Symmetrical peripheral gangrene associated with cardiac surgery

At this stage, we noticed bluish discoloration of all upper limb fingers [Figure 1], which was soon noticed in lower limb toes also. All peripheral pulses were palpable and of normal volume. Patient has a borderline cardiac output (3.8 L/min) and cardiac index (2.1 L/min/m2). A clinical diagnosis of systemic peripheral gangrene (SPG) was made. We started milrinone 0.3 μg/Kg/min at this point for its inodilatory effect. This improved the cardiac output. Affected parts were covered with cotton pads to prevent them from trauma and to keep them warm. Considering sepsis in mind, antibiotics were escalated to meropenem, linezolid, and ciprofloxacin. Thereafter, ABG and cardiac output were repeated every 4th h. Gradually patient was weaned off from ventilator and trachea was extubated after 12 h of ICU admission. IABP tapered off and we were able to remove it at 48 h of its insertion. The fine adjustment was done in administration of fluids bolus and pulmonary artery pressure. With this maneuver, we were able to taper off inotropic support. The patient improved symptomatically with this treatment. The physiotherapist was called to provide gentle exercise of extremity joints. Lower limb ischemia turned to dry gangrene of foot, from tip of all toes to mid metatarsal on the right side, and up to the base of toes in the left side [Figures 2 and 3]. In next few days, clear demarcation line appeared between gangrenous and nongangrenous parts. After 2nd week, amputation of affected toes was done. Gradually patient improved and discharged home after 1 month of admission.