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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 4  |  Issue : 2  |  Page : 72-73

Foot gangrene following dorsalis pedis artery cannulation: Risk versus benefit of arterial cannulation in polytrauma patient


Assistant Professor, Department of Trauma & Emergency (Plastic Surgery), Department of Trauma & Emergency (Anaesthesia), All India Institute of Medical Sciences, Bhubaneswar, India

Date of Submission17-Dec-2018
Date of Acceptance29-Dec-2018
Date of Web Publication4-Feb-2019

Correspondence Address:
Ritesh Panda
Department of Trauma and Emergency, AIIMS Bhubaneswar-751019
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2395-2113.251445

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How to cite this article:
Panda R, Mohanty CR. Foot gangrene following dorsalis pedis artery cannulation: Risk versus benefit of arterial cannulation in polytrauma patient. Indian J Community Fam Med 2018;4:72-3

How to cite this URL:
Panda R, Mohanty CR. Foot gangrene following dorsalis pedis artery cannulation: Risk versus benefit of arterial cannulation in polytrauma patient. Indian J Community Fam Med [serial online] 2018 [cited 2019 Dec 16];4:72-3. Available from: http://www.ijcfm.org/text.asp?2018/4/2/72/251445



Digital gangrene following arterial cannulation for invasive blood pressure monitoring is a dreaded complication. Radial artery is the preferred site for arterial cannulation but dorsalis pedis artery can be used in polytrauma patients when there are concomitant upper limb injuries. Though finger ischemia and gangrene following radial artery cannulation has been reported in literature, but gangrene of foot and toes following dorsalis pedis artery cannulation in adult is not yet reported. We are reporting a case of foot gangrene following dorsalis pedis artery cannulation in a patient of polytrauma with blunt trauma abdomen.

A 32-year old gentleman presented to our emergency department with polytrauma due to road traffic accident and sustained blunt trauma to abdomen with crush avulsion injury and multiple fractures of bilateral upper limbs. His vitals were Blood pressure - 108/56 mm Hg in lower limb, Pulse rate-132/min, Respiratory rate- 20/min, GCS-14/15, RTS (revised trauma score)- 7.841, ISS (injury severity score)- 75, TRISS(trauma injury severity score)-40.8% and FAST positive. Arterial blood gas analysis showed metabolic acidosis with lactic acidosis. Patient was intubated in emergency, right Internal Jugular Vein central line and left dorsalis pedis arterial cannulation was done due to fracture of bilateral upper limbs.

Intra-operative after giving laparotomy incision, there was sudden hypotension (BP- 76/34 mm Hg) which was managed with fluid and noradrenaline infusion. There was bowel perforation with peritonitis so thorough washout followed by closure with colostomy done. In the postoperative period, patient was kept in ICU for mechanical ventilation and vitals monitoring. In view of septic shock, noradrenaline support was continued. In the second postoperative day, patient developed patchy discoloration over dorsum of left foot, instep area and first 3 toes. Suspecting arterial thrombosis, arterial cannula was removed immediately and supportive treatment was started. The patient was in septic shock with coagulopathy (raised PT and INR), so heparin was avoided. Foot was covered and kept warm. Aspirin 100 mg/day OD and clopidogrel 75 mg/day was started. USG Doppler suggested pulsatile triphasic flow with normal flow velocities in CFA, SFA, popliteal artery, ATA and PTA and monophasic flow in dorsalis pedis artery. There was gradual progress of gangrene with demarcation and was limited to foot [Figure 1], [Figure 2]. Eventually patient succumbed to his injuries on POD 10. We suspect peripheral gangrene due to arterial thrombosis precipitated by low perfusion caused by high-dose vasopressors along with prolonged arterial cannulation as the causative factor.
Figure 1: Discoloration over dorsum of left foot and medial three toes on POD 2 and tape residue over dorsum showing site of arterial cannulation.

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Figure 2: Discoloration over plantar aspect of medial three toes, medial aspect of foot and instep area.

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Discussion: Peripheral gangrene is a rare devastating complication involving distal portions of two or more extremities simultaneously precipitated by low perfusion, high dose of inotropes, disseminated intravascular coagulation, and arterial cannulation. Radial artery cannulation for invasive blood pressure monitoring is the preferred site.[1] and dorsalis pedis artery cannulation preferred in polytrauma patient when there is concomitant upper limb injuries. Vascular complications from arterial cannulation are uncommon, factors that may increase risk include vasospastic arterial disease, previous arterial injury, thrombocytosis, protracted shock, high-dose vasopressor administration, prolonged cannulation, and infection.[2],[3]

To conclude, we strongly recommend monitoring of limbs for signs of ischemia in patients with any of above risk factors in whom cannula has to kept for prolonged period and early removal of cannula when benefit is less than risk of keeping arterial cannula.



 
  References Top

1.
Mandel MA, Dauchot PJ: Radial artery cannulation in 1000 patients. Precautions and complications, J Hand Surg 2(6):482- 485,1977.  Back to cited text no. 1
    
2.
Brzezinski M, Luisetti T, London MJ: Radial artery cannulation: acomprehensive review of recent anatomic and physiologic investigations,AnesthAnalg109(6):1763-1781, 2009.  Back to cited text no. 2
    
3.
Rehfeldt KH, Sanders MS: Digital gangrene after radial artery catheterization in a patient with thrombocytosis, Anesth Analg 90:45-46, 2000.  Back to cited text no. 3
    


    Figures

  [Figure 1], [Figure 2]



 

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