Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow

Rehabilitation and prosthesis after four-limb amputation

– case description
Rehabilitacja i protezowanie po amputacji czterech kończyn
– opis przypadku

Aneta Pirowska A,B,D,E,F, Thibaud Vincent B,E,F, Julie Clotilde-Trotel B,E,F, Caroline Voiry B,D,E ,
Elise Joannot B,E , Doan Vu Tri B,E,F, Gérard ChiesaE

Artificial Limb Centre (CRA – Centre de Rééducation et d’Appareillage), Institut Robert Merle d’Aubigné (IRMA), Valenton,
Ile-de-France

Key words
multi-limb amputation, bilateral amputation, sepsis, septic shock, purpura fulminans, disseminated intravascular coagulation, reha-
bilitation after four-limb amputation, four-limb prosthetics
Abstract
Four-limb amputation is carried out rarely. In life-threatening conditions of the patient, the need for its implementation may result
in the occurrence of septic shock evolving with severe sepsis, as well as other rarely occurring complications – purpura fulminans
(PF). These extremely dangerous systemic reactions of the organism may develop as a result of bacterial infection: Staphylococcus
aureus, Streptococcus pneumoniae, Haemophilus influenzae type b, Legionella pneumophila, meningococcas – Neisseria meningitid-
is. The average stay of patients after four-limb amputation at the Institut Robert Merle d’Aubigné is about six months. During this
time, patients participate in complex rehabilitation therapy, ergotherapy, sport and recreational therapy, prosthetic fitting, thus the
production and adaptation of upper – and lower-limb prosthetics, and they are also under the care of a psychologist and a social as-
sistant. During the entire stay, they are subject to on-site supervision of medical specialists: angiologist, diabetologist, cardiologist,
podologist, psychiatrist, rehabilitation specialists, and undergo necessary medical consultations conducted in cooperation with oth-
er hospitals and clinics. This case description illustrates the clinical condition of a 35-year-old man following a skull injury compli-
cated by hemodynamic shock and acute thrombotic distal ischemia of four limbs, which were amputated as a result of these compli-
cations. The paper illustrates the steps of rehabilitation that were carried out, as well as ergotherapy and prosthesis, the purpose of
which was recovering efficiency and independence of the patient as much as possible, and to efficiently teach him how to perform
daily activities in preparation for independent living. The presented case description shows that even a patient with such a difficult
clinical interview, after passage of the initial shock of the near death experience and four-limb amputation, may return to being fit
and start to live independently again.

Słowa kluczowe
amputacja wielokończynowa, amputacja bilateralna, sepsa, wstrząs septyczny, plamica piorunująca, zespół rozsianego śródnaczynio-
wego wykrzepiania, rehabilitacja po amputacji czterokończynowej, protezowanie czterech kończyn
Streszczenie
Amputację czterech kończyn przeprowadza się rzadko. Do potrzeby jej wykonania, w stanie zagrożenia życia chorego, doprowadzić
może wystąpienie wstrząsu septycznego rozwijającego się z ciężkiej sepsy, jak również jej nieczęsto pojawiającego się powikłania –
plamicy piorunującej. Te skrajnie niebezpieczne ogólnoustrojowe reakcje organizmu mogą się rozwinąć w wyniku zakażenia bakteri-
ami: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae typu b, Legionella pneumophila, meningokokami
– Neisseria meningitidis. Średni czas pobytu chorych po amputacji czterokończynowej w Institut Robert Merle d’Aubigné wynosi
około sześciu miesięcy. W tym czasie pacjenci uczestniczą w kompleksowych zajęciach rehabilitacji, ergoterapii, sportowo-rekreacy-
jnych, protezowania, czyli produkcji i adaptacji protez kończyn dolnych i górnych, korzystają także z pomocy psychologa i asysten-
ta socjalnego. Podczas całego pobytu są objęci na miejscu opieką lekarzy specjalistów: angiologa, diabetologa, kardiologa, podologa,
psychiatry, specjalistów rehabilitacji, a także korzystają z niezbędnych medycznych konsultacji prowadzonych we współpracy z inny-
-
-

The individual division on this paper was as follows: a – research work project; B – data collection; C – statistical analysis; D – data interpretation;
E – manuscript compilation; F – publication search

Article received: 15.03.2016; accepted: 16.05.2016

-

Please cited: Pirowska A., Vincent T., Clotilde-Trotel J., Voiry C., Joannot E., Vu Tri D., Chiesa G. Rehabilitation and prosthesis after four-limb amputation –
case description. Med Rehabil 2015; 19(4): 34-45
-

Internet version (original): www.rehmed.pl

34
-

mi szpitalami i klinikami. Opis przypadku obrazuje stan kliniczny 35-letniego mężczyzny po urazie czaszki powikłanym wstrząsem
hemodynamicznym i ostrym zakrzepowym dystalnym niedokrwieniem czterech kończyn, w konsekwencji czego amputowano mu
wszystkie kończyny. Praca przedstawia etapy przeprowadzonej rehabilitacji, ergoterapii i protezowania, których celem było odzys-
kanie możliwie jak największej sprawności i samodzielności przez chorego oraz efektywne nauczenie go wykonywania codziennych
czynności w przygotowaniu do niezależnego życia. Przedstawiony opis przypadku dowodzi, że nawet chory z tak ciężkim wywia-
dem klinicznym, po przejściu wstrząsu z zagrożeniem utraty życia i po amputacji czterech kończyn, może powrócić do sprawności i
znowu zacząć żyć samodzielnie.
INTRODUCTION
Four limb-amputation is rarely per-
formed. Its need, in life-threatening
conditions of the patient, may re-
sult in the occurrence of septic shock
evolving with severe sepsis, as well
as the rarely occurring complication
– purpura fulminans (PF)1. These ex-
tremely dangerous systemic reactions
of the organism may develop as a re-
sult of bacterial infection by: Staphy-
lococcus aureus, Streptococcus pneu-
moniae 1-3, type b Haemophilus in-
fluenzae1, Legionella pneumophila,
meningococcas2,4 – Neisseria menin-
gitidis1-2,5.
Purpura fulminans was first de-
scribed in 18866. It may occur in pa-
tients with protein C and protein S
deficiencies1,4. Its course is charac-
terized by the occurrence of shock
and rapidly progressive symmetrical
peripheral gangrene (SPG) caused
by disseminated intravascular coag-
ulation (DIC)1,4,6, which as a conse-
quence, due to embolism in the mi-
crocirculation, leads to ischemia and
hemorrhagic strokes in the skin1,4 and
necrosis of the distal body parts1,4,7.
The occurrence of symmetrical pe-
ripheral gangrene is associated with
a high mortality rate (about 40%)5-6.
In about half of patients, limb ampu-
tation is performed in order to save
lives 5. Septic shock caused by menin-
gococcas is extremely severe4,8.
Infection causing sepsis may be as-
sociated with peritonitis, pancreatitis,
hepatitis, pneumonia, nephritis, infec-
tions in the oral cavity (periodontal),
sinusitis or tonsillitis4.
-
Sepsis is the third leading cause of
death from infectious diseases in the
-
world and the tenth leading cause of
death in general9. With each year, the
number of cases of severe sepsis in-
-
creases by about 9%, which may re-
sult from the growing field of medi-
-
cal knowledge about sepsis and there-
-
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
fore, a greater number of registered
cases, more often used invasive pro-
cedures in diagnosis and treatment,
increased bacterial resistance to anti-
biotics and the increasing number of
immuno-compromised patients (can-
cer, acquired immune deficiency syn-
drome, diabetes, alcoholism, malnu-
trition, organ transplant)9. It was also
shown that up from 1987, the cause
of sepsis are more likely Gram-posi-
tive rather than Gram-negative bacte-
ria, and since 1980, the incidence of
sepsis caused by fungal infections has
increased by more than 200%9.
Sepsis (Septicaemia) (Figure 1) is
defined as the systemic inflammatory
response syndrome (SIRS) of the body
caused by infection10.
The symptoms of sepsis include11:
–– body temperature above 38˚C or
below 36˚C,
–– tachycardia (above 90 beats/min),
–– tachypnea (respiratory rate above
20/min),
–– leukocyte blood count of less than
4000/μl (leukopenia) or above
12000/μl (leukocytosis),
–– hyperglycaemia above 7,7 mmol/l
in non-diabetic patients,
–– disturbances of consciousness or
significant swelling may also co-
exist.
If organ failure occurs during the
course of sepsis, it is defined as a se-
vere sepsis10.
If a decrease in blood pressure (hy-
potension) below 90/60 mmHg occurs
in the course of severe sepsis, we are
dealing with septic shock10.
The symptoms occurring during
septic shock are the same as in the
case of sepsis, however, the following
additional symptoms are present12:
–– decrease in blood pressure below
90/60 mm Hg,
–– hypocapnia in blood gasometry
(pCO2 below 32 mmHg),
–– oliguria,
–– the skin is hot and reddened.
In rare cases, multi-limb amputa-
tion is sometimes the consequence of
septic shock, which may occur in ob-
stetric pathologies during pregnancy,
at birth or during pueperium4. This
sometimes happens during HELLP
syndrome – a severe complication of
pre-eclampsia or eclampsia4. Some-
times, septic shock occurs due to
chemotherapy cancer treatment com-
plications or as a result of poisonous
bites4.
Other types of shock, such as hypo-
volemic shock, arising from profuse
bleeding following severe trauma or
burns, obstructive shock as a result
of pulmonary embolism, cardiac tam-
ponade, tumors or cardiogenic shock
due to myocardial infarction, arrhyth-
mia or heart defects, may also mani-
fest the syndromes of disseminated in-
travascular coagulation (DIC)4 and in-
evitably lead to the amputation of sev-
eral limbs.
In the last three years, 12 patients
were hospitalized after four-limb am-
putation at our Institute (IRMA). 4
cases in 2013, 2 patients in 2014 and
6 patients in 2015. The causes leading
to amputation in these patients were,
among others: secondary ischemic ne-
crosis as a result of septic shock oc-
curring as a complication of pyelone-
phritis, septic shock as a complication
of uterus cancer with the coexistence
of neutropenia which was a compli-
cation of chemotherapy, purpura ful-
minans following meningococcal in-
fection, purpura fulminans coexist-
ing with septic shock due to acute uri-
nary tract infection. All 3 of the 12
patients revealed no pre-existing con-
ditions. During interviews, symptoms
similar to the course of influenza ap-
peared, which occurred a few days be-
fore the shock incident. Almost all pa-
tients had both lower limbs amputat-
ed at the below-knee level (with the
exception of 2 people with amputa-
tion in the foot area) and the upper
35
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
limbs, mostly around the hand area,
and some patients at the radiocarpal
joints.
The average stay of patients at our
Institute following four-limb amputa-
tion is about six months. During this
time, patients are involved in com-
plex rehabilitation therapy, ergother-
apy, activities in sports and recreation,
prosthetic fitting – thus, the produc-
tion and adaptation of upper – and
lower-limb prosthetics, and also re-
ceive help from a psychologist and
a social assistant. During the entire
stay, they are under the care of on-
site medical specialist supervision: an-
giologist, diabetologist, cardiologist,
podologist, psychiatrist, rehabilita-
tion specialists, and also undergo nec-
essary medical consultations conduct-
ed in cooperation with other hospitals
and clinics.
CASE DESCRIPTION
The patient, a 35-year-old man with
skull trauma, with sub-meninges he-
matoma and in a coma, was admitted
to the neurosurgery ward of the spe-
cialist hospital. The resulting hema-
toma, classified as small, was not an
indication to perform surgical drain-
age. After admission to the neurosur-
gical ward, hemodynamic shock of
unknown etiology occurred (probably
as a result of inflammation of the liv-
er or pancreas). CPR was performed.
Then, acute thrombotic distal isch-
emia of four limbs took place, which
required four-limb amputation with
the purpose of saving vital functions.
For both lower limbs the below-knee
amputation in the middle third of the
tibia was performed and both upper
limbs were amputated at the level of
radiocarpal joints. The levels of am-
putation were consulted by the sur-
geon planning the operation with the
doctor from our Institute in order to
maintain the optimal length of the
limbs for the best possible prosthesis
-
fitting, and at the same time, to ensure
the patient with the highest possible
-
quality of life later on. Once the four-
limb amputation was completed, the
patient’s condition stabilized.
-
During the interview, the patient
did not report any serious illnesses or
-
injuries in the past. However, of im-
36
-
burns, trauma, pacreatitis, transfusion reaction, interstinal
perforation, chemical aspiration, other causes
infection
sepsis
severe sepsis
Figure 1
Systemic Inflammatory Response Syndrome (SIRS), infection and various stages of
sepsis13
portance may be the fact that the pa-
tient was homeless and remained des-
titute for many months.
After a five-month hospitalization
period, the patient was transported
to our Institute for further rehabilita-
tion and prosthesis fitting.
Preliminary tests
During the preliminary tests which
were conducted on the day of admis-
sion to the Institute, it was found that
the stumps of both legs had the same
clinical features; similar in length, the
post-amputative wounds had com-
pletely healed with distal transverse
scars, the tibia bones were preserved
longer in relation to fibula bones,
and were ended at Farabeuf ’s angle
in both of the stumps. The presence of
moderate oedema of both stumps, and
it’s correct trophics was noted. Range
of motion and muscle strength in both
stumps were rated as very good. Phan-
tom sensation was of low intensity in
both lower limbs.
In the examination of the upper
limbs showed a healed state of both
stumps, but features of hyper sensi-
bility within the post-amputative scars
were found. The distal parts of both
bones: the radius and ulna in both
stumps were clearly exposed. There
was no presence of oedema. During
septic shock
the test on upper-limb mobility, limi-
tation of supination was observed in
both elbows. Muscle strength was rat-
ed as very good. Pain state was found
for the left shoulder joint.
No other clinical disorders were
noted.
In the assessment of the patient’s
independence in performing basic ac-
tivities, it was noted that the patient
was able to move independently on
the bed, as well as perform the bed-
wheelchair-bed transfers, but needed
help with toilet-hygienic actions.
The mental state of the patient was
assessed as balanced with optimis-
tic characteristics. After the MADRS
(Montgomery – Åsberg Depression
Rating Scale) test was performed, anx-
iety-depressive syndrome was not ob-
served.
For independent movement within
the Institute, it was necessary to adapt
the electric wheelchair with bilater-
al stump boards for the lower limbs.
An ergotherapist was also appointed
to adapt the patient’s room to ensure
the greatest possible independence.
Clinical prognosis – the outcome
The purpose of the patient’s stay
at the Institute was: global mus-
cle-strength enhancement, prosthesis
fitting of the lower limbs and learning
 Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow

to walk as soon as possible, graded,

simultaneous prosthesis fitting of the
upper limbs using myoelectrical pros-
thesis and aid from an ergotherapist
in learning how to use them. At the
same time, psychological counseling
was proposed.
It was determined that the anticipat-
ed duration of patient’s stay would be
6 months.

Figure 2
REHABILITATION
Stump bandaging
The rehabilitation of patients fol-
lowing four-limb amputation can be
divided into three stages:
–– stage 1 – post-operative/hospital,
–– stage 2 – prior to prosthesis at re-
habilitation center,
–– stage 3 – rehabilitation with the use
of prostheses.

Stage 1 – post-operative/hospital
At this stage of post-amputative reha-
bilitation, the first and foremost tasks
of the physiotherapist is to prevent
trophic disorders within the stump.
Post-operative swelling forms as a re-
sult of amputation performed with-
in the stump. From the first moments
following the operation, the resulting
swelling must be fought when plan-
ning proper prosthesis of the ampu-
tated limbs. For this purpose, bandag-
ing of all four amputated limbs is per-
formed, regardless of amputation eti-
ology (Figure 2). Bandages on all the
stumps of limbs are worn by the pa-
tient continuously, with the exception
of the time during dressing changes.
This ensures efficiency in the fight
against oedema formation and prop-
er modeling of the stump in order to
correctly fit the stump with a prosthe-
sis as soon as possible.
Equally important it is the correct
positioning of the stumps. When the
patient is in bed, pillows and soft pads
are placed under the limbs in a cer-
tain manner. When the patient is sit-
-
a b
Figure 3
Stump boards under below-knee stumps : a. stump board under one below-knee
stump ; b. stump boards under both below-knee stumps
Another field of activity of the duction, metacarpophalangeal joints
physiotherapist is to fight improper in flexion; and the lower limbs – hip
stump positioning habits adopted by joints positioned in flexion, abduction
the patient. After amputation, the pa- and external rotation, knees flexed,
tient usually tries to find an analge- feet set in clubfoot position and met-
sic position that alleviates symptoms atarsal-phalangeal joints in flexion.
as a consequence of previous surgery In addition to teaching the patient
or the disease itself. Improper flexion how to assume the correct body po-
positions of the stumps, which are sition, it is also important that the
most willingly performed by the pa- therapist performs joint mobilization
tient, are conducive to the formation in the patient as part of their rehabil-
of contractures, and thereby lead to itation in order to prevent the forma-
joint-stiffness, resulting in shortening tion of contractures.
of the ligament-muscle structures. For Another aim of the therapist’s work
this reason, the fundamental need for with a patient at this stage of rehabil-
action on the part of the therapist is to itation is simultaneously preventing
teach the patient to assume the correct the loss of the overall muscle strength.
position in bed, on a chair or wheel- Activities within this area should be
chair, maintaining a compromise be- carried out from the first moments.
tween the uncomfortable, but the cor- Training bed to wheelchair transfer
rect position and one that sufficiently should start as soon as the patient’s

ting in a wheelchair, the lower-limb counteracts contractures. condition allows it. The patient’s sup-
stumps should be rested on special The incorrect positions assumed by port on the amputated upper and low-
-

stump boards added to the seat (Fig- the patient after amputation are usual- er limbs may be limited, while avoid-
ure 3) in order to prevent venous and ly as follows: the upper limbs – shoul- ing reliance on the distal parts of the
lymphatic stasis. A physiotherapist der joints are raised and positioned in stumps. The therapist teaches the pa-
-

also can perform treatments of lym- abduction and internal rotation, el- tient how to sit up from a lying posi-
phatic drainage, if permitted by the bow joints in flexion and pronation, tion and how to lay down from sit-
-

condition of the stump. radiocarpal joints in flexion and ad- ting, turning around and “walking”

37
-
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
on the buttocks. The latter movement
is used by the patient to learn the bed-
wheelchair-bed transfer. With each
passing day, the patient should spend
more and more time in an armchair or
a wheelchair, and less in bed. Gradu-
ally more and more exercises in a sit-
ting position are introduced, including
balance exercises. It is also important
to exercise the postural muscles of the
abdomen and the back muscles. Ex-
ercises to strengthen the corset mus-
cle are performed in supine as well as
seated positions. The usage of a Bo-
bath-type rehabilitation table is prac-
tical in the case of these exercises.
During the post-operative stage, the
main purpose of the work with a pa-
tient following four-limb amputation
is striving to maximize his/her inde-
pendence in performing daily activ-
ities.
During the hospital stay, the de-
scribed patient also took part in er-
gotherapy sessions teaching maximum
independence in performing daily ac-
tivities.
The first stage of hospital treatment
ended for our patient five months af-
ter limbs amputation.
Stage 2 – prior to prosthesis
at rehabilitation center
This stage of rehabilitation of the pa-
tient began immediately after trans-
porting him from the hospital to our
Institute. The stumps of all his limbs
had already been healed (Figure 4).
During this stage of rehabilitation,
there were new, additional aims, but
those of the previous stage remained
valid. During the second stage, the
aim was verticalization of the patient
as quickly as possible using prostheses
and, understood as widely as possible,
the use of the upper limbs – initially
without prosthetics, and later with the
use of prostheses as well.
Working with the patient, we still
continued to struggle with post-ampu-
-
tative oedema. The stumps of the up-
per and lower limbs were constantly
-
bandaged. The faster the molding of
the stumps, including the reduction of
swelling, the more durable prosthesis
-
fitting with the first definitive pros-
thetic is. The ergotherapist supplied
-
the patient with an electric wheelchair
38
-
Figure 4
Upper-limb stumps of the patient
that could move independently with-
in the Institute and around the sur-
rounding park. Initially, we supervised
his movement education, which took
a minimal amount of time because
the patient did very well right from
the start. Two stump boards were at-
tached to the wheelchair to maintain
proper positioning of the below-knee
stumps, which prevents joint contrac-
tures.
As part of analytical rehabilitation,
the physiotherapist continued pas-
sive-active musculo-articular mobili-
zation, used already at the hospitali-
zation stage and exercises to strength-
en the muscles, balance exercises in
a seated position, improvement of
bed-wheelchair transfer, at which
our patient excelled himself. In pa-
tients with lower limb amputation
in the below-knee area, it is very im-
portant to strengthen the quadriceps
muscles due to their responsibility for
straightening of the knee joints. This
is not only about preventing the onset
of contracture spasms, but also about
the ability to maintain an erect posi-
tion of the body with the use of pros-
theses and begin learning how to walk
as soon as possible. Therefore, exer-
cises strengthening this muscle group
are mandatory in the rehabilitation of
patients with the same profile as the
presented patient. Our patient was
very involved in all of the proposed
exercises, so the results of coopera-
tion could be quickly observed. While
in his room, outside the therapy ses-
sions, he rarely asked for help. How-
ever, some forms of activity caused
him pain, and therefore, he still took
analgesics. The patient was offered
psychological counselling, but he de-
clined. This possibility remained open
until the end of the patient’s stay at
our Institute, and at any time, he may
make an appointment with a psycho-
therapist.
The patient rapidly developed in-
dependence, even without using the
prostheses. He was able to get dressed,
move from the bed to a wheelchair,
use the toilet without assistance. Dur-
ing meals, he only needed help when
cutting. He could already eat well us-
ing a band to secure the silverware.
He had already practiced this action
while in the hospital. He still required
limited assistance to perform some ac-
tivities of personal hygiene, such as
bathing or shaving.
Added to therapeutic activities,
apart from those lead by a physiother-
apist and ergotherapist, was light dai-
ly exercises in a wheelchair, dynamic
exercises on mats (Figure 5) in groups
and exercises in a swimming pool lead
by sports educators.
Rehabilitation at the Institute is
conducted in a comprehensive, par-
allel manner by several therapists in
various areas of activities and special-
ization. All forms of exercise comple-
ment each other.
Stage 3 – rehabilitation
with the use of prostheses
The stage of rehabilitation with pros-
theses overlaps with the previous
stage. This is due to the fact that al-
 Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow

ready in the first days of the patient’s

stay, prosthesis preparation begins by
selection of materials and prosthet-
ic components, fittings using ready-
made prostheses liners and testing
their contact with the skin, watching
for possible allergic reactions. As soon
as the medical committee of the In-
stitute initially decides what type of
prosthetic materials to use and eval-
uates the condition of the stumps as
ready to start the prosthesis fitting
process, the first stage begins imme-
diately. Stage 3 of rehabilitation starts
Figure 5
just a few days after the beginning of
the stage 2 – both of which continue Dynamic exercises on mats carried out with a group of patients
simultaneously, complementing each
other, until the end of the patient’s the stumps of limbs without the help
stay at the Institute. of others.
In the first week of the patient’s The patient took part in most of the
stay at the Institute, a prosthetist fit- therapeutic sessions while having the
ted the patient with the previously liners on, accustoming the skin of the
ordered (after taking measurements stumps to all-day contact with the lin-
of both leg stumps) copolymer liners ers, which at a later time, are to be
which were the appropriate size for worn with the prostheses. The pa-
the future temporal tibial prosthesis tient learned how to put on the lin-
(Figure 6). Each day, the patient pro- ers themselves, using the below-elbow
longed the time-period of wearing the stumps of the upper limbs. It turned
liners. The physiotherapist also fulfills out that even this task was performed
a role here, observing the condition of very well and the patient quickly be-
the skin stumps in response to con-
came independent. After about 3-5
tact with liners during all therapeu- Figure 6
days of the beginning to wear the lin-
tic activities. Sometimes, there is an
ers, the prosthetist took further cir- Copolymer liner on the below-knee
allergic reaction in the form of red- stump
cumference and length measurements
ness and itching of the skin. In this
of the stumps, and evaluated their
case, the type of prosthetic material
form, this time to start the produc- ral prostheses, and was then subjected
is changed. After each removal of the
tion of the first temporal prostheses to the first verticalization on a verti-
liners, the stumps were immediately
for the lower limbs. The patient was calization bed for 5 minutes at an an-
dressed with elastic bandages, which
still constantly involved in all forms gle of 40˚. Lack of a full, one-hun-
the patient wore until the liners were
of therapy. dred percent load during the first ver-
put on once more the following day.
Shortly after, in the presence of the ticalization was done to avoid possible
The patient should not sleep with the
prosthetist and physiotherapist, the injury to the skin of the stumps at first
liners on, only with bandages. Thanks
patient was fitted with the first tempo- contact with the prostheses. The pa-
to this, the skin of the residual limb
does not lose contact with air. Oth-
erwise, this could lead to maceration
and damage.
Later, at the end of the patient’s
stay, instead of bandages, special elas-
tic compression socks are used on
the stumps (Figure 7). They are or-
-

dered in accordance with the appro-

priate size, after taking current meas-
-

urements of the stump circumferenc-

es. This is particularly important in
patients after multi-limb amputation,
-

because thanks to the constant an-

tioedematous action, they are able to Figure 7
-

independently take care of the state of Elastic antioedematous compression sock on the below-knee stump

39
-
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
tient after four-limb amputation, in
a standing position, cannot obtain
partial unburdening of the lower
limbs by leaning his arms on the par-
allel bars, as both of his upper limbs
were amputated as well.
Due to the good tolerance of the
lower-limb stump contact with the
prostheses and no pain, with each
passing day, the verticalization bed
angle and the time of verticalization
were increased. After a week, further
verticalization on the bed seemed un-
necessary and the patient, with the
help of a physiotherapist, took his
first attempt to stand up in the par-
allel bars. The patient drew on the
strength of the below-elbow stumps.
During the first session, he performed
the first balance exercises in a stand-
ing position with a variable load on
both of the lower limbs, constantly as-
sisted by the physiotherapist. During
the next session, the patient already
performed the first steps in the paral-
lel bars, at all times, supported by the
physiotherapist. At this stage, the pa-
tient began initial walking education.
After two weeks, the patient walked in
the parallel bars independently, with-
out help from the physiotherapist, but
under his supervision. The next step
was learning to walk “arm-in-arm”
with the physiotherapist outside the
parallel bars, initially in the walking
education lab, then on different sur-
faces outside, stairs and ramps. Be-
sides learning gait, the patient attend-
ed sessions with different degrees of
difficulty, carried out by physiother-
apists with a small group of patients.
The first sessions were held in the I
static atelier, later the II, successive-
ly in the I dynamic atelier, II and lat-
er in the functional atelier. The choice
of atelier was dependent on the func-
tional level of the patient (degree of
difficulty). In each atelier, the pa-
tients practiced using prosthetics. In
the static atelier, balance, propriocep-
tion and coordination exercises were
-
performed in a standing position. In
the dynamic atelier, walking exercis-
-
es were performed combined with
coordination, speed and precision of
movement, as well as balance and pro-
-
prioception exercises. In the function-
al atelier, exercises were carried out in
-
conditions similar to those of every-
40
-
day life, usually in the park surround-
ing the Institute, on different surfac-
es, stairs and ramps. The presented
patient was a very quick learner, and
his physical strength, combined with
general functional status allowed him
to participate in the ateliers with the
highest degrees of difficulty. What is
more, the patient in a short time from
application of the first temporal pros-
theses could independently put them
on and take them off (Figure 8). It is
this independence that is strived for in
patients after multi-limb amputation.
The prosthetist, in collaboration with
the physiotherapist, were still obliged
to observe and assess the condition of
the stump skin every time the pros-
thetics were put on or removed, and
had to ensure bandaging of the stumps
as well. Later, the patient learned to
independently put on the prostheses
in his room, and their removal was
still supervised by a physiotherapist or
prosthetist.
At this stage, the patient came to
therapeutic sessions independently,
and moved around the Institute with-
out restrictions (Figure 9). In addi-
tion, he took part in sports activities
conducted by sports educators.
At the time, when the patient start-
ed learning to use the first temporal
lower limb prosthetics, the ergothera-
pist carried out the first myoelectrical
tests on the upper limb stumps, pre-
paring the patient for their prostheses.
All actions with the patient took place
on many levels simultaneously.
The patient, who already moved
around the Institute and surround-
ing park with high autonomy, grad-
ually took part in additional forms of
physical activity. He was also offered
to participate in hippotherapy sessions
every two weeks outside the center,
but was not interested in this form of
activity. He also had the opportunity
to participate in gardening activities in
our park. However, he was more in-
terested in drawing classes at the ate-
lier.
PHYSICAL-RECREATIONAL
ACTIVITY
After the end of the stay at our Insti-
tute, the patient had the opportunity
to participate in out-of-town recrea-
tion-and-sports training camps, organ-
ized by the sports club for people af-
ter limb-amputation, which has exist-
ed for 30 years. Should he wish to do
so in the future, it is possible for the
patient to join the group from that as-
sociation.
PROSTHESIS FITTING
Lower-limbs
Throughout his stay at the Institute
(when prostheses are not on), the pa-
tient wore velpeau type elastic bandages
on the limb-stumps in order for them to
be molded, which also helped to reduce
swelling. Before beginning fitting for the
temporal lower-limbs prosthetics, the
prosthetist ordered the appropriate size
copolymer liners after taking measure-
ments of both stumps. Both liners, for the
right and left lower limbs were the same
size. Due to the relatively high sensitivi-
ty of the skin after amputation as a result
of septic shock, this type of material was
selected for the patient. The condition of
the skin response to contact with liners
was observed on a regular basis. Howev-
er, there is a risk of an allergic reaction,
which would entail the need to change
prosthetic injunctions. For our patient,
due to the multi-limb amputation and his
overall high efficiency, liners without dis-
tal fixing pins were chosen. This allowed
the patient to maintain greater stability of
the stumps inside the sockets of the pros-
theses at greater activity levels and dur-
ing faster walking through the addition-
al use of the knee sleeves, and prevent-
ed distal micro-pumping inside the lin-
ers, which is a risk for the sensitive skin
of the stumps. Nonetheless, for most pa-
tients after four-limb amputation, liners
with distal pins are usually selected to fa-
cilitate independent usage (putting them
on) without great contribution from the
upper amputated limbs, eliminating the
need to apply an extra knee-sleeve, which
could be a big handicap for them. In the
case of our patient, we indulged in this
additional difficulty, knowing his over-
all efficiency in order to enhance securi-
ty against the risk of stump injuries and
achieve more comfortable gait. As a fur-
ther prosthesis component, we selected
a Class II prosthetic foot for averagely
active persons. The temporal prosthetic
sockets with infrapatellar support were
 Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow

a b c d

e f g h
Figure 8
Stages of independently putting on temporary prosthetic legs by the patient in a sitting position on a chair: a and b – attaching
copolymer liner to below-knee stump; c – patient checks if liner is properly attached to the stump (without leaving space between
the distal part of the liner interior and the distal part of the stump); d – inserting the limb-stump into the socket of the prosthesis;
e, f, and g – unrolling knee-sleeve supporting the prosthesis onto the limb; h – verification of sense of stability and comfort with
the prosthesis in standing position

made of thermoplastic Surlyn. As addi-
tional elements supporting the prostheses
on the lower limbs, flexible knee-sleeves
made from polymer gel and covered with
textile material were used.
The temporal prostheses required
continuous adaptation due to high
activity of the patient and the relat-
ed rapidly progressive reduction in
-
of sockets, which were produced from
plastic. The definitive prostheses were
covered with polyurethane foam for
their cosmetic finishing (Figure 10).
Upper limbs
Due to persistent pain in the left
shoulder joint, the patient was offered
on the patient’s limb-stump in order
to determine the possibility of func-
tional control of the future prosthesis
by muscular contractions of the be-
low-elbow stump of the limb. The at-
tempts ended successfully. Through-
out the whole period of upper-limb
prosthetic fitting, the patient worked
with the ergotherapist, learning to use

oedema of the lower-limb stumps. an aesthetic, light, left upper-limb the myoelectrical prosthesis in a va-
The sockets of the temporary pros- prosthesis. In turn, for the right up- riety of daily and recreational activ-
-

theses were changed three times due per-limb, a myoelectrical prosthesis ities. During the prosthetic fitting of
to the rapid evolution of shape and was proposed (Figure 11). The pa- the upper-limb, full cooperation of
circumference of the stumps. tient was right-handed. the prosthetist with the ergotherapist
-

The definitive prostheses were Before production of the myoelec- was indispensable.
made from components such as: tem- trical prosthesis began, the ergother- The prosthetic right upper limb con-
-

poral prostheses, with the exception apist performed myoelectrical tests sists of an inner silicone liner, used to

41
-
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
a b
Figure 9 a and b
The patient walks around the center independently
increase the comfort of contact the hy-
persensible stump skin with the pros-
thesis socket, a plastic socket with at-
tached electrodes at the proximal
height of the below-elbow stump and
the myoelectrical prosthetic hand in
the shortened version without a pro-
no-supination system so that the limb
is not artificially lengthened. Physio-
logical prono-supination was main-
tained in the patient. In order for the
prosthesis to be aesthetically finished,
the prosthetic hand is covered with
a glove made of PVC, its color match-
ing the color of the patient’s skin.
The upper left limb prosthesis was
also comprised of an inner silicone
liner used in order to maintain a high-
er degree of comfort, a plastic sock-
et and a prosthetic hand glove made
from PVC, its color matching that of
the patient’s skin.
ERGOTHERAPY
From the first moments of his stay at
the Institute, the patient showed ex-
ceptional self-reliance. It turned out
-
that he quickly developed the abili-
ty to cope with everyday life. Trans-
-
fers from the bed to the wheelchair
were already mastered with a great
degree of independence. Most bath-
-
room activities could be performed in-
dependently and he also did not re-
-
quire assistance with getting dressed.
42
-
Ergotherapeutic evaluation of the
patient allowed to establish new, more
precise targets for implementation.
They were formulated in such a man-
ner to be as helpful to the patient as
possible, and also to show him the op-
portunity to carry out even the most
difficult tasks in his disability, namely:
–– enabling fully autonomous move-
ment while anticipating the start of
walking using prostheses,
–– assisting in regaining full independ-
ence associated with intimate hy-
giene and eating meals,
–– accompanying the patient in per-
forming activities that are impor-
tant to him,
–– developing the patient’s movement
compensation for individual man-
ual tasks,
–– equipping the patient with instru-
ments and amenities of daily living
activities and improving those al-
ready used,
–– planning, preparing and teaching
the usage of functional upper-limb
prostheses.
At our Institute specializing in the
prosthetic fitting concept, great im-
portance is placed on helping a pa-
tient regain independence. On the
one hand, we mean pre-prostheses in-
dependence, allowing the patient to
learn to be independent in terms rele-
vant to his/her activities, without wait-
ing for the exclusive benefits of pros-
Figure 10
The definitive upper – and lower-limb
prosthetics
theses usage. On the other hand, we
refer to the general independence, in
the event that the prosthetics are not
used by the patient.
The following question should be
put forward: is independence without
a prosthesis failure?
An ergotherapist was once accused
of “overcompensation” of disability
in one of the patients after four-limb
amputation through the realization of
her excess technical assistance prior to
producing and adapting the prosthe-
ses. Later disapproval and rejection of
the upper-limb prosthetics was con-
sidered by some therapists as a conse-
quence of too much comfort, obtained
as the result of the use of various tech-
nical aids, which does not leave room
for the integration of prostheses.
Our patient, awaiting lower-limb
prosthetics, used an electric wheel-
chair with a customized joystick con-
trolled by the forearm. Thanks to
the specific morphology of the dis-
tal stump of the forearm, which was
characterized by the clearly exposed
ulna and radial bones, the patient
could precisely control his wheelchair,
i.e. independently change its settings,
as well turn it on or off. This allowed
him to quickly begin to independent-

Figure 11
The definitive aesthetic prosthesis of
the left upper-limb, consisting of an
inner silicone liner, a plastic socket
and covering cosmetic prosthetic
hand glove made of PVC in the color
corresponding to the patient’s skin
color and definitive myoelectrical
prosthesis of the right upper-limb, which
consists of inner silicone liner, plastic
socket with electrodes attached at the
height of the proximal below-elbow
stump and shortened version of the
myoelectrical hand prosthetic without
prono-supination system covered with
a cosmetic glove made of PVC, the color
matching the patient’s skin color
ly go to rehabilitation sessions, meals,
dressing and to the park surrounding
the Institute.
In terms of self-reliance while eat-
ing meals, the patient initially used
both his forearms to manipulate the
fork. This action was difficult and tir-
ing for him due to both lack of preci-
sion of movement and stability, as well
as the lack of optimal attachment of
the fork, which often ended in its in-
correct use.
As technical assistance, a wide band
situated at the below-elbow stump
with a pocket for cutlery was used,
which the patient could attach him-
self.
-
Later, different technical assistance
was used – an attached knife which
-
allowed him to independently cut the
food during the meal.
However, it is not enough to pro-
-
duce technical assistance. It is re-
quired that the patient test and prac-
-
tice using such amenities. The first
-
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
meals were eaten in peace and with
patience under the guidance of the er-
gotherapist in the ergotherapy lab, not
alone in the restaurant.
Despite several tests and trials re-
garding technical assistance with in-
timate hygiene, we never really man-
aged to find out from the patient what
his level of independence in this area
was. The patient systematically avoid-
ed answering the question and made
it understood that he did not wish to
deepen this topic.
The patient was a reserved, not very
talkative but very committed and dil-
igent person. He did not allow to un-
derstand his expectations, he did not
express them. This was not due to
a language barrier. He did not speak
French, but understood the instruc-
tions and commands. One time, it
was noticed that he sketched beautiful
drawings in a notebook with a pen.
He was passionate about drawing. He
was able to draw holding a pen in his
below-elbow stumps.
The conducted ergotherapy ses-
sions were also designed to create
such technical assistance to be able
to write/draw with the best possible
grip of a pen/pencil, with the great-
est precision, with the possibility of
independently changing the drawing
or writing instrument. It was neces-
sary to use a light socket made from
low-temperature thermo-moldable
material, to which a directional trans-
verse tube for the writing instrument
was attached.
Later, writing or drawing with
a myoelectrical prosthesis was made
possible by the performance of move-
ments in the shoulder joint and block-
ing a pen or pencil in the prosthetic
hand (Figure 12). It should be empha-
sized that for this patient with ampu-
tation of both upper limbs, the biggest
problem in this activity was the posi-
tioning of the pen/pencil in the hand.
As a result of these measures, the pa-
tient could draw in his room by him-
self.
Upper-limb prosthesis fitting was
another reason for many visits of
the patient to the ergotherapy lab.
The prosthetist and ergotherapist
worked closely together. Learning
about the functioning of the myoe-
lectrical system took place at the er-
gotherapy lab. Two separate motor
points, operating according to a spe-
cific program, could already be used
in the temporary myoelectric prosthe-
sis. The development of the patient’s
ability to independently put on the
prosthesis was overseen, and the peri-
od of wearing the prosthesis was pro-
gressively lengthened for the patient
to better tolerate its weight.
At the beginning, largely performed
was analytical work associated with
control of prosthesis actions, by try-
ing to grip objects of various shapes
and sizes. Practiced was not only grip
control, holding and releasing an ob-
ject, but also control of the prosthetic
hand clamping force and its postural
adaptation.
Later, an attempt at independent
meal preparation was performed. Un-
der the supervision of an ergothera-
pist and using the necessary guidance,
the patient cooked dinner in the ergo-
therapy lab adapted for this purpose.
Later – still in the context of the ther-
apeutic activity and using prostheses
– in a pleasant atmosphere, he ate the
meal he prepared along with thera-
pists and prosthetists invited by him.
The successful attempt gave the pa-
tient great satisfaction and boosted his
belief in his own abilities.
Ultimately, sought for is the integra-
tion of the prostheses in performing
activities of daily living. At this stage
of action, the therapist is in a very un-
comfortable situation because along
with the patient, s/he must find the
same level of confidence of perform-
ing actions with the use of prosthesis
as reached before without the pros-
thesis. We need to strive to achieve
the same, but now with the prosthesis.
Home visit
A home visit is proposed to the pa-
tient at the doctor’s request or at the
suggestion of an ergotherapist. A pa-
tient’s socially or family isolated way
of living and the assumption that the
apartment or house in which the pa-
tient lives probably does not meet
the criteria for adaptation to its cur-
rent functional capabilities (informa-
tion collected on the basis of initial
interview), are all factors that require
proposing home visits to the patient.
43
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
Figure 12
Writing using a myoelectrical prosthesis with a pen blocked in prosthetic hand
A home visit is carried out in the pres-
ence of the patient and ergotherapist.
The ergotherapist takes the necessary
technical tools needed for moving
the patient (walker or crutches, slid-
ing board to transfer from wheelchair
to car seat, a special bath board that
can be attached to the bathtub, etc.).
A patient with prostheses and if nec-
essary, using a walker or crutches, has
the opportunity to take his/her first
steps in his/her own apartment, if s/
he did not go for therapeutic week-
ends during their stay at our Institute.
A home visit is a very important part
of the patient’s preparation for a re-
turn to everyday life. Thanks to it,
and thanks to the support and sug-
gestions of ergotherapists, and result-
ing from their subsequent adaptation
of the apartment, the patient is able
to quickly and easily “find him/her-
self ” in the place of life, at the end
of a long hospital stay and a long stay
at our Institute. The patients are of-
ten afraid to return to their homes in
their current functional status, and
during this type of visit, any neces-
sary adjustments of furniture, the re-
organization of the premises, adaption
of technical aids or even major modi-
fications including remodeling can be
-
earlier planned and discussed before
the patient leaves our Institute. It may
-
be the case that the cooperation of so-
cial assistants, craftsmen, construction
workers and agencies supporting peo-
-
ple with disabilities may be required.
At the same time, it sometimes occurs
-
that the home visit ends with the pa-
44
-
tient stating lack of possibility to re-
turn to his/her home, and then s/he
needs assistance in planning the move,
looking for another property. In the
case of the homeless, as well as the
presented patient, it is necessary to
start searching for a residence that ful-
fills all the necessary conditions.
It also sometimes happens that the
patient, following the home visit, does
not agree with any suggested chang-
es in his/her apartment and wants, in
spite of everything, to return to the
status quo. In such a situation, the mis-
sion of ergotherapist and the whole
team and ends with only advice, with-
out the implementation of assisting
measures. However, when it seems
that the patient is not fully aware of
the risks and limitations, and thus the
lack of capacity to deal with the cur-
rent functional state, re-discussion re-
garding assistance proposals is pushed.
END OF STAY AT THE INSTITUTE
The period of stay of the patient at the
Institute was 6 months. During that
time, a social assistant sought out suit-
able accommodation, because he was
homeless.
The patient left our Institute walk-
ing independently, without help. All
four amputated limbs were fitted
with definitive prostheses. The pros-
theses were worn for about 6 hours
a day. His walking distance was rat-
ed as unrestricted. He regained full
self-reliance and was ready to live in-
dependently.
A month after leaving the Institute,
he came in for his first medical-pros-
thetic check-up. The condition of the
stumps was rated as very good, with
the disappearance of swelling and
progressive muscle atrophy. It was
necessary to adapt the prostheses to
the current shapes and perimeters of
the stumps by pasting foam to the in-
side of the prosthesis sockets, and to
put on additional socks to fill out the
reduced stump perimeters. Also noted
was further progress in the recovery
of efficiency and independence. With
the aid of the lower limb prosthetics,
the patient could overcome greater
distances with less fatigue. He lives
alone and easily moves around using
public transport.
The patient remains under the con-
stant medical and prosthetic care of
our Institute indefinitely. About 3
months after the end of the stay, pro-
duction of new prostheses begins.
The aim is to replace the sockets of
the prostheses due to the progressive
reduction of the volume of the stumps
as a result of declining swelling and
muscle atrophy. At the same time, the
patient uses all necessary medical con-
sultations and, if necessary, continues
rehabilitation within the partial hospi-
talization system at the Institute.
SUMMARY
Rehabilitation and prosthesis follow-
ing four-limb amputation requires
a longer period of time than in the
case of amputation of one limb and
usually lasts twice as long. In order to
achieve satisfactory results, coordinat-
ed cooperation of a full team of thera-
pists, prosthetists and doctors is need-
ed. It is advisable for the whole range
of activities to be carried out at one in-
stitute. Thanks to this, more positive
benefits can be achieved. With great
commitment, motivation and patience
on the part of the patient, joint work
can bring positive results so that the
patients will not need assistance in dai-
ly activities and be able to live inde-
pendently. The presented case shows
that even a patient with such a difficult
clinical interview, and after the initial
life-threatening shock and four-limb
amputation, may return to being fit
and start to live independently again.

Conflict of interest: noneA
Piśmiennictwo/References
1. Wadełek J. Wstrząs septyczny z niewydol-
nością wielonarządową w przebiegu inwa-
zyjnej choroby pneumokokowej u pacjenta
z asplenią – opis przypadku. [Septic shock
with multiple organ dysfunction syndrome
during invasive pneumococcal disease in
asplenic patient – a case report]. Anest Ra-
tow2014; 8: 392-398.
2. Bollero D., Stella M., Gangemi E.N., Spazian-
te L., Nuzzo J., Sigaudo G., et al. Purpura ful-
minans in meningococcal septicaemia in an
adult: a case report. Ann Burns Fire Disa-
sters 2010; 23(1): 43-47.
3. Phan P.N.H., Acharya V., Parikh D., Shad A.
A rare case of symmetrical four limb gangre-
ne following emergency neurosurgery. Int J
Surg Case Rep 2015; 16: 15-18.
4. Elalamy I. Coagulation intravasculaire dis-
séminée. EMC 2012; 13-022-C-20. Doi:
10.1016/S1155-1984(06)40045-5 [http://
www.em-consulte.com/article/51338/co-
agulation-intravasculaire-disseminee].
5. Parmar M.S. Symmetrical peripheral gangre-
ne: a rare but dreadful complication of sep-
sis. CMAJ 2002; 167(9): 1037-1038.
-
-
-
A
Aneta Pirowska – physiotherapist and prosthetist, Thibaud Vincent – physiotherapist, Julie Clotilde-Trotel – ergotherapist, Caroline Voiry – physiotherapist
-
and prosthetist, Elise Joannot – prosthetist, Doan Vu Tri – rehabilitation, angiology and podology specialist, Gérard Chiesa – rehabilitation specialist
-
Medical Rehabilitation (Med Rehabil) 2015, 19 (4): 34-45   eISSN 1896–3250 ISSN 1427–9622   © AWF Krakow
6. Endo A., Shiraishi A., Aiboshi J., Hayashi Y.,
Otomo Y. A case of purpura fulminans cau-
sed by Hemophilus influenzae complicated
by reversible cardiomyopathy. J Intensive
Care 2014; 2(1): 13. doi: 10.1186/2052-0492-
2-13.
7. Shenoy R., Aqarwal N., Goneppanavar U.,
Shenoy A., Sharma A. Symmetrical periphe-
ral gangrene – a case report and brief review.
Indian J Surg 2013; 75(Suppl 1):163-165.
8. Lowe K.G., Boyce J.M. Rehabilitation of
a child with meningococcal septicemia and
quadrilateral limb loss: a case report. Arch
Phys Med Rehabil 2004; 85(8): 1354-1357.
9. Tsalik E.L., Woods C.W. Sepsis redefined:
the search for surrogate markers. Int J Anti-
microb Agents 2009; 34(Suppl 4): S16-S20..
10. Jaeschke R., Brożek J., Dellinger R.P. 2008
update of international guidelines for the
management of severe sepsis and septic
shock: should we change our current clini-
cal practice? Pol Arch Med Wewn 2008; 118
(3):92-95.
11. Dellinger R.P., Levy M.M., Carlet J.M., Bion
J., Parker M.M., Jaeschke R. i wsp.; Inter-
national Surviving Sepsis Campaign Gu-
idelines Committee; American Association
of Critical-Care Nurses; American College
of Chest Physicians; American College of
Emergency Physicians; Canadian Critical
Care Society; European Society of Clinical
Microbiology and Infectious Diseases; Eu-
ropean Society of Intensive Care Medicine;
European Respiratory Society; International
Sepsis Forum; Japanese Association for
Acute Medicine; Japanese Society of Inten-
sive Care Medicine; Society of Critical Care
Medicine; Society of Hospital Medicine; Sur-
gical Infection Society; World Federation of
Societies of Intensive and Critical Care Me-
dicine. Surviving Sepsis Campaign: Interna-
tional guidelines for management of severe
sepsis and septic shock: 2008. Crit. Care
Med. 2008; 36(1): 296-327.
12. Kübler A., Weinert M.: Anestezjologia. Else-
vier Urban & Partner 2008: 127-129.
13. Members of the ACCP/SCCM Consensus
Conference Committee: American Colle-
ge of Chest Physicians/Society of Critical
Care Medicine Consensus Conference: de-
finitions for sepsis and organ failure and gu-
idelines for the use of innovative therapies in
sepsis. Crit. Care Med., 1992; 20: 864-874.
Address for correspondence
Aneta Pirowska, PhD
Institut Robert Merle d’Aubigné
2 rue du Parc
94460 Valenton, France
email: piran@op.pl
45