The Incidence of Distal Extremity Necrosis Associated with Vasopressor use in Critically Ill Patients

Purpose: Medication adverse events are associated with significant morbidity and mortality, increased hospital length of stay, and create a high burden of cost for both the patient and the healthcare system. Vasopressors are a class of medication with a known association with digital necrosis due to excessive peripheral vasoconstriction, in order to prioritize blood flow to the vital organs. We aim to identify the incidence of distal extremity necrosis in critically ill patients receiving vasopressors for cardiovascular support.

Methods: A retrospective analysis was performed of all patients treated with vasopressors including epinephrine, norepinephrine, phenylephrine, and vasopressin during the study period: January 1, 2012, through December 31, 2020, at a single institution. Patients treated with vasopressors with a concomitant documented diagnosis of distal extremity (upper and/or lower) ischemia, gangrene, or necrosis were identified. This subset of patients underwent further chart review to confirm the onset of digital necrosis was within 4 months of vasopressor use. The incidence of distal extremity necrosis in critically ill patients receiving vasopressors for cardiovascular support was then calculated.

Results: A total of 1,980,300 patients were screened, of which 46,792 had documented vasopressor use and were included in the at-risk population. Of all patients that had received vasopressors within our study period, 1,151 also had a documented diagnosis of distal extremity necrosis. Overall, a total of 56 (0.12%) patients had documented distal extremity necrosis within 4 months after sustained vasopressor use. 31 patients (36.1%) were given 3 or 4 vasopressors concurrently, 28 (50%) had isolated toe and/or foot necrosis, 15 (26.8%) had necrosis of both the distal upper and lower extremities, and 13 (23.2%) developed necrosis isolated to the hand and/or fingers. The average age of those who developed digital necrosis was 59 years. While there was more distal extremity necrosis when multiple pressors were used concurrently, the association was not significant (p=0.77)

Conclusion: The use of vasopressors for cardiac support in critically ill patients is often unavoidable. This treatment comes with the risk of inducing distal extremity ischemia and necrosis. The incidence of distal extremity necrosis is extremely low, but the risk increases when multiple vasopressors are used concurrently.