Surgical management of multiple limb gangrene following dehydration in children

Multiple limb gangrene and auto-amputation without arterial vascular occlusive disease is uncommon. Seven such paediatric patients were managed at King Edward VIII Hospital, Durban, during the 6-year period ending in 1989. The spectrum and degree of limb gangrene ranged from phalangeal necrosis to distal limb mummification affecting one or more limbs. The most affected child had gangrene and mummification of all limbs as well as gangrene of the ear lobes and the tip of the nose. The main associated factor was severe fluid loss--2 children had received herbal enemas, with resultant hypotension, hypoperfusion, hypernatraemia and acidosis, which, it is postulated, led to peripheral thrombosis and the ensuing gangrene. It is suggested that aggressive fluid therapy, including low molecular weight dextran and correction of the metabolic derangement, should form the main thrust of the therapeutic endeavour. Once gangrene is established, surgical debridement and rehabilitation is all that is possible. Using this procedure only 2 patients died in the acute resuscitation phase.