WA discussed about writing the paper with SB and NR. 3) and underwent bilateral transmetatarsal amputations (figure 4) with application of a Veraflow wound vacuum-assisted closure (VAC) 1?week later. Open in a separate window Figure 1 The left hand after amputation of digits 1, 4 and 5. Open in a separate window Figure 2 Demarcated gangrene on the dorsal aspect of both feet. Open in a separate BI605906 window Figure 3 Demarcated gangrene on the plantar aspect of both feet. Open in a separate window Figure 4 Both feet 3?months after transmetatarsal amputations and application of Versaflow wound VAC. One full year after the patient was first admitted to the hospital, and 3?months after his bilateral transmetatarsal amputations, a split-thickness skin graft was applied on both his feet (figure 5). Open in a separate window Figure 5 Both feet after application of split-thickness skin grafts. Outcome and follow-up The patient is currently continuing his recovery as an outpatient with the goal of full ambulation over the next several months. Discussion SPG is an infrequent clinical manifestation of an acute BI605906 onset of ischaemia in two or more extremities without obstruction of the arteries that supply the extremity.2 Fingers and toes are most commonly affected, and the?least affected are the nose, earlobes and scrotum.2 Hutchinson first described SPG in 1891 in a 37-year-old man who developed gangrene of the fingers, toes and earlobes after shock.4 Since then, single case reports and small case series have been reported in the medical literature.4 SPG has been linked to infective and non-infective aetiologies and can develop in any age or sex. 3 5 Acute conditions are Gram-negative and Gram-positive septicaemia, low-output states and vasopressor use. Some chronic conditions include essential thrombocythaemia, polycythaemia rubra vera, Raynauds syndrome, diabetes and small vessel obstruction.4C6 However, disseminated intravascular coagulation (DIC) has been found widespread and is probably the last cause of microvascular injury resulting in SPG.3 Strossel and Levy first described the association between DIC and SPG in 1970.3 4 Septicaemia is commonly associated with clinical DIC and occurs in approximately 30%C50% of patients with SPG.4 The majority of SPG cases we reviewed attributed SPG to treatment for cardiogenic shock BI605906 or septic shock with DIC.1C3 5 7 The pathomechanics of DIC associated with SPG is primarily driven by a disordered clotting pathway.8 9 This dysfunction may lead to inappropriate thrombin activation resulting in increased fibrin breakdown products and intravascular microthromboses.8 10 Mouse monoclonal to ALDH1A1 Furthermore, the additional use of vasoconstrictive drugs exacerbates tissue hypoperfusion and ischaemia, leading to eventual tissue necrosis and gangrene. 11 Also septic shock can be associated with high lactate. One article reported that very high serum lactate levels may be detected just prior to the onset of SPG.4 Our patients lactate was significantly elevated on the same day vasopressors were initiated and remained elevated for the next few days. The three stages leading up to SPG are sepsis, ischaemia and gangrene. Treatment can be administered at each stage to prevent, slow or reverse the course to SPG. Septic shock, the first stage, results in low perfusion to the peripheral circulatory system and must be aggressively managed.2 5 Treatment includes resuscitation with fluids, intravenous antibiotics, anticoagulants and vasopressors.5 7 12 The vasopressors recommended by the Surviving Sepsis Guidelines are either dopamine or norepinephrine as the initial vasopressor of choice, and vasopressin can supplement norepinephrine.13 However, it has been noted that dopamine, epinephrine and norepinephrine can cause digital gangrene at recommended or curative dosage levels, especially in patients with DIC and hypovolaemia.1 For example, renal and mesenteric bed vasodilatation occurs in low-dose dopamine ( 5?g/kg/min), cardiac contractions can occur at moderate doses (5C10?g/kg/min), and vasoconstriction can occur at higher doses of 10C20?g/kg/min.2 Peripheral gangrene attributed to the vasospastic action.