Anesth Analg 2004;99:438-439
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000121960.22554.D7
ANESTHETIC PHARMACOLOGY
Anesthetic Management of Patients with Severe Peripheral Ischemia Due to Calciphylaxis
Takafumi Horishita, MD PhD,
Kouichiro Minami, MD PhD,
Junichi Ogata, MD PhD, and
Takeyoshi Sata, MD PhD
Department of Anesthesiology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
Address correspondence and reprint requests to Kouichiro Minami, MD, PhD, Department of Anesthesiology, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishiku, Kitakyushu 807-8555, Japan. Address e-mail to kminami{at}med.uoeh-u.ac.jp
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Abstract
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Calciphylaxis is a small-vessel disease associated with renal failure. Here, we report the management of a 43-yr-old man with calciphylaxis who received left lower leg amputation with prostaglandin E1 (PGE1) under monitoring by laser Doppler blood flowmetry in the left second and third fingers. Anesthesia was induced with midazolam, fentanyl, and vecuronium and was maintained with oxygen, nitrous oxide, and sevoflurane. The peripheral blood flow varied and decreased gradually; therefore, we added PGE1 20 ng · kg–1 · min–1, which increased blood flow of the tissues. Three weeks after the operation, we again anesthetized the patient. We maintained the blood flow with PGE1 throughout anesthesia. Monitoring by laser Doppler blood flowmetry and PGE1 20 ng · kg–1 · min–1 could be useful for patients with impaired peripheral circulation, as in calciphylaxis.
IMPLICATIONS: We managed a patient with calciphylaxis during anesthesia by using laser Doppler blood flowmetry and infusion of prostaglandin E1. This management procedure is useful for patients with calciphylaxis and severely impaired peripheral circulation.
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Introduction
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Calciphylaxis is a rare, life-threatening complication that occurs in patients with end-stage renal disease (1). It is a small-vessel disease and results in ischemia and tissue necrosis (2). Treatment includes wound debridement, wound excision, and removal of the parathyroid gland. It is important to maintain peripheral blood flow during anesthesia. However, there has been no report of the management of anesthesia for patients with calciphylaxis. Here, we report successful management by using prostaglandin E1 (PGE1) with monitoring by laser Doppler blood flowmetry.
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Case Report
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A 43-yr-old man presented with a diagnosis of calciphylaxis and necrosis of the left foot and right fingers. He had been receiving dialysis for chronic renal failure for 12 yr. He had severe peripheral ischemia and severe ulcerous lesions in his fingers. During dialysis, circulation impairment in his fingers became worse, and his fingers became cyanotic and cold when the systolic blood pressure was less than 100 mm Hg. He was scheduled for left lower leg amputation because necrosis of his left foot was advanced. Because his right second and third fingers developed painful ulcerous lesions (Fig. 1A), we used laser Doppler flowmetry (BRC-100; Bioresearch Center, Nagoya, Japan) to measure the blood flow in the fingers and to estimate peripheral circulation (Fig. 1B). We recorded data by using the MacLab/2 data acquisition system (AD Instruments Pty. Ltd., Castle Hill, NSW, Australia).
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Figure 1. A, Ulcerous lesions of the right second and third fingers (a) at the first operation. B, We measured blood flow in the left second and third fingers with a Doppler blood flowmeter. We attached the probe of the flowmeter to the ventral side of the fingers (b) and measured oxygen saturation on the fourth finger (c). C, Blood flow during anesthesia in the first operation. After sevoflurane was started, the blood flow to the left fingers increased from 20 to 25 mL · 100 g–1 · min–1. The blood flow decreased when bleeding increased during anesthesia and improved from 15 to 25 mL · 100 g–1 · min–1 with infusion of 250 mL of plasma protein fraction. After we gave prostaglandin E1 (PGE1), the blood flow increased from 15 to 30 mL · 100 g–1 · min–1.
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Before anesthesia, we could not measure oxygen saturation with pulse oximetry because of severely impaired peripheral circulation; however, we could measure the blood flow in his fingers by flowmetry. Anesthesia was induced with 4 mg of midazolam, 200 µg of fentanyl, and 6 mg of vecuronium IV and was maintained with 2 L/min of oxygen, 3 L/min of nitrous oxide, and 2%–3% sevoflurane. Blood flow was increased gradually after the administration of sevoflurane, but we still could not measure oxygen saturation with pulse oximetry. Peripheral circulation was evaluated by the flowmeter instead of pulse oximetry throughout anesthesia. The blood flow decreased gradually at the end of anesthesia. We then infused 250 mL of plasma protein fraction and added PGE1 20 ng · kg–1 · min–1. Blood flow subsequently increased (Fig. 1C) and was maintained until the end of the operation, which was performed uneventfully.
Three weeks after the amputation, the patient was scheduled for resuture because of suture failure. The ulcerous lesions in his right fingers had worsened over the previous 3 wk. The induction and maintenance of anesthesia were the same as with the first operation. We used a laser Doppler flowmeter to measure the blood flow in the left fingers and began to administer PGE1 20 ng · kg–1 · min–1 before anesthesia. Throughout anesthesia, we maintained the blood flow. The postoperative period was uneventful, and the ulceration of his fingers did not advance during anesthesia.
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Discussion
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Extensive microvascular calcification leads to nonhealing ulcers and sepsis. Secondary infection of skin lesions is common, often leading to sepsis and death. Because the etiology of calciphylaxis remains unclear and because there is little understanding of the pathophysiology of the disease, treatment is usually unsatisfactory, prognosis poor, and mortality common (1).
In this case, the patient had severe peripheral ischemia and severe ulcerous lesions in his fingers. During dialysis, his fingers became cyanotic and cold because of a small decrease of blood pressure. Therefore, it was important to evaluate blood flow continuously to prevent aggravating ischemia and tissue necrosis during anesthesia. Measuring arterial blood pressure or cardiac output continuously could be useful. However, direct measurement of arterial blood pressure could also cause arterial injury, resulting in tissue ischemia, and the insertion of a pulmonary artery catheter could be invasive for patients undergoing dialysis, with concerns of coagulopathy and infection. As a noninvasive measurement, the pulse oximeter is useful for detecting peripheral vascularity. However, it is difficult to monitor the actual peripheral blood flow. Indeed, in this case, we could not measure oxygen saturation at the fingers with pulse oximetry. Laser Doppler flowmetry gives immediate information on actual peripheral blood flow and the variation of blood flow. Moreover, it is a noninvasive monitor. Therefore, the laser Doppler blood flowmeter would be an appropriate method for patients with severe peripheral circulation impairment, as in this case of calciphylaxis.
Anesthetics such as sevoflurane are vasodilators, and, in our patient, the blood flow was increased after induction. The blood flow decreased gradually at the end of anesthesia: we therefore considered that it was necessary to administer transfusion and vasodilators besides anesthetics to recover blood flow. PGE1 increases peripheral blood flow, and PGE1 has been used for patients with venoocclusive disease, such as arteriosclerosis obliterans (1–3). Therefore, we chose PGE1 for vasodilation, and blood flow increased, suggesting that a vasodilator would be useful for maintaining blood flow.
Green et al. (3) reported that neurolytic lumbar sympathetic blockade provides pain relief and is a treatment modality to be considered in managing the pain associated with calciphylaxis. Most patients with this disease undergo hemodialysis. In our case, the patient had undergone hemodialysis, and the preoperative data revealed coagulopathy. His prothrombin time percentage was 67.4%, and his activated partial thromboplastin time was 33.2 seconds (control, 30.7 seconds), so we did not use epidural block or spinal block. Although epidural block may be useful in some cases, the anesthesiologist should be cautious because it is possible that hemorrhage may occur.
In conclusion, by continuously estimating blood flow in the fingers by using laser Doppler blood flowmetry and infusion of PGE1, we were able to correctly evaluate blood flow and protect our patient from ischemia and necrosis of the fingers during surgery.
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References
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- Budisavljevic MN, Cheek D, Ploth DW. Calciphylaxis in chronic renal failure. J Am Soc Nephrol 1996; 7: 978–82.[Abstract]
- Wilmer WA, Magro CM. Calciphylaxis: emerging concepts in prevention, diagnosis, and treatment. Semin Dial 2002; 15: 172–86.[Web of Science][Medline]
- Green JA, Green CR, Minott SD. Calciphylaxis treated with neurolytic lumbar sympathetic block: case report and review of the literature. Reg Anesth Pain Med 2000; 25: 310–2.[Web of Science][Medline]
Accepted for publication January 28, 2004.
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Abstract
Introduction
