key: cord-0924662-qyawyjru authors: Siegel, Amanda; Al Rubaiay, Ammar; Adelsheimer, Andrew; Haight, John; Gawlik, Scott; Oropallo, Alisha title: Pedal Gangrene in a Patient with COVID-19 Treated with Prone Positioning and Extracorporeal Membrane Oxygenation date: 2021-03-04 journal: J Vasc Surg Cases Innov Tech DOI: 10.1016/j.jvscit.2021.02.013 sha: 3cd790f3e0e75015c91a6d71c826b048aff588c7 doc_id: 924662 cord_uid: qyawyjru Many patients hospitalized with coronavirus disease 2019 (COVID-19) are treated with veno-venous ECMO (VV-ECMO) and prone positioning to optimize oxygenation. However, this combination can result in lower extremity tissue necrosis, especially without adequate offloading. We report a case of a 31-year-old male who required mechanical ventilation and VV-ECMO secondary to complications from COVID-19, and subsequently developed pedal dry gangrene. The patient was discharged and healed without requiring an amputation. Our institution has since revised the prone positioning protocol to address offloading the lower extremities and feet. and respiratory acidosis, so he was placed on extracorporeal carbon dioxide removal. He was 8 subsequently transitioned to veno-venous ECMO (VV-ECMO) for refractory hypoxemia and 9 was started on methylprednisone. The ECMO cannulas were placed in the right internal jugular 10 vein and the right femoral vein. Once ECMO was initiated, anticoagulation therapy was 11 transitioned to argatroban continuous infusion, as per hospital protocol. Dosing was therapeutic 12 with a goal aPTT of 50 to 90 seconds. The patient's ICU course was complicated by new onset 13 atrial fibrillation, with emergent successful cardioversion. He was treated with amiodarone. 14 ECMO was successfully decannulated on day 24, and the patient was extubated on day 34. 15 examination revealed palpable femoral, popliteal, dorsalis pedis and posterior tibial artery pulses 18 bilaterally. Epicritic sensation was intact to the toes bilaterally. There was partial-thickness dry 19 gangrene on the plantar aspect of the right hallux, plantar distal aspect of the right second digit, 20 plantar distal aspect of the left fifth digit, and the plantar aspect of metatarsal heads 3-5 of the 21 left foot. The left plantar forefoot skin was slightly dusky and mottled in appearance (Figure 1) . 22 No signs of infection were present. It was noted that the patient's feet were firmly pressed 23 against the footboard of the hospital bed and not properly offloaded. Z-flow boots for offloading 1 of the feet were placed on at this time, and local wound care with betadine paint every other day 2 was started. The plan was to await demarcation of the gangrene to determine if the skin would 3 become viable or ultimately require an amputation. 4 5 Throughout the hospital course, increased necrosis was noted to the left plantar forefoot ( Figure 6 2). Based on the stable nature and partial-thickness depth of the gangrene, the prognosis for 7 healing and prevention of limb and toe loss was favorable. The patient was discharged to acute 8 rehab after a 55-day length of stay. The plan was to continue wearing offloading boots, wound 9 care with betadine paint every other day, and regular follow up with podiatry to monitor 10 demarcation. Unfortunately, the patient was lost to follow up. The patient was called for follow 11 up, and family revealed that he moved to the Dominican Republic, and his foot wounds healed 12 without requiring amputation. patient selection is stringent, and is reserved for those younger than 65 years, BMI of less than 9 40, not immunocompromised, and on mechanical ventilation for less than 10 days. 7,9 Therefore, 10 this patient was an ideal candidate. Limb ischemia can result from ECMO due to vessel damage 11 during cannulation, preexisting atherosclerotic disease, and prolonged vasopressor use. 10 limb ischemia and digital gangrene despite anticoagulation. 15-17 Low-intensity heparin infusion is 20 recommended in critically ill patients with COVID-19, and has been associated with survival 21 benefit. 16, 18, 19 This is reflected in our hospital's anticoagulation protocol. 22 Vasopressors are associated with development of digital gangrene, as they create peripheral 1 vasoconstriction in order to perfuse organs during hemodynamic instability. 20 This patient was 2 on vasopressors (epinephrine injection, phenylephrine and norepinephrine infusions) for 30 days. 3 Vasopressor-induced digital necrosis is a known side effect reported in the literature, often times 4 reported as being bilateral and symmetrical in the toes. 21-23. Atrial fibrillation has also been 5 associated with toe necrosis due to showering of microemboli, though less likely in this patient 6 due to short duration of arrhythmia. 24 of vascular complications of extra-corporeal membrane oxygenation. Cardiovascular 11 Diagnosis and Therapy Pressure Injury Prevention in COVID-14 19 Patients with Acute Respiratory Distress Syndrome: Perspective Article Extracorporeal Life Support Organization (ELSO) COVID-19 Interim Guidelines Extracorporeal membrane oxygenation support in COVID-19: an international cohort 9 study of the Extracorporeal Life Support Organization registry. 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