title: Shock, acute disseminated intravascular coagulation, and microvascular thrombosis: is 'shock liver' the unrecognized provocateur of ischemic limb necrosis?
abstract: For unknown reasons, a small minority of critically ill patients with septic or cardiogenic shock, multiorgan failure, and disseminated intravascular coagulation develop symmetrical acral (distal extremity) limb loss due to microvascular thrombosis ('limb gangrene with pulses'). Case reports have described preceding 'shock liver' in some critically ill patients who developed such a picture of ischemic limb necrosis. This suggests that profoundly disturbed procoagulant-anticoagulant balance featuring uncontrolled generation of thrombin-resulting from failure of the protein C and antithrombin natural anticoagulant systems due to insufficient hepatic synthesis of these crucial proteins-could explain the microvascular thrombosis and associated limb loss. We hypothesize that shock liver is the key predisposing risk factor underlying ischemic limb necrosis in the majority of patients who develop this complication in the setting of acute disseminated intravascular coagulation complicating septic or cardiogenic shock. As shock liver precedes onset of limb ischemia by several days, therapeutic intervention may be possible.
authors.affiliation: Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.|Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: T E
authors.initials: TE
authors.lastname: Warkentin
authors.affiliation: Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada.|Department of Medicine, Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
authors.forename: M
authors.initials: M
authors.lastname: Pai
mesh_terms: D000208:Acute Disease; D000818:Animals; D001777:Blood Coagulation; D001779:Blood Coagulation Factors / Q000378:metabolism*; D018450:Disease Progression; D004211:Disseminated Intravascular Coagulation / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D005121:Extremities / Q000098:blood supply*; D005734:Gangrene / Q000209:etiology; D006801:Humans; D007511:Ischemia / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D008099:Liver / Q000378:metabolism*; D008107:Liver Diseases / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D009102:Multiple Organ Failure / Q000097:blood / Q000209:etiology; D012769:Shock / Q000097:blood / Q000150:complications* / Q000175:diagnosis / Q000628:therapy; D013927:Thrombosis / Q000097:blood / Q000175:diagnosis / Q000209:etiology* / Q000628:therapy; D013997:Time Factors
chemical_list: D001779:Blood Coagulation Factors
keywords: acute; antithrombin III; disseminated intravascular coagulation; gangrene; liver failure; protein C