Peripheral ischemic limb necrosis in septic shock patient

Rationale: Peripheral ischemic limb necrosis is a rare condition that progresses rapidly and aggressively, and eventually requires amputation. Disseminated intravascular coagulation (DIC) is a common cause of ischemic limb necrosis and vasopressors for maintaining blood pressure could be risk factors for ischemic limb necrosis. This case study aimed to identify the risk factors for ischemic limb necrosis in septic shock and determine the optimal time of surgical treatment for necrosis considering the progression of risk factors. Patient concerns: A 62-year-old male pig farmer visited the hospital complaining of dyspnea, general weakness, and skin color changes in the whole body, including both hands and feet. Initial vital signs were unstable. Diagnoses: The patient was diagnosed with sepsis and DIC based on the laboratory results. Blood cultures were positive for S suis . The skin lesions on both hands and feet were diagnosed as ischemic limb necrosis. Interventions: The patient was immediately treated with antibiotics, fluids, and vasopressors in the intensive care unit. Regular dressing was applied to the demarcated hands and feet. After 49 days, the left ring and small fingers and the right index, long, ring, and small fingers were amputated. Both toes were amputated simultaneously and debridement was performed on the left heel. Outcomes: No further necrosis was observed until postoperative 55 days. However, the left heel showed a soft tissue defect. Ultimately, a free ALT flap was created on the left heel by a plastic surgeon. Lessons: Physicians should consider peripheral ischemic limb necrosis in patients with septic shock presenting with DIC and treated with vasopressors. Surgical treatment should be performed only when necrosis is sufficiently demarcated considering the improvement in DIC and cessation periods of vasopressors without aggravating factors.