Iatrogenic-induced Peripheral Gangrene: From Multiple Limb Amputations to Prosthetic Restoration

Objectives: Multiple limb amputations are an uncommon complication from inotrope-induced peripheral gangrene. Case Presentation: A 20-year-old lady with valvular heart disease had septic shock secondary to infective endocarditis and required prolonged cardiopulmonary resuscitation. Despite aggressive fluid resuscitation, the patient had triple strength intravenous noradrenaline to maintain hemodynamic stability. On day 5 of post-shock, dry gangrene occurred in distal parts of all limbs, and inotrope was stopped. Although the gangrenous changes were non-progressive, she required a significant degree of assistance with mobility and daily function performance. The patient was counseled for multiple limb amputations to promote walking and hand function through prosthetic restoration. Five months after the event, she had a right transtibial amputation, left Chopart amputation, left wrist disarticulation, and right second, third, fourth, and fifth fingers amputation. Three specific goals for inpatient rehabilitation were independent short-distance ambulation with prostheses, performing basic activities of daily living with adaptive devices, and independent wheelchair propulsion for long-distance mobility using a right-sided transtibial prosthesis, left-sided Syme's prosthesis with Kingsley's foot, right-sided silicone-based cosmetic glove and left-sided body-powered transradial prosthesis. Discussion: Although an uncommon complication, inotrope may lead to multiple limb amputations secondary to peripheral gangrene. Following amputation, the ultimate rehabilitative goal is to restore the mobility and capacity to perform daily functions through prosthetic restoration, whether walking for lower amputees or functioning hand for upper limb amputees. Prescribing prosthesis in a single limb loss is relatively straightforward, but restoring multiple limb amputations bears many challenges toward successful recovery of walking and functions.