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

Gregory Landry, Courtney J. Mostul, Daniel S. Ahn, Bryant J. McLafferty, Timothy Liem, Erica Mitchell, Enjae Jung, Cherrie Abraham, Amir Azarbal, Robert Mclafferty, Gregory (Greg) Moneta

Research output: Contribution to journalArticle

Abstract

Objective: 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. Methods: 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. Results: 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). Conclusions: 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 the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.

Original languageEnglish (US)
JournalJournal of Vascular Surgery
DOIs
StateAccepted/In press - Jan 1 2018

Fingerprint

Fingers
Intensive Care Units
Ischemia
Amputation
Vascular Access Devices
Photoplethysmography
Patient Care
clopidogrel
Phenylephrine
Connective Tissue
Norepinephrine
Ephedrine
Neoplasms
Survival
Mortality
Peripheral Arterial Disease
Platelet Aggregation Inhibitors
Toes
Mechanical Ventilators
Therapeutics

Keywords

  • Finger
  • Intensive care unit
  • Ischemia
  • Vasospasm

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

@article{65069bbaf8e64198bc00bd100a3b249b,
title = "Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit",
abstract = "Objective: 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. Methods: 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. Results: 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). Conclusions: 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 the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.",
keywords = "Finger, Intensive care unit, Ischemia, Vasospasm",
author = "Gregory Landry and Mostul, {Courtney J.} and Ahn, {Daniel S.} and McLafferty, {Bryant J.} and Timothy Liem and Erica Mitchell and Enjae Jung and Cherrie Abraham and Amir Azarbal and Robert Mclafferty and Moneta, {Gregory (Greg)}",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.jvs.2018.01.050",
language = "English (US)",
journal = "Journal of Vascular Surgery",
issn = "0741-5214",
publisher = "Mosby Inc.",

}

TY - JOUR

T1 - Causes and outcomes of finger ischemia in hospitalized patients in the intensive care unit

AU - Landry, Gregory

AU - Mostul, Courtney J.

AU - Ahn, Daniel S.

AU - McLafferty, Bryant J.

AU - Liem, Timothy

AU - Mitchell, Erica

AU - Jung, Enjae

AU - Abraham, Cherrie

AU - Azarbal, Amir

AU - Mclafferty, Robert

AU - Moneta, Gregory (Greg)

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Objective: 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. Methods: 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. Results: 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). Conclusions: 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 the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.

AB - Objective: 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. Methods: 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. Results: 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). Conclusions: 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 the presence of cancer. Non-ICU patients hospitalized with finger ischemia more frequently require finger amputations, probably because of more frequent connective tissue disorders.

KW - Finger

KW - Intensive care unit

KW - Ischemia

KW - Vasospasm

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JO - Journal of Vascular Surgery

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