title: Physiologic Cryoamputation in Managing Critically Ill Patients with Septic, Advanced Acute Limb Ischemia.
abstract: BACKGROUND
  Certain critically ill patients with advanced acute limb ischemia with a nonviable extremity may be unsuitable for transport to the operating room to undergo definitive amputation. In these unstable patients, rapid regional cryotherapy allows for prompt infectious source control and correction of hemodynamic and metabolic abnormalities, thereby lessening the risk associated with definitive surgical amputation. We describe our refined technique for lower extremity physiologic cryoamputation and review our institutional experience.
  
  
  METHODS
  After adequate analgesia is administered to the patient, a heating pad is secured circumferentially at the proximal amputation margin and the affected extremity is placed in a customized Styrofoam cooler. A circumferential seal is secured at the proximal chill zone without use of a tourniquet and dry ice is placed into the cooler to surround the entire affected leg. Delayed definitive lower extremity amputation is later performed when hemodynamic and metabolic derangements are corrected.
  
  
  RESULTS
  We reviewed 5 patients who underwent lower extremity cryoamputation with this technique identified at our institution between 2005 and 2015. Age ranged from 31 to 79 years old. All presented with severe foot infection and septic shock requiring vasopressor support. All 5 patients stabilized hemodynamically following the initial cryoamputation and later underwent definitive lower extremity amputation, with a median time of 3 days following initial cryoamputation.
  
  
  CONCLUSIONS
  Lower extremity physiologic cryoamputation is an effective, immediate bedside procedure that can provide local source control and the opportunity for correction of metabolic derangements in initially unstable patients to lessen the risk for definitive major lower extremity amputation. Refinement of the cryoamputation technique, as described in this report, allows for a predictable and reproducible physiologic amputation.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA.
authors.forename: Samuel L
authors.initials: SL
authors.lastname: Chen
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA.
authors.forename: Isabella J
authors.initials: IJ
authors.lastname: Kuo
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA.
authors.forename: Nii-Kabu
authors.initials: NK
authors.lastname: Kabutey
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Irvine Medical Center, Orange, CA. Electronic address: rmfujita@uci.edu.
authors.forename: Roy M
authors.initials: RM
authors.lastname: Fujitani
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000671:Amputation, Surgical / Q000009:adverse effects / Q000379:methods*; D002140:California; D016638:Critical Illness; D003452:Cryosurgery / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007511:Ischemia / Q000175:diagnosis / Q000382:microbiology / Q000503:physiopathology / Q000601:surgery*; D007902:Length of Stay; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D012772:Shock, Septic / Q000175:diagnosis / Q000382:microbiology / Q000503:physiopathology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome