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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 127-129

Sepsis and anticoagulant, is amputation a lifesaving surgery?


1 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Cardiothoracic Vascular Surgery, All India Institute of Medical Sciences, Patna, Bihar, India
3 Department of Burn and Plastic Surgery, All India Institute of Medical Sciences, Patna, Bihar, India

Date of Submission08-Mar-2020
Date of Decision15-May-2020
Date of Acceptance03-Jun-2020
Date of Web Publication21-Apr-2021

Correspondence Address:
Dr. Amarjeet Kumar
Room No. 501, PG-1, All India Institute of Medical Sciences Campus, Patna, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_12_20

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  Abstract 


Patients with severe sepsis are associated with coagulation abnormalities ranging from minimal to major activation of coagulation system, which may lead to fulminant disseminated intravascular coagulation (DIC) and multiorgan failure. Lower extremity amputation is indicated to remove ischemic, infected, or necrotic tissue or locally unresectable tumor and, at times, may be lifesaving. Peripheral artery disease and diabetes are the leading causes of non-traumatic lower extremity amputation. Amputation of lower limb in patient of severe sepsis associated with coagulation abnormalities may be limb saving surgery but may not be lifesaving surgery as in our case patient died due to multiorgan failure.

Keywords: Amputation, anticoagulation, sepsis


How to cite this article:
Kumar N, Kumar A, Kumar A, Kumar S, Singh V. Sepsis and anticoagulant, is amputation a lifesaving surgery?. APIK J Int Med 2021;9:127-9

How to cite this URL:
Kumar N, Kumar A, Kumar A, Kumar S, Singh V. Sepsis and anticoagulant, is amputation a lifesaving surgery?. APIK J Int Med [serial online] 2021 [cited 2021 Jun 12];9:127-9. Available from: https://www.ajim.in/text.asp?2021/9/2/127/314194




  Introduction Top


Patients with severe sepsis are associated with coagulation abnormalities and activation of the coagulation system. These abnormalities range from minimal to major activation of the coagulation system, which may lead to fulminant disseminated intravascular coagulation and multiorgan failure. Sometimes, clinical presentation can be helpful in making the diagnosis. Septic patients have severe forms of coagulation factor activation which may present with clinical thromboembolic events, with thrombi in middle–larger-sized arteries and veins. However, they are clinically less apparent at the microvascular level in the form of fibrin deposition, which predominantly presents as multiple organ dysfunction.[1]


  Case Report Top


We present the case of a 75-year-old female, with a history of moderate overweight (height: 158 cm, weight: 65 kg, body mass index: 26 kg/m2), but no prior venous thromboembolic disease, admitted to the emergency department following acute exacerbation of chronic obstructive pulmonary disease with signs of lower respiratory tract infection and was managed conservatively using noninvasive ventilation, nebulization, and iv antibiotics. On day 2, the patient suddenly developed severe pain in the left lower limb. Urgent computed tomography (CT) angiography of the left lower limb showed subacute/chronic thrombus filling up most of the left lower limb artery including the left common iliac artery. Simultaneously, we also performed bedside two-dimensional echocardiography of the heart which showed no clot or vegetation, and all valve chambers were within normal limits. All routine blood studies and coagulation tests were within the normal limits except the total count which was 14,000/mm3. Plain Chest X-ray and ECG were normal.

Hence, heparinization was started immediately after the diagnosis of acute limb ischemia was made as a limb reperfusion strategy. Initially, 80 U/kg of unfractionated heparin was injected intravenously, and continuous intravenous heparinization was performed keeping the activated partial thromboplastin time (aPTT) between 60 and 100 s. Oral warfarin 5 mg was also added to overlap with the heparin treatment. Heparin was stopped when the international normalized ratio (INR) reached levels between 2.0 and 2.5. Hence, urgent surgical thromboembolectomy was planned using Fogarty catheter sizes 2 and 3 Fr for distal thromboembolectomy and sizes 4 and 5 Fr for proximal thromboembolectomy. We obtained written and informed consent from the patient relative. We serially measured the flow in the dorsalis pedis, posterior tibial, peroneal artery, and popliteal artery of the left limb using handheld color Doppler in the intraoperative period. On the 2nd postoperative day, severe rest pain with marked discoloration of the lower leg and foot and complete loss of sensory and motion functions was observed. Few hours after noticeable skin discoloration of the left lower limb, she suddenly presented with severe respiratory distress, and urgent laboratory work up showed marked increase in the total leukocyte count to 43,000/mm3 associated with deranged coagulation profile as INR-9, aPTT – 124, a sudden drop in the urine output. We urgently transfused 6 units of fresh frozen plasma (FFP) and planned for emergency below knee amputation (BKA) of the left lower limb under general anesthesia. In the intraoperative period, the patient developed epistaxis from the nose, and the mean arterial pressure measured was <60 mmHg. Hence, urgent posterior nasal packing and noradrenaline infusion was started at 2 mcg/kg/min. The urine output was monitored hourly which was within the normal limit. Surgery lasted for <1 h, and the patient was shifted to the intensive care unit. On local examination, there was no oozing from the amputation site. Neurological examination revealed Glasgow Coma Scale E1VTM3 with bilateral mid-dilated pupil and showed sluggish response to light. On noncontrast CT of the brain, there was intraparenchymal left temporoparietal bleed. The treatment protocol for the raised intracranial pressure was started. We again transfused 6 units of FFP, and serial measurement of INR and aPTT was done which dropped down to 4 and 65, respectively. The patient was on continuous ventilatory support, and on the seventh postoperative period, she died due to severe sepsis following multiorgan failure.


  Discussion Top


In our case, This patient was admitted with no symptoms of limb ischemia. She had respiratory symptoms on day 2 of admission with severe pain in the left lower limb which gave us clinical suspicion of ischemia for that CT angiography was done to delineate the vascular anatomy which showed thrombus in the left iliac artery. The CT angiography report showed subacute/chronic thrombus filling up most of the left lower limb artery including the left common iliac artery. As both surgical and radiological skills were required, always a close cooperation between the surgeon and the radiologist was necessary for taking decision of Fogarty thromboembolectomy.[2] In our case, it might have been an acute on chronic thrombus, so embolectomy would help till gangrenous changes occur, at least it would have helped to lower down the level of BKA surgery. Hence, initially, we started heparin as a reperfusion strategy in this patient. Fogarty catheter embolectomy was associated with certain complications, among them intimal dissection leading to thrombosis was very common. Injury to the intimal layer may occur during embolectomy procedure leading to re-thrombosis. We had taken all precautions in minimizing the force that was generated by a typical embolectomy procedure, and if any would have occured, it was always reversible, and within a week, hypercellularity of the intima takes place with increased ribosomal activity in the media layer.[3] We also did embolectomy at the time of amputation through the cut end of the artery at stump for better wound healing.

A lower extremity amputation is indicated to remove ischemic, infected, or necrotic tissue or locally unresectable tumor and at times, may be lifesaving. Peripheral artery disease and diabetes are the leading causes of nontraumatic lower extremity amputation.[4] Complications following major lower extremity amputation include medical complications related to preexisting conditions and local complications related to the surgery, which include stump hematoma, infection, need for repeat amputation, phantom limb syndrome, and flexion contracture.[5] Patients undergoing major lower extremity amputation are at high risk for thromboembolism.[6] It was very difficult to diagnose thrombosis secondary to sepsis because lots of factors can lead to the hypercoagulable state, especially during the postoperative period. Activation of the coagulation system in severe sepsis, associated with severe inflammatory activation, can result in widespread thrombosis at the microvascular level despite effective anticoagulation. To evaluate thrombosis secondary to severe sepsis, the assessment of coagulation and hemostasis must include fibrinogen, platelet count, prothrombin time, aPTT, and partial thromboplastin time as screening test and coagulation factor testing, especially factor V and factor VII levels which may be increased. Prophylactic antibiotics significantly reduce the incidence of amputation wound infection.[7] The choice of antibiotic therapy and duration depend on the clinical situation. Pharmacologic prophylaxis reduces the incidence of deep vein thrombosis (DVT) to approximately 10%. Thrombophilia can be a cause of coagulopathy during severe sepsis and must be ruled out.[8] It was very difficult to do surgery in patient with severe sepsis associated with coagulation abnormalities. Perioperative mortality rates for major amputation in patients with peripheral artery disease are 11%–18% for above knee amputation, 4%–9% for BKA, and 2%–7% for foot amputation (total or partial).[9] Factors that increase perioperative mortality following major amputation include age >80, dependent functional status, dialysis, chronic glucocorticoid use, preoperative sepsis, delirium, thrombocytopenia, coagulopathy, and renal insufficiency.[10]


  Conclusion Top


Amputation of the lower limb in a patient of severe sepsis associated with coagulation abnormalities may be limb-saving surgery but may not be lifesaving surgery as in our case, the patient died due to multiorgan failure following amputation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levi M, Ten C H, Van DPT, Vandeventer SJH. Pathogenesis of disseminated intravascular coagulation in sepsis. JAMA 1993;270:975-9.  Back to cited text no. 1
    
2.
Miller DL, Patronas N, Artwohl RR, Doppman JL. Fogarty catheter complication treated with angiographic techniques: New use for balloon occlusion catheter. Cardiovasc Intervent Radiol 1984;7:214-7.  Back to cited text no. 2
    
3.
Jorgensen RA, Dobrin PB. Balloon embolectomy catheters in small arteries. IV. Correlation of shear forces with histologic injury. Surgery 1983;93:798-808.  Back to cited text no. 3
    
4.
Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FG, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 2007;45 Suppl S: S5-67.  Back to cited text no. 4
    
5.
Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, et al. Major lower extremity amputation: Outcome of a modern series. Arch Surg 2004;139:395-9.  Back to cited text no. 5
    
6.
Lastória S, Rollo HA, Yoshida WB, Giannini M, Moura R, Maffei FH. Prophylaxis of deep-vein thrombosis after lower extremity amputation: Comparison of low molecular weight heparin with unfractionated heparin. Acta Cir Bras 2006;21:184-6.  Back to cited text no. 6
    
7.
Huang ME, Johns JS, White J, Sanford K. Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation. Arch Phys Med Rehabil 2005;86:73-8.  Back to cited text no. 7
    
8.
Burke B, Kumar R, Vickers V, Grant E, Scremin E. Deep vein thrombosis after lower limb amputation. Am J Phys Med Rehabil 2000;79:145-9.  Back to cited text no. 8
    
9.
Fromentin M, Talec P, Stephanazzi J, Samama CM. Sepsis and thrombosis: An unusual extensive inferior vena cava thrombosis. Anaesth Crit Care Pain Med 2018;37:377-8.  Back to cited text no. 9
    
10.
Sandnes DK, Sobel M, Flum DR. Survival after lower-extremity amputation. J Am Coll Surg 2004;199:394-402.  Back to cited text no. 10
    




 

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