Norepinephrine-Induced Peripheral Ischemia Leading to Gangrene: A Case Series.

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.

RETROUTERINE PERFORATED GANGRENOUS APPENDICITIS.

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.

[Videolaparoscopic and morphological parallels in diagnosis of different forms of acute appendicitis].

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.

Increased electrical nerve stimulation threshold of the sciatic nerve in patients with diabetic foot gangrene: a prospective parallel cohort study.

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 (n = 30) and non-diabetic patients (n = 30) 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 0.1 ms and a stimulation frequency of 1 Hz 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] mA in non-diabetic and 1.9 (95% CI 1.6 to 2.2) mA in diabetic patients. The geometric mean of the electrical stimulation threshold was significantly (P < 0.001) 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.

Reliability and repeatability of toe pressures measured with laser Doppler and portable and stationary photoplethysmography devices.

BACKGROUND: There are two principally different methods for measuring toe pressures (TP)-photoplethysmography (PPG) and laser Doppler (LD). PPG is based on detecting changes in the blood filling of the digital arteries and arterioles, and the LD perfusion signal is derived from the Doppler shift undergone by the emitted infrared laser light after reflection from moving particles (red blood cells). The aim of the study was to compare two PPG devices and one LD device in TP measurement. The PPG devices used were the Nicolet VasoGuard (Nicolet Vascular Inc, Madison, WI; PPG1) and Systoe (Atys Medical, France; PPG2), and the LD device was the Perimed system 5000 (Perimed, Stockholm, Sweden). MATERIALS AND METHODS: TPs were measured from 54 nonselected consecutive patients who visited the vascular surgical outpatient clinic or underwent an endovascular procedure owing to chronic lower limb ischemia. A total of 107 toes were measured. The symptoms were claudication in 51.4% (n = 55), rest pain in 4.7% (n = 5), and ulcer or gangrene in 14.0% (n = 15) of the legs. Of the measured legs, 29.9% (n = 32) were asymptomatic. Forty patients had undergone endovascular revascularization immediately before the TP measurement. The limits of agreement show the estimated range within which the differences between measurements by the two devices would fall in approximately 95% of the measurements. The approximate 95% limits of agreement were calculated as the mean difference ± 2 standard deviation and presented in the Bland-Altman scatter plots. RESULTS: For PPG1 versus LD, the mean difference between two measurements was 14 mm Hg and the limits of agreement were 38 mm Hg. In 47% of the toes, the difference was ≥10 mm Hg, and in 37% of the toes, it was ≥15 mm Hg. For PPG2 versus LD, the mean difference between the TPs was 12 mm Hg and the limits of agreement were 24 mm Hg. In 44% of the cases, the difference was ≥10 mm Hg, and in 30%, it was ≥15 mm Hg. For PPG1 versus PPG2, the mean difference between two measurements was 14 mm Hg and the limits of agreement were 24 mm Hg. In 50% of the cases, the difference between the two machines was ≥10 mm Hg, and in 33%, it was ≥15 mm Hg. Repeatability measured with LD, PPG1, and PPG2 showed that the difference between the first and second measurement was <10 mm Hg in 93%, 86%, and 78% of the cases, respectively, and <15 mm Hg in 98%, 94%, and 88% of the cases, respectively. CONCLUSIONS: TP values vary greatly depending on the device used. However, the repeatability seemed to be acceptable with LD and PPG1. We recommend using same device when circulation is repeatedly assessed in the same patient. Also, we emphasize the importance of clinical examination and low threshold for angiography and revascularization especially in diabetics with wound healing problems.

Application of autologous bone marrow mononuclear cells in six patients with advanced chronic critical limb ischemia as a result of diabetes: our experience.

BACKGROUND AIMS: Previous clinical studies have reported that the injection of bone marrow (BM)-derived mononuclear cells (MNC) results in improvement in symptoms and healing of ulcers in patients with critical limb ischemia (CLI) up to stage IV of Fontaine's classification. However, most patients with Fontaine stage IV CLI limbs had to undergo amputation even after stem cell therapy. We report on six patients, who had poorly controlled diabetes with extensive ulceration and gangrene of limbs because of Fontaine stage IV CLI and had been advised amputation elsewhere, who underwent injection of autologous BM MNC. METHODS: In all six patients, BM was aspirated and the isolated MNC from the BM were injected intralesionally at various sites of the ulcer and its surroundings after necessary debridement. The patients were followed up at regular intervals for at least 6 months. RESULTS: At the end of the 6-month follow-up, the lower limb pain and ulcers had improved significantly in all patients. The mean toe-brachial index had increased from 0.26 to 0.36. One patient died a month after therapy because of causes unrelated to the procedure. Limb salvage was possible in the remaining five patients and they had a pain-free walking distance of 100 m within 6 months. CONCLUSIONS: Limb salvage was possible in all six diabetic patients with Fontaine stage IV CLI following autologous BM MNC injection. The procedure was safe without any adverse outcomes.

[Treatment of chronic critical ischemia by neuroischemic form of the diabetic foot syndrome].

Treatment results of 203 patients with critical ischemia by neuroischemic form of the diabetic foot sindrome were analyzed. 45 patients had open, endovascular or hybrid vascular reconstructions. The method was decised basing on the results of angiographic studies. The support function was saved in 34 (75,6%) cases of 45 operated patients. Revascularization proved to be an effective and reasonable method of surgical intervention by critical ischemia caused by the neuroischemic form of the diabetic foot syndrome.

[The attempt of clinical classification of the complicated diabetic foot syndrome].

The experience of surgical treatment of 1532 patients with the complicated forms of diabetic foot syndrome (DFS) was analyzed. The original clinical classification of the complicated DFS was suggested. The classification considered the clinical form (symbol "C"), anatomic localization (symbol "Z") and etiology (symbol "E"). The classification allows to define surgical tactics depending on concrete complications of the DFS, frames conditions for the unification and uniform registration of the form and severity of the disease and volume of the surgical treatment.

Cardiovascular, hematological and neurosensory impact of COVID-19 and variants.

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.

Acral Gangrene: Ugly Cousin of "COVID Toes" in Multisystem Inflammatory Syndrome in Children Associated with SARS-CoV-2?

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.

A 47-Year-Old Hispanic Man Who Developed Cutaneous Vasculitic Lesions and Gangrene of the Toes Following Admission to Hospital with COVID-19 Pneumonia.

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.

Therapeutic potential of atrial natriuretic peptide administration on peripheral arterial diseases.

Peripheral arterial diseases are caused by arterial sclerosis and impaired collateral vessel formation, which are exacerbated by diabetes, often leading to leg amputation. We have reported that an activation of the natriuretic peptides/cGMP/cGMP-dependent protein kinase pathway accelerated vascular regeneration and blood flow recovery in murine legs, for which ischemia had been induced by a femoral arterial ligation as a model for peripheral arterial diseases. In this study, ip injection of carperitide, a human recombinant atrial natriuretic peptide, accelerated blood flow recovery with increasing capillary density in ischemic legs not only in nondiabetic mice but also in mice kept upon streptozotocin-induced hyperglycemia for 16 wk, which significantly impaired the blood flow recovery compared with nondiabetic mice. Based on these findings, we tried to apply the administration of carperitide to the treatment of peripheral arterial diseases. The study group comprised a continuous series of 13 patients with peripheral arterial diseases (Fontaine's classification I, one; II, five; III, two; and IV, five), for whom conventional therapies had not accomplished appreciable results. Carperitide was administrated continuously and intravenously for 2 wk to Fontaine's class I-III patients and for 4 weeks to class IV patients. The dose was gradually increased to the maximum, with the patient's systolic blood pressure being kept above 100 mm Hg. Carperitide administration improved the ankle-brachial pressure index, intermittent claudication, rest pain, and ulcers. In conclusion, this study showed a therapeutic potential of carperitide to treat peripheral arterial diseases refractory to conventional therapies.

Reactive thrombocytosis with digital gangrene.

Patients with reactive thrombocytosis are generally asymptomatic and platelet counts of up to 1,000,000/microL are seen in this disorder. However, in a small proportion of cases platelet counts may be in the range generally seen in Clonal Thrombocytosis (CT). In elderly patients or those with symptomatic atherosclerosis or thrombotic disease or immobility, thrombosis may occur even with reactive thrombocytosis. We report a case of a rare presentation of Reactive Thrombocytosis with digital gangrene in an elderly lady. She was evaluated for thrombocytosis and was given supportive treatment after which she clinically improved.

Treatment of Nonreconstructable Critical Limb Ischemia With Ischemic Wounds Utilizing a Noninvasive Intermittent Pneumatic Compression Device Monitored With Fluorescence Angiography.

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.

Survival and associated risk factors in patients with diabetes and amputations caused by infectious foot gangrene.

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.

Penile gangrene in a patient on renal dialysis: CT findings.

We presented a case of a 63-year-old man with type 2 diabetes mellitus and end-stage renal disease on hemodialysis. Precontrast CT images showed atrophy of kidneys bilaterally and calcification of the abdominal aorta, small branches of bilateral renal arteries and small arteries of the pelvis, including the internal pudendal artery and penile artery. Postcontrast CT scans revealed a nonenhancing glans penis with a clear margin relative to normal tissue. The CT findings were compatible with gangrenous penis and were confirmed by surgery and histology. Findings of CT images can help urologists to decide the cutting margin in planning surgery.

Bone setters' gangrene.

BACKGROUND: Gangrene usually supervenes following prolonged pressure of tight splintage by traditional bone setters (TBS) in the process of treating fractures. However, various complications such as blisters, pressure, sores, Volkmann's ischaemia/contracture, Crush syndrome and pregangrene occur by the same mechanism depending on degree of pressure and duration of splintage of the limb. METHOD: This is a guest lecture delivered to resident doctors. Literature search was done through the internet and some unlisted journals and texts. Experiences of various institutions in Nigeria and abroad concerning bone setters' gangrene were elucidated. Attempt was made to broaden the concept of bone setters' gangrene to include all complications that arise through the same mechanism. The aetiology, pathophysiology and treatment of the vsrious conditions were highlighted and the solution and way-forward suggested. RESULT: The various health institutions recorded unacceptably high percentage of amputations secondary to bone setters' gangrene e.g. Zaria--57% to 63%, Jos--60-77.8%. Enugu recorded mortality of 26.7% while Banjul had 11.1% mortality in their series. Nearly all the series suggested education of bone setters as a solution. CONCLUSION: A different approach to limiting bone setters' gangrene is suggested such as condemning bone setters' practice and expanding orthopaedic care.