Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit

• Published in: Journal of vascular surgery 2018-11, Vol.68 (5), p.1499-1504
• Main Authors: Landry, Gregory J., Mostul, Courtney J., Ahn, Daniel S., McLafferty, Bryant J., Liem, Timothy K., Mitchell, Erica L., Jung, Enjae, Abraham, Cherrie Z., Azarbal, Amir F., McLafferty, Robert B., Moneta, Gregory L.
• Format: Article
• Language: English
• Subjects: Adult; Aged; Amputation; Anticoagulants - therapeutic use; Catheterization, Peripheral - adverse effects; Critical Illness; Female; Finger; Fingers - blood supply; Humans; Intensive care unit; Intensive Care Units; Ischemia; Ischemia - diagnosis; Ischemia - etiology; Ischemia - physiopathology; Ischemia - therapy; Male; Middle Aged; Patient Admission; Photoplethysmography; Platelet Aggregation Inhibitors - therapeutic use; Regional Blood Flow; Retrospective Studies; Risk Factors; Time Factors; Treatment Outcome; Vasoconstrictor Agents - adverse effects; Vasospasm
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2018.01.050

Vascular surgeons may be consulted to evaluate hospitalized patients with finger ischemia. We sought to characterize causes and outcomes of finger ischemia in intensive care unit (ICU) patients. All ICU patients who underwent evaluation for finger ischemia from 2008 to 2015 were reviewed. All were evaluated with finger photoplethysmography. The patients' demographics, comorbidities, ICU care (ventilator status, arterial lines, use of vasoactive medications), finger amputations, and survival were also recorded. ICU patients were compared with concurrently evaluated non-ICU inpatients with finger ischemia. There were 98 ICU patients (55 male, 43 female) identified. The mean age was 57.1 ± 16.8 years. Of these patients, 42 (43%) were in the surgical ICU and 56 (57%) in the medical ICU. Seventy (72%) had abnormal findings on finger photoplethysmography, 40 (69%) unilateral and 30 (31%) bilateral. Thirty-six (37%) had ischemia associated with an arterial line. Twelve (13%) had concomitant toe ischemia. Eighty (82%) were receiving vasoactive medications at the time of diagnosis, with the most frequent being phenylephrine (55%), norepinephrine (47%), ephedrine (31%), epinephrine (26%), and vasopressin (24%). Treatment was with anticoagulation in 88 (90%; therapeutic, 48%; prophylactic, 42%) and antiplatelet agents in 59 (60%; aspirin, 51%; clopidogrel, 15%). Other frequently associated conditions included mechanical ventilation at time of diagnosis (37%), diabetes (34%), peripheral arterial disease (32%), dialysis dependence (31%), cancer (24%), and sepsis (20%). Only five patients (5%) ultimately required finger amputation. The 30-day, 1-year, and 3-year survival was 84%, 69%, and 59%. By Cox proportional hazards modeling, cancer (hazard ratio, 2.4; 95% confidence interval, 1.1-5.6; P = .035) was an independent predictor of mortality. There were 50 concurrent non-ICU patients with finger ischemia. Non-ICU patients were more likely to have connective tissue disorders (26% vs 13%; P = .05) and hyperlipidemia (42% vs 24%; P = .03) and to undergo finger amputations (16% vs 5%; P = .03). Finger ischemia in the ICU is frequently associated with the presence of arterial lines and the use of vasopressor medications, of which phenylephrine and norepinephrine are most frequent. Anticoagulation or antiplatelet therapy is appropriate treatment. Whereas progression to amputation is rare, patients with finger ischemia in the ICU have a high rate of mortality, particularly in