Septic Shock following Prostate Biopsy: Aggressive Limb Salvage for Extremities after Pressor-Induced Ischemic Gangrene.

Vasopressors used to treat patients with septic shock can cause ischemic necrosis of appendages such as the ears and nose, as well as the extremities. Cases of quadruple-extremity necrosis have high morbidity and mortality, and a profound negative impact on quality of life. This case report details the successful limb salvage and return to function using free tissue transfer as a means to salvage bilateral lower extremities in a patient who suffered vasopressor-induced ischemia of upper and lower extremities after prostate biopsy-induced septic shock. Septic shock following transrectal ultrasound-guided prostate biopsy is a rare, yet life-threatening complication. Successful treatment included thorough planning and staging of therapies such as awaiting tissue demarcation and serial surgical debridement to adequately prepare the tissue bed for free tissue transfer. Adjunctive treatments such as hyperbaric oxygen therapy, negative-pressure wound therapy, and meticulous wound care played a crucial role in wound healing. This vigilant planning and coordinated care resulted in the successful lower extremity salvage, consisting of bilateral transmetatarsal amputations and free tissue transfer to both limbs. We present our long-term follow-up of a functional ambulatory patient after catastrophic, life-threatening infection and appropriate multidisciplinary care.

Transrectal ultrasound–guided biopsy is routinely used to find atypical prostate tissue. Common complications include rectal bleeding, hematuria, and prostatitis. Though serious complications are rare, sepsis and septic shock leading to extremity necrosis have been reported.[1]

To date, there is little published literature on the use of free tissue transfer in patients suffering pan-extremity pressor-related necrosis. This case report describes the effectiveness of coordinated planning for salvage of gangrenous extremities and successful functional outcome in pressor-related ischemic gangrene.

CASE REPORT

This patient is a healthy 62-year old male (body mass index of 21.6) with a medical history of gastroesophageal reflux disease and benign prostatic hyperplasia, who presented to the emergency department with septic shock following a transrectal ultrasound–guided prostate biopsy for elevated prostate-specific antigen. He was admitted to the intensive care unit (ICU) for management of urosepsis from extended spectrum beta lactamase Escherichia coli complicated by pyelonephritis. He required a prolonged course of continuous high-dose vasopressors including phenylephrine, vasopressin, and norepinephrine. His hospital course was further complicated by hypoxemic respiratory failure, shock liver, acute renal failure, and acalculous cholecystitis. He was in the ICU for 12 days before being transferred to the medicine ward.

While hospitalized, bilateral upper and lower extremities underwent distal pressor-induced ischemia and gangrene (Fig. 1; see figure, Supplemental Digital Content 1, which displays gangrenous lower extremities awaiting tissue demarcation, http://links.lww.com/PRSGO/A544). Topical nitroglycerin and hyperbaric oxygen therapy (HBOT) were used to salvage viable tissue. Two percentage nitroglycerin topical ointment was applied twice daily starting on the ninth day of his ICU stay and continued until discharge for a total of 31 days. HBOT was started the day before discharge and continued daily, totaling 28 dives. Nevertheless, bilateral amputations of all fingers at the level of the proximal interphalangeal joints were required. The lower extremity tissue demarcated at the level of the metatarsal heads, with loss of all plantar skin on the left foot, weight-bearing skin on the right foot, and partial loss of both calcanei. Considerations of salvage versus bilateral below the knee amputations were discussed with the patient and family, and the decision was made to undergo aggressive attempts at limb salvage.

Fig. 1.

Gangrenous lower extremities after prolonged vasopressor use.

His wounds required multiple debridement, intravenous antibiotics, and wound bed preparation with both bilayered bovine collagen and porcine xenografts. Once the tissues fully demarcated, he underwent bilateral transmetatarsal amputations (TMAs) with removal of both necrotic calcanei and soft tissues (Fig. 2; see figure, Supplemental Digital Content 2, which displays a right lower extremity in early stages of serial debridement, http://links.lww.com/PRSGO/A545). INTEGRATM Bilayer Matrix Wound Dressing (Integra Life Sciences, Plainsboro, N.J.) was used as a scaffold for skin grafts to the dorsum of his TMAs to retain as much as length as possible.

Fig. 2.

Left lower extremity in early stages of debridement.

Once the tissues proved viable and cultures were negative (postinjury day 109), bilateral free flap planning ensued. Due to the extent of soft and bony tissue loss, the patient required a robust reconstruction to achieve the goal of independent ambulation (Fig. 3; see figure, Supplemental Digital Content 3, which displays a right lower extremity after serial debridement with healthy, bleeding tissue, http://links.lww.com/PRSGO/A546). Angiography revealed widely patent anterior tibial and peroneal arteries bilaterally. The patient received a sensate anterolateral thigh (ALT) flap to his left foot via end-to-side anastomosis to the inframalleolar posterior tibial artery with end-to-end venous anastomosis to the saphenous vein and deep vena comitantes, and neurotization via the lateral femoral cutaneous nerve to the posterior tibial nerve. A 4 × 6 cm piece of Integra was used to cover the remaining wound over his TMA and was later replaced with a split-thickness skin graft from the left thigh. Thirteen days later, he returned to the operating room, where a similar neurotized ALT flap was inset to the right foot via end-to-side anastomosis to the inframalleolar posterior tibial artery with 2-vein anastomosis and coaptation of the lateral circumflex femoral nerve to the posterior tibial nerve, (see figure, Supplemental Digital Content 4, which displays a left lower extremity after successful free tissue transfer with ALT flap from ipsilateral thigh, http://links.lww.com/PRSGO/A547; see figure, Supplemental Digital Content 5, which displays a right lower extremity healing well after free tissue transfer with ALT flap from ipsilateral thigh, http://links.lww.com/PRSGO/A548).

Fig. 3.

Well debrided left lower extremity after serial debridement in the operating room.

The patient tolerated both procedures well and remained non–weight-bearing for 6 weeks. Due to the loss of achilles tendon insertions, he required ankle foot orthoses and custom braces. With intensive physical therapy and protective sensation of bilateral heels, he began walking 2 months after free tissue transfer. Eight months after surgery, he has retained sensation of both free flaps and is functionally ambulatory with an ExoSymTM (Hanger Inc., Austin, Tex.) prosthesis. (Fig. 4; see figure, Supplemental Digital Content 6, which displays a dorsal view of lower extremities 11 months after bilateral free tissue transfer, http://links.lww.com/PRSGO/A549; see figure, Supplemental Digital Content 7, which displays a patient wearing a ExoSymTM prosthesis in clinic 11 months after free tissue transfer, http://links.lww.com/PRSGO/A550; see video, Supplemental Digital Content 8, which displays patient ambulating with prostheses 9 months after free tissue transfer, http://links.lww.com/PRSGO/A551).

Fig. 4.

Well-healed lower extremities 11 months after bilateral free tissue transfer.

See video, Supplemental Digital Content 8, which displays patient ambulating with prostheses 9 months after free tissue transfer, http://links.lww.com/PRSGO/A551.

DISCUSSION

In cases of ischemic gangrene of all extremities, vigorous limb salvage must be undertaken to achieve good quality of life and functional outcome. A multidisciplinary approach is the most effective means to optimize salvage. In our experience, multiple staged debridement, HBOT, negative-pressure wound therapy (NPWT), and meticulous wound care are essential tools.

Complete tissue demarcation is crucial in this setting to preserve limb length. Early surgical intervention before full demarcation leads to more extensive tissue loss, as what seems necrotic superficially may still contain viable tissue in deeper layers. Complete demarcation can take up to 6 months but yields a higher degree of salvaged tissue.[2] The use of HBOT helps revive damaged tissue and delineate viable from necrotic tissues.

Once demarcation has occurred, serial debridement is required to remove all necrotic tissue and promote intrinsic granulation before reconstructing defects. NPWT is vital, as it promotes tissue granulation and decreases bacterial infiltration.[3]

The use of neurotized flaps for lower extremities play an important role in long-term functional success by preventing tissue trauma and allowing for a more expeditious return to function.[4] In addition, it is critical to understand the biomechanical implications of limb salvage. Loss of the distal feet and bilateral achilles tendon insertions must be managed with an experienced prosthetist that can mitigate the forefoot length loss and provide ankle bracing. This allows for a for more rapid and efficient rehabilitation after tissue healing and a quicker return to normal activities.

SUMMARY

There are limited reports of extremity ischemia as sequelae of vasopressor use in the setting of sepsis.[2,5,6] In our experience, a multidisciplinary approach with careful planning leads to successful functional outcome. Awaiting demarcation, staging surgical interventions, HBOT, and NPWT are critical for successful free tissue transfer. Free tissue transfer is an effective method of limb salvage and retained function in patients suffering extremity necrosis after vasopressor-induced ischemia.