RESUMO
A 59-year-old male, with a history of angiogram via the left radial artery during the workup for multi-trauma, presented to the hand clinic with a 14-day history of progressive critical ischemia in the left thumb and index finger, along with dry gangrene of the distal index fingertip. Radial artery occlusion was confirmed on imaging. The patient underwent radial artery thrombectomy, arterial reconstruction with vein graft, and amputation of the index fingertip. Postoperatively, perfusion to the thumb and index finger was restored, resulting in the resolution of associated pain and hypersensitivity. This case demonstrates the delayed presentation of ischemia following radial artery cannulation, which was successfully managed with radial artery thrombectomy and a saphenous vein graft.
RESUMO
Upper extremity arterial thrombosis is less common than that in the lower extremity. Upper extremity arterial thrombosis, when present, is more likely to occur on the ulnar side of the circulation. Severe ischemia resulting from radial artery thrombosis is rare, but iatrogenic cannulation is the most common etiology when it occurs. The risk factors underlying this dreadful presentation are numerous and still under investigation. Pregnancy and the immediate postpartum period are physiological hypercoagulable states. Here we present unusual cases of acute limb ischemia post iatrogenic cannulation in two patients within six weeks postpartum. At four weeks postpartum, a 26-year-old para-1 live-1 female presented to the emergency department with swelling in her right upper limb for four weeks and its blackish discoloration for one week. A 24-year-old primigravida female who had a termination of a blighted ovum 12 days ago presented to the emergency department with gangrenous changes in her right hand and forearm. Both patients reported recent antecubital fossa cannulation within six weeks postpartum, triggering gangrenous hand changes. Both patients had to undergo amputation of the digits and hand ultimately. Thus we postulate the need for extra care and education of healthcare workers in the cannulation of pregnant and post-pregnancy patients to prevent limb-threatening complications.
RESUMO
Vasopressors used in critically ill patients with refractory shock poses a serious risk of non-occlusive peripheral limb ischemia leading to tissue necrosis and amputation. Acute limb ischemia is associated with high morbidity and mortality. Evidence-based medical literature is scarce on the prevention and management of vasopressor-induced acute limb ischemia (VIALI). Despite being a well-known and frequent complication of vasopressors, there is no standardized guideline for the prevention and management of vasopressor-induced limb ischemia. Vasopressors are required for the management of refractory shock which is defined as hypotension not responsive to intravenous fluid resuscitation alone. Distributive shock, which includes septic shock, causes inadequate tissue perfusion in adjunct with vasopressor use and is the most common cause of non-occlusive peripheral limb ischemia. This case study will focus on how early recognition and prompt treatment of VIALI are crucial in minimizing tissue necrosis and preventing amputations. We present a case of a middle-aged woman who developed distributive shock from sepsis of a urinary source secondary to obstructive uropathy (ureteral calculi). She presented with refractory shock and continued to remain in shock while undergoing emergent rigid cystoscopy with the placement of a ureteral stent. Despite adequate volume resuscitation, she required high doses of vasopressors resulting in peripheral extremity ischemia and necrosis of all her fingers and toes. By promptly initiating mitigation and preventive management strategies, we succeeded in minimizing tissue ischemia and reducing morbidity resulting from iatrogenic vasopressor-induced peripheral non-occlusive ischemia. These strategies include but are not limited to external warming of bilateral lower extremities, nitroglycerin paste application over the entire extremity, arterial assist pump, and low-dose therapeutic anticoagulation. The novel use of the arterial pump in acutely ischemic lower extremities likely helped salvage the toes which appeared to be at high risk of amputation.
RESUMO
En diciembre de 2019 en la ciudad china de Wuham se reportaron los primeros casos de una nueva enfermedad asociada al SARS-Cov2, denominada COVID-19 y declarada como pandemia por la OMS, con alta letalidad en pacientes mayores de 60 años, que reportaban, en algunos casos, una predisposición a desarrollar microtrombosis y/o trombosis en el sistema arterial y venoso. Cuba presentó su primer caso en abril de 2020, con un comportamiento similar, por lo que nuestro sistema de salud aplicó medidas efectivas, así como puso en práctica el conocimiento acumulado por la comunidad científica. En este sentido, se presenta un caso de gangrena isquémica de miembro inferior en paciente con COVID-19, de interés científico. A la paciente de 42 años se le diagnosticaron COVID-19 y otras comorbilidades, así como un cuadro respiratorio agudo severo, asociado con un proceso de microtrombosis y lesiones de gangrena isquémica distal de los dedos del miembro inferior izquierdo, por la producción de microtrombosis relacionadas con excesiva inflamación, activación plaquetaria, disfunción endotelial y estasis. Según protocolos aplicados en Cuba, la paciente logró sobrevivir a dichas complicaciones. Este caso da a conocer una complicación no relatada en toda su magnitud hasta el momento, lo cual debe ser reportado y conocido como interés científico teórico-práctico de nuestros profesionales de la salud(AU)
In December, 2019 in the Chinese city of Wuhan were reported the first cases of a new disease associated to SARS-CoV-2, called COVID-19 and it was declared as a pandemic by WHO. This disease had high lethality in patients older than 60 years whom in some cases reported predisposition to develop microthrombosis and/or thrombosis in the arterial and venous system. Cuba presented its first case in April, 2020 with a similar behaviour, then our health system implemented effective measures and put into practice all the knowledge accumulated by the scientific community. In this sense, it is presented a scientific interest case of ischemic gangrene of low limb in a patient with COVID-19. The 42 years old female patient was diagnosed with COVID-19 and other comorbidities, as well as with a severe acute respiratory condition, associated to a microthrombosis process and lesions of distal ischemic grangrene of left low limb´s toes, due to the microthrombosis related with excesive inflammation, platelets activation, endothelial dysfunction and stasis. Thanks to the protocols applied in Cuba, the patient survived to those complications. This case shows a complication that is not fully described to the moment, something which must be reported and known as theoric-practical scientific interest of our health professionals(AU)
Assuntos
Humanos , Masculino , Feminino , Síndrome Respiratória Aguda Grave , Gangrena , COVID-19/epidemiologia , Organização Mundial da SaúdeRESUMO
The time limit for the removal of a tourniquet is short; any delay in tourniquet deflation, especially if it exceeds the 3 hour limit, exposes to amputation hazards. Our objective was to report three cases of ischemic limb gangrene, caused by having forgotten to take a tourniquet off after a blood sampling, to inform healthcare professionals about the risk associated with that negligence. We encountered 3 cases of infants (2 three-month-old infants and 1 five-month-old infant), hospitalized in intensive care unit of Yalgado Ouédraogo University Hospital for upper-left limb swelling. Their medical history shows that there was a delay in tourniquet deflation after a blood sampling of 24 hours in two cases and of 48 hours in one case. Physical examination revealed a diffuse edema associated with upper limb gangrene spread to the mid-third of the upper arm, abolition of the ulnar and radial pulse as well as loss of sensation in the hand in 2 cases. In one case clinical signs were attenuated. The diagnosis of ischemic limb gangrene was confirmed in all cases. Laboratory examinations were normal. Two cases needed urgent trans-humeral amputation and one case needed debridement plus amputation of four fingers. The evolution was simple in all cases. Iatrogenic dry gangrene caused by a delay in tourniquet removal should never happen at hospitals. This can be guaranteed only by tightening up health management and by performing regular and accurate patient monitoring.
