title: Four limb amputations due to peripheral gangrene from inotrope use - Case report and review of the literature.
abstract: BACKGROUND
  We present a rare case of 4 limb amputations due to peripheral gangrene which resulted from the use of inotropes for septic shock.
  
  
  METHODS
  A 72-year-old woman with no past medical history presented with fever and pain in bilateral big toes. She was diagnosed with Streptococcal pneumoniae septicaemia and was started on broad spectrum antibiotics, dopamine and noradrenaline in the medical intensive care unit. She developed peripheral gangrene of all 4 extremities due to microvascular spasm from inotrope use and 4 limb amputations were performed electively in a single stage.
  
  
  CONCLUSIONS
  The gangrene was contributed by the presence of disseminated intravascular coagulation and septic shock. There was no evidence of an autoimmune disorder or vasculitis on laboratory investigations and tissue histology.
  
  
  CONCLUSIONS
  Microvascular spasm is a rare complication of inotrope use which may lead to extensive peripheral gangrene. Anecdotal reports of reversal agents have been discussed. Four limb amputations are a reasonable option especially if done in an elective setting after the gangrene has demarcated itself. Rehabilitation with prosthesis after 4 limb amputations can result in good functional outcome.
authors.affiliation: Department of Orthopaedic Surgery, Singapore General Hospital, Singapore. Electronic address: angchuanhan@gmail.com.
authors.forename: Chuan Han
authors.initials: CH
authors.lastname: Ang
authors.affiliation: Department of Orthopaedic Surgery, Singapore General Hospital, Singapore. Electronic address: otkoo@hotmail.com.
authors.forename: Oon Thien
authors.initials: OT
authors.lastname: Koo
authors.affiliation: Department of Orthopaedic Surgery, Singapore General Hospital, Singapore. Electronic address: howe.tet.sen@sgh.com.sg.
authors.forename: Tet Sen
authors.initials: TS
authors.lastname: Howe
keywords: Amputation; Gangrene; Inotrope