Life-saving but limb-threatening: vasopressor-induced acral ischaemia and necrosis – two cases and review of the literature

Acral ischaemia and necrosis are rare but severe complications of high-dose or prolonged vasopressor therapy in critically ill patients. Although these agents are life-saving in distributive shock, intense α-adrenergic vasoconstriction, microcirculatory failure, and coagulopathy can converge to cause irreversible digital or limb necrosis, often requiring amputation and sometimes leading to medicolegal disputes. We report two cases of vasopressor-associated acral necrosis. These cases illustrate the multifactorial pathogenesis of vasopressor-induced acral necrosis, in which profound vasoconstriction, endothelial injury, microthrombosis, and the severity of underlying shock lead to distal tissue loss despite intact large-vessel pulses. Consequences include prolonged hospitalisation, the need for staged surgical or reconstructive procedures, long-term functional deficits, and substantial psychosocial burden. The dramatic nature of limb loss after life-saving therapy frequently triggers medicolegal scrutiny regarding dosing, monitoring, and documentation. Awareness of this uncommon but devastating complication is essential.