CASE REPORT COVID-19 has been associated with cardiovascular disease entities including stroke, acute coronary syndrome, venous thromboembolism, and peripheral vascular disease. We present a case in which a 47-year-old Hispanic man arrived at the Emergency Department with COVID-19 and was admitted for respiratory failure. Despite anticoagulation initiated on admission in the presence of an elevated D-dimer, the patient developed gangrene of all his toes, which required bilateral transmetatarsal amputation. CONCLUSIONS This case shows that dermatologic manifestations may develop in patients who initially present with COVID-19 pneumonia. These symptoms may be due to venous thrombosis following SARS-CoV-2 vasculitis, leading to challenging decisions regarding anticoagulation therapy. Randomized controlled trials are needed to evaluate the efficacy of anticoagulation, to choose appropriate anticoagulants and dosing, and to assess bleeding risk.
Asunto(s)
Infecciones por Coronavirus/complicaciones , Gangrena/etiología , Gangrena/cirugía , Neumonía Viral/complicaciones , Síndrome Respiratorio Agudo Grave/complicaciones , Dedos del Pie/cirugía , Vasculitis/etiología , Amputación Quirúrgica/métodos , COVID-19 , Infecciones por Coronavirus/diagnóstico , Servicio de Urgencia en Hospital , Estudios de Seguimiento , Gangrena/fisiopatología , Hispánicos o Latinos , Humanos , Masculino , Huesos Metatarsianos/cirugía , Persona de Mediana Edad , Multimorbilidad , Pandemias , Admisión del Paciente , Neumonía Viral/diagnóstico , Insuficiencia Respiratoria/diagnóstico , Insuficiencia Respiratoria/etnología , Insuficiencia Respiratoria/etiología , Medición de Riesgo , Síndrome Respiratorio Agudo Grave/diagnóstico , Dedos del Pie/irrigación sanguínea , Dedos del Pie/fisiopatología , Resultado del Tratamiento , Vasculitis/fisiopatologíaAsunto(s)
Reanimación Cardiopulmonar , Gangrena , Paro Cardíaco , Trombosis de la Vena , Gangrena/etiología , Gangrena/patología , Gangrena/fisiopatología , Gangrena/cirugía , Paro Cardíaco/etiología , Paro Cardíaco/patología , Paro Cardíaco/fisiopatología , Paro Cardíaco/cirugía , Humanos , Masculino , Persona de Mediana Edad , Necrosis , Trombosis de la Vena/complicaciones , Trombosis de la Vena/patología , Trombosis de la Vena/fisiopatología , Trombosis de la Vena/cirugíaAsunto(s)
Adenocarcinoma del Pulmón/fisiopatología , Dedos/irrigación sanguínea , Antebrazo/fisiopatología , Gangrena/fisiopatología , Síndromes Paraneoplásicos/fisiopatología , Enfermedades Vasculares/fisiopatología , Adenocarcinoma del Pulmón/complicaciones , Amputación Quirúrgica , Femenino , Antebrazo/cirugía , Gangrena/cirugía , Humanos , Persona de Mediana Edad , Síndromes Paraneoplásicos/cirugía , Resultado del Tratamiento , Enfermedades Vasculares/complicacionesAsunto(s)
Enfermedades Musculoesqueléticas/diagnóstico por imagen , Fascitis Necrotizante/diagnóstico por imagen , Fascitis Necrotizante/fisiopatología , Gangrena/diagnóstico por imagen , Gangrena/fisiopatología , Humanos , Infarto/diagnóstico por imagen , Infarto/fisiopatología , Enfermedades Musculoesqueléticas/fisiopatología , Osteomielitis/diagnóstico por imagen , Osteomielitis/fisiopatología , Osteonecrosis/diagnóstico por imagen , Osteonecrosis/fisiopatologíaAsunto(s)
Ciego/patología , Ciego/cirugía , Enfermedades del Colon/etiología , Enfermedades del Colon/cirugía , Cuerpos Extraños/complicaciones , Obstrucción Intestinal/etiología , Abdomen Agudo/diagnóstico , Abdomen Agudo/etiología , Adulto , Enfermedades del Colon/diagnóstico por imagen , Estudios de Seguimiento , Cuerpos Extraños/diagnóstico , Cuerpos Extraños/cirugía , Gangrena/etiología , Gangrena/fisiopatología , Gangrena/cirugía , Humanos , Obstrucción Intestinal/diagnóstico por imagen , Obstrucción Intestinal/cirugía , Laparotomía/métodos , Masculino , Pakistán , Medición de Riesgo , Resultado del TratamientoRESUMEN
We present an atypical case of retrouterine gangrenous perforated appendicitis with Douglas abscess in a 33-year-old woman, with clinical picture developing over two weeks. Laparotomy and appendectomy with abdominal drainage and antibiosis were performed and resulted in complete recovery.
Asunto(s)
Absceso Abdominal/tratamiento farmacológico , Absceso Abdominal/cirugía , Apendicitis/tratamiento farmacológico , Apendicitis/cirugía , Gangrena/cirugía , Perforación Uterina/tratamiento farmacológico , Perforación Uterina/cirugía , Absceso Abdominal/etiología , Absceso Abdominal/fisiopatología , Adulto , Apendicectomía/métodos , Apendicitis/complicaciones , Apendicitis/fisiopatología , Femenino , Gangrena/fisiopatología , Humanos , Laparoscopía/métodos , Resultado del Tratamiento , Perforación Uterina/etiología , Perforación Uterina/fisiopatologíaRESUMEN
INTRODUCTION: Critical limb ischemia (CLI) is a leading cause of lower extremity amputation. When CLI is identified, revascularization should be performed if possible. When options for revascularization do not exist, use of a noninvasive intermittent pneumatic compression device (NPCD) can be considered. OBJECTIVE: Presented here are 2 cases of patients with nonreconstructable CLI at risk for limb loss who were serially assessed with indocyanine green fluorescence angiography (ICGFA) to determine the effects of NPCD use on local tissue perfusion. MATERIALS AND METHODS: Both patients were treated with the NPCD for 1 hour, 3 times per day, for 4 weeks. Serial ICGFA utilizing a ICGFA device was performed at various time points to monitor the effects of NPCD use on tissue perfusion. RESULTS: The treatment of both patients with serial ICGFA provided limited objective evidence of increased local tissue perfusion which expedited wound resolution. CONCLUSIONS: Larger randomized control trials of this modality of perfusion assessment and NPCD use are recommended.
Asunto(s)
Angiografía con Fluoresceína , Gangrena/terapia , Claudicación Intermitente/terapia , Aparatos de Compresión Neumática Intermitente , Isquemia/terapia , Recuperación del Miembro , Extremidad Inferior/patología , Enfermedad Crítica , Gangrena/diagnóstico , Gangrena/fisiopatología , Humanos , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/fisiopatología , Isquemia/fisiopatología , Recuperación del Miembro/métodos , Masculino , Persona de Mediana Edad , Flujo Sanguíneo Regional , Piel/irrigación sanguínea , Resultado del Tratamiento , Cicatrización de HeridasAsunto(s)
Accidentes por Caídas , Hernia Diafragmática/etiología , Dolor Abdominal/etiología , Anciano , Consumo de Bebidas Alcohólicas/efectos adversos , Dolor en el Pecho/etiología , Gangrena/complicaciones , Gangrena/etiología , Gangrena/fisiopatología , Hernia Diafragmática/complicaciones , Hernia Diafragmática/cirugía , Humanos , Masculino , Estómago/anomalías , Estómago/lesionesRESUMEN
BACKGROUND: Infectious gangrene of the foot is a serious complication of diabetes that usually leads to a certain level of lower-extremity amputation (LEA). Nevertheless, the long-term survival and factors associated with mortality in such patients have yet to be elucidated. METHODS: A total of 157 patients with type 2 diabetes who received treatment for infectious foot gangrene at a major diabetic foot center in Taiwan from 2002 to 2009 were enrolled, of whom 90 had major LEAs (above the ankle) and 67 had minor LEAs (below the ankle). Clinical data during treatment were used for the analysis of survival and LEA, and survival was tracked after treatment until December 2012. RESULTS: Of the 157 patients, 109 died, with a median survival time of 3.12 years and 5-year survival rate of 40%. Age [hazard ratio 1.04 (95% confidence interval 1.01-1.06)], and major LEA [1.80 (1.05-3.09)] were independent factors associated with mortality. Patients with minor LEAs had a better median survival than those with major LEAs (5.5 and 1.9 years, respectively, P < 0.01). An abnormal ankle-brachial index was an independent risk factor [odds ratio 3.12 (95% CI 1.18-8.24)] for a poor outcome (major LEA) after adjusting for age, smoking status, hypertension, major adverse cardiac events, and renal function. CONCLUSIONS: Efforts to limit amputations below the ankle resulted in better survival of patients with infectious foot gangrene. An abnormal ankle-brachial index may guide physicians to make appropriate decisions with regards to the amputation level.
Asunto(s)
Amputación Quirúrgica , Diabetes Mellitus Tipo 2/complicaciones , Pie Diabético/cirugía , Gangrena/cirugía , Extremidad Inferior/cirugía , Factores de Edad , Anciano , Índice Tobillo Braquial , Diabetes Mellitus Tipo 2/fisiopatología , Pie Diabético/etiología , Pie Diabético/fisiopatología , Femenino , Gangrena/etiología , Gangrena/fisiopatología , Tasa de Filtración Glomerular/fisiología , Humanos , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Pronóstico , Factores de Riesgo , Infecciones de los Tejidos Blandos/etiología , Infecciones de los Tejidos Blandos/fisiopatología , Infecciones de los Tejidos Blandos/cirugíaRESUMEN
AIM: Diabetic foot ulcers are associated with an increased risk of death. We evaluated whether ulcer severity at presentation predicts mortality. METHODS: Patients from a national, retrospective, cohort of veterans with type 2 diabetes who developed incident diabetic foot ulcers between January 1, 2006 and September 1, 2010, were followed until death or the end of the study period, January 1, 2012. Ulcers were characterized as early stage, osteomyelitis, or gangrene at presentation. Cox proportional hazard regression identified independent predictors of death, controlling for comorbidities, laboratory parameters, and healthcare utilization. RESULTS: 66,323 veterans were included in the cohort and followed for a mean of 27.7months: 1-, 2-, and 5-year survival rates were 80.80%, 69.01% and 28.64%, respectively. Compared to early stage ulcers, gangrene was associated with an increased risk of mortality (HR 1.70, 95% CI 1.57-1.83, p<0.001). The magnitude of this effect was greater than diagnosed vascular disease, i.e., coronary artery disease, peripheral arterial disease, or stroke. CONCLUSION: Initial diabetic foot ulcer severity is a more significant predictor of subsequent mortality than coronary artery disease, peripheral arterial disease, or stroke. Unrecognized or under-estimated vascular disease and/or sepsis secondary to gangrene should be explored as possible causal explanations.
Asunto(s)
Diabetes Mellitus Tipo 2/complicaciones , Diabetes Mellitus Tipo 2/mortalidad , Pie Diabético/diagnóstico , Gangrena/diagnóstico , Osteomielitis/diagnóstico , Salud de los Veteranos , Anciano , Estudios de Cohortes , Pie Diabético/complicaciones , Pie Diabético/mortalidad , Pie Diabético/fisiopatología , Registros Electrónicos de Salud , Femenino , Estudios de Seguimiento , Gangrena/complicaciones , Gangrena/mortalidad , Gangrena/fisiopatología , Humanos , Masculino , Persona de Mediana Edad , Osteomielitis/complicaciones , Osteomielitis/mortalidad , Osteomielitis/fisiopatología , Pronóstico , Modelos de Riesgos Proporcionales , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Estados Unidos/epidemiología , United States Department of Veterans AffairsAsunto(s)
Gangrena/epidemiología , Sistema de Registros , Esclerodermia Sistémica/diagnóstico , Esclerodermia Sistémica/epidemiología , Úlcera Cutánea/diagnóstico , Úlcera Cutánea/epidemiología , Adulto , Factores de Edad , Análisis de Varianza , Estudios de Cohortes , Comorbilidad , Progresión de la Enfermedad , Femenino , Dedos/patología , Gangrena/fisiopatología , Gangrena/terapia , Humanos , Incidencia , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Estudios Prospectivos , Medición de Riesgo , Esclerodermia Sistémica/terapia , Índice de Severidad de la Enfermedad , Factores Sexuales , Úlcera Cutánea/terapiaRESUMEN
OBJECTIVE: To demonstrate potential thrombotic complications after radial arterial line placement in patients with scleroderma. METHODS: This is a retrospective case series of 4 patients with scleroderma who were hospitalized in the intensive care unit (ICU) requiring invasive hemodynamic monitoring and developed severe complications after radial arterial line placement. We reviewed their medical records to assess their laboratory findings and clinical presentations. RESULTS: All 4 patients met the 2013 ACR/EULAR criteria for systemic sclerosis and had a radial arterial line placement in the setting of invasive hemodynamic monitoring. Overall, 2 of 4 patients had arterial line placement during surgery; while 1 patient had it placed for invasive blood pressure monitoring during an ICU admission for renal crisis; and 1 patient had arterial line placement during cardiac resuscitation, but before administration of vasopressor support. In all, 3 of 4 patients had major ischemic events including digital gangrene, hand auto-amputation, and below-elbow amputation. Among all, 1 patient had temporary hand ischemia with recovery of perfusion with immediate arterial line removal within 24 hours. CONCLUSIONS: Radial arterial line placement may trigger critical ischemic events in scleroderma patients. This experience suggests that placement of radial lines needs to be thoughtfully weighed prior to insertion in patients with scleroderma, and alternative options should be carefully considered.
Asunto(s)
Gangrena/etiología , Arteria Radial , Esclerodermia Sistémica/fisiopatología , Trombosis/etiología , Dispositivos de Acceso Vascular/efectos adversos , Adulto , Femenino , Gangrena/fisiopatología , Humanos , Persona de Mediana Edad , Estudios Retrospectivos , Trombosis/fisiopatologíaRESUMEN
AIM: To compare results of macroscopic assessment and materials of histological examination of 1635 appendices removed using videolaparoscopy in patients with acute appendicitis. All patients have been treated in N.V.Sklifosovsky Research Institute of Emergency Care for the period from 2002 to 2014. MATERIAL AND METHODS: Intraoperative macroscopic assessment of appendix's inflammatory changes was performed using some conventional signs. Сatarrhal, phlegmonous and gangrenous changes were suspected in 77 (4.7%), 1432 (87.5%) and 126 (7.7%) cases respectively. RESULTS: Histological examination revealed catarrhal, phlegmonous and gangrenous changes in 86 (5.3%), 1338 (81.8%) and 115 (7.0%) cases respectively. In 65 (4.0%) patients changes were estimated as chronic, 31 (1.9%) patients had not inflammation. Intraoperatively suspected diagnosis of different forms of appendicitis was confirmed by histological survey in 94.1%. Most cases of matched intraoperative and histological diagnosis were observed in case of phlegmonous appendicitis (88.2%). Only 5.9% of patients had not acute inflammation of appendix that may be explained by overdiagnosis and excess of indications for appendectomy.
Asunto(s)
Apendicectomía , Apendicitis , Apéndice , Errores Diagnósticos/prevención & control , Laparoscopía/métodos , Adulto , Apendicectomía/efectos adversos , Apendicectomía/métodos , Apendicitis/diagnóstico , Apendicitis/fisiopatología , Apendicitis/cirugía , Apéndice/diagnóstico por imagen , Apéndice/patología , Diagnóstico Diferencial , Femenino , Gangrena/patología , Gangrena/fisiopatología , Humanos , Inflamación/patología , Inflamación/fisiopatología , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Ultrasonografía , Cirugía Asistida por Video/métodosRESUMEN
Limb gangrene in a neonate is an extremely rare clinical problem and bilateral symmetrical lower limbs type is even rarer. Only few clinical cases have been reported thus far with idiopathic etiology or associated with rare conditions. Known causes in literature are sepsis, extravasation of intravenous fluid, following a complicated delivery and secondary to invasive monitoring. This report describes neonate was first developed sepsis and later was exposed to cold leading to bilateral gangrene of lower limbs.
Asunto(s)
Gangrena/diagnóstico , Extremidad Inferior/fisiopatología , Sepsis/complicaciones , Gangrena/etiología , Gangrena/fisiopatología , Humanos , Recién Nacido , MasculinoRESUMEN
CONTEXT: Peripheral neuropathy may affect nerve conduction in patients with diabetes mellitus. OBJECTIVE: This study was designed to test the hypothesis that the electrical stimulation threshold for a motor response of the sciatic nerve is increased in patients suffering from diabetic foot gangrene compared to non-diabetic patients. DESIGN: Prospective non-randomised trial with two parallel groups. SETTING: Two university-affiliated hospitals. PARTICIPANTS: Patients scheduled for surgical treatment of diabetic foot gangrene (nâ=â30) and non-diabetic patients (nâ=â30) displaying no risk factors for neuropathy undergoing orthopaedic foot or ankle surgery. MAIN OUTCOME MEASURE: The minimum current intensity required to elicit a typical motor response (dorsiflexion or eversion of the foot) at a pulse width of 0.1âms and a stimulation frequency of 1âHz when the needle tip was positioned under ultrasound control directly adjacent to the peroneal component of the sciatic nerve. RESULTS: The non-diabetic patients were younger [64 (SD 12) vs. 74 (SD 7) years] and predominantly female (23 vs. 8). The geometric mean of the motor stimulation threshold was 0.26 [95% confidence interval (95% CI) 0.24 to 0.28]âmA in non-diabetic and 1.9 (95% CI 1.6 to 2.2)âmA in diabetic patients. The geometric mean of the electrical stimulation threshold was significantly (Pâ<â0.001) increased by a factor of 7.2 (95% CI 6.1 to 8.4) in diabetic compared to non-diabetic patients. CONCLUSION: The electrical stimulation threshold for a motor response of the sciatic nerve is increased by a factor of 7.2 in patients with diabetic foot gangrene, which might hamper nerve identification.
Asunto(s)
Estimulación Eléctrica/métodos , Pie/inervación , Gangrena/fisiopatología , Bloqueo Nervioso/métodos , Nervio Ciático/fisiología , Anciano , Estudios de Cohortes , Diabetes Mellitus/fisiopatología , Pie Diabético/terapia , Femenino , Pie/cirugía , Gangrena/cirugía , Humanos , Masculino , Persona de Mediana Edad , Conducción Nerviosa , Umbral del Dolor , Estudios Prospectivos , Factores de Riesgo , Nervio Ciático/fisiopatologíaAsunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial , Gangrena , Isquemia , Extremidad Inferior , Trombosis/complicaciones , Anciano , Amputación Quirúrgica/métodos , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Ecocardiografía , Femenino , Arteria Femoral/fisiopatología , Gangrena/etiología , Gangrena/fisiopatología , Gangrena/cirugía , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Humanos , Isquemia/etiología , Isquemia/patología , Isquemia/fisiopatología , Extremidad Inferior/irrigación sanguínea , Extremidad Inferior/patología , Extremidad Inferior/fisiopatología , Cumplimiento de la Medicación , Trombosis/fisiopatología , Resultado del Tratamiento , Negativa del Paciente al Tratamiento , Ultrasonografía Doppler en ColorRESUMEN
Symmetrical peripheral gangrene (multilimb ischemia without large artery occlusion) is a rare condition usually associated with disseminated intravascular coagulation, hemodynamic compromise, and/or sepsis. However, it has not been described in patients on extracorporal membrane oxygenation (ECMO). Over a 5 year period, four pediatric patients developed symmetrical peripheral gangrene on ECMO after cardiac surgery. They subsequently died and came to autopsy. History, physical examination, and laboratory studies were examined. Gross and microscopic autopsy material was reviewed. Patients were 11 days to 13 years old. Extracorporal membrane oxygenation duration was 11-22 days, and limb ischemia began 2-4 days before death. Three patients had rapid onset, with ischemia developing in <48 hours. In the fourth, ischemic changes began as focal lesions and gradually spread. Two patients were septic. Three had evidence of other end-organ damage. Pressors were used in 3 patients before the limb ischemia. Autopsies disclosed ischemic changes involving all limbs, with confluent ecchymoses. In a detailed examination in 1 case, large arteries of the extremities were patent. Involved skin and soft tissue showed bland fibrin thrombi in the microcirculation, with tissue necrosis and hemorrhage. This report describes the first 4 cases of symmetrical peripheral gangrene complicating ECMO. The 4 pediatric patients all had recent surgery for congenital cardiac disease, and all had significant exposure to ECMO prior to developing limb ischemia. Symmetrical peripheral gangrene is an unusual complication of ECMO that may arise in the setting of disseminated intravascular coagulation, sepsis, or other hemostatic and/or hemodynamic imbalance.