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Skin necrosis in a critically ill patient due to a blood


pressure cuff
Devbhandari MP, Shariff Z, Duncan AJ

Department of ABSTRACT
Cardiothoracic Surgery,
The non-invasive method of blood pressure measurement is regarded as a safe procedure and the reports of
Blackpool Victoria
Hospital, Blackpool, any serious complications are rare. We report a unique case of extensive skin necrosis due to an intermittently
United Kingdom inflating blood pressure cuff in a 65-year-old critically ill lady following a third time redo mitral valve surgery. A
brief review of the literature on complications associated with noninvasive method of measurement of blood
Correspondence: pressure is presented along with possible mechanisms of skin injury and ways to avoid it.
Mohan Devbhandari,
E-mail:
mdevbhandari@yahoo.co.uk

Received : 12-04-05
Review completed : 05-05-05
Accepted : 08-07-05
PubMed ID :
J Postgrad Med 2006;52:136-8 KEY WORDS: Skin necrosis, blood pressure cuff

Introduction hypotension and low cardiac output complicated her post­


operative course. Despite IABP and additional ionotropic
Non-invasive blood pressure (NIBP) monitoring is regarded as support with admistration of adrenaline 1.66 µg/min, dopamine
a safe procedure.[1] Recently there has been a rapid increase in 4 µg/Kg/min and noradrenaline 4 µg/min, her mean arterial
its usage to record ambulatory blood pressure (BP). We report pressure and mean systolic BP were 65 mm Hg (range 50 -70
the case of a critically ill patient who developed a significant mm Hg) and 96 mm Hg (range 70-110) respectively. The best
problem with NIBP. hemodynamic parameters after optimization of fluid,
ionotropes, IABP and vasoconstrictor were C.I. 2.2 L/min/m2,
Case History C.O. 3.5 L/min and SVRI 2217 dynes s/cm5/m2. Six hours after
her arrival in the intensive care unit, she had to be returned to
A 65-year-old female presented with worsening shortness of the operating room for cardiac tamponade that resulted from
breath due to severe rheumatic mitral stenosis. She had a the bleeding raw surfaces. The chest was formally closed the
history of two previous closed mitral valvotomies done 35 and next day when the bleeding had stopped.
25 years ago. Preoperative investigations confirmed severe
mitral stenosis with raised pulmonary artery pressure, impaired An NIBP (oscillometric method) cuff of appropriate size was
left ventricular function and left anterior descending coronary applied to the arm and set to inflate every 15 minutes. It was
artery stenosis. continued on the post-operative night alternately on her left
and right arms and was changed approximately at four hourly
At surgery, the heart was densely adherent to the pericardium. intervals. On the next day, automatic cycling was changed to
The dissection required to free the heart from pericardium occasional inflation on manual instruction.
resulted in a large raw surface. A mechanical mitral valve
replacement with a single coronary artery bypass grafting was On the third postoperative day, the skin on the anterior aspect
undertaken. She was weaned off cardiopulmonary bypass of her arms was found to be discolored. This continued to
supported by ionotropes and an intra-aortic balloon pump worsen resulting in full thickness skin necrosis of the anterior
(IABP). Hemeostasis was difficult to achieve due to persistent aspect of both the arms involving up to two-third of
ooze from raw areas. The pericardial cavity was packed with circumference, two days later [Figure 1]. Additionally, both
swabs and the chest left open, except the skin. her great toes, the 4th and 5th toe on right side and 5th toe on
left side became gangrenous. The IABP and ionotropes were
Continued bleeding, marked hemodynamic instability, gradually weaned over several days. A tracheostomy tube was

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Devbhandari et al: Skin necrosis due to blood pressure cuff �

invasive monitoring line. It is unhelpful and may even prove


to be hazardous to employ NIBP for this purpose.

Compartment syndrome is a well-documented complication


of NIBP.[5,6] This is however, unlikely in our patient, as the
neuromuscular function of the arm was intact. Possibility of a
local allergy to the cuff material was considered, but this could
not explain the absence of the lesions preoperatively when her
blood pressure was measured using a similar cuff. Drug allergy
could not explain the condition, as the lesions were very much
localized. Furthermore, the circumferential position of the
lesions in the mid-arm exactly matched the sites where the
cuffs had been applied. The other possibility of chemical burns
due to povidone iodine used for surgical preparation was ruled
out after the staff were interviewed. Another remote possibility
was friction. Friction usually causes blisters at the sites of
Figure 1: Skin necrosis of the arm, at the sites of application of blood adhesive plasters and tends to be superficial and so it is an
pressure cuff. This picture was taken 3 weeks after surgery when wound had unlikely explanation in this case.
started to improve. a. Right arm b. Left arm
NIBP monitoring is considered to have an excellent record of
inserted to assist respiratory weaning. A plastic surgery review safety. Reported complications of NIBP are rare and
was made and a plan was made for a split skin graft to the arm. consequently there is limited awareness among clinicians.
Fortunately the arm wound healed slowly and she did not Compartment syndrome requires prompt surgical
require skin grafting. The affected toes needed to be intervention.[5] Patients on anticoagulants are at an increased
amputated. After 25 days in intensive care and two and half risk of hematoma formation and compartment syndrome with
months, of rehabilitation in the ward, she was finally discharged NIBP.[7] NIBP cuffs are also known to be a source of infection.[8]
and sent home. She has been under follow up for the past six Other reported complications include compressive neuropathy,
years and has been doing well. petechial rash, thrombophlebitis, venous stasis, ecchymoses
and phlebitis.[5,9,10]
Discussion
Previous reports have pointed out that excessive machine
Prolonged hypoperfusion due to occlusion of the cycling, device malfunction and continuous pressure of a firmly
microcirculation of the skin leads to pressure necrosis, of which applied deflated cuff are contributory factors.[6] In the presence
bedsores are the best examples.[2] Localized pressure has been of arrhythmia, movement artefacts (muscular straining,
reported to be the cause of skin necrosis of other parts of the shivering, movement disorder) or shock, multiple and
body such as the bridge of the nose following the use of a prolonged inflations may be needed for one successful reading,
continuous positive airway pressure mask for ventilation and greatly increasing the risk of this complication.[6,11] Suggestions
penile skin due to a negative pressure device for erectile to avoid this problem are to avoid wrapping cuff too tightly
dysfunction.[3,4] However skin necrosis due to NIBP has not and to avoid bony prominences. Anesthetized patients and
been described so far in the literature. those at extremes of age need special attention. The sites
should be alternated and regularly inspected for any evidence
In this patient, the NIBP was used to rule out erroneous reading of bruising or petechie. The cuff cycling should be kept to the
from the arterial line. This was chosen as an alternative to minimum necessary frequency consistent with satisfactory
insertion of a new arterial line as it was difficult to cannulate monitoring. The role of alternative methods of blood pressure
her radial and femoral arteries, which had already been measurement such as Finapres remains uncertain, as their
traumatized at earlier attempts to cannulate for IABP reliability and accuracy are not yet established.[12]
monitoring. The NIBP equipment was used as per
manufacturer’s standard instructions and the sides alternated We would like to conclude that even innocuous noninvasive
as recommended. L ow cardiac output and critical clinical monitoring of blood pressure with a NIBP cuff can cause
hypoperfusion combined with the use of ionotropes and potentially serious skin necrosis in a critically ill patient with
vasoconstrictors explain the development of gangrene of the compromised hemodynamics. Appropriate precautions should
toes on both sides without any external interruption to the be taken to prevent this complication.
blood flow. In this setting of global hypoperfusion, brief but
repeated mechanical compressions damaged the References
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a context one should only rely on an appropriately placed 1993;118:889-92.

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1993;73:902-4. compartment syndrome associated with the use of a noninvasive blood
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7. Alford JW, Palumbo MA, Barnum MJ. Compartment syndrome of the arm: or Portapres rather than intra-arterial or intermittent non-invasive
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