A Retrospective Analysis of Nonocclusive Mesenteric Ischemia in Medical and Surgical ICU Patients: Clinical Data on Demography, Clinical Signs, and Survival

Abstract

Background: To analyze demography, clinical signs, and survival of intensive care patients diagnosed with nonocclusive mesenteric ischemia (NOMI) and to evaluate the effect of a local intra-arterial prostaglandin therapy. Methods: Retrospective observational study screening 455 intensive care patients with acute arterial mesenteric perfusion disorder in a tertiary care hospital within the past 8 years. Lastly, 32 patients with NOMI were enrolled, of which 11 received local intra-arterial prostaglandin therapy. The diagnosis of NOMI was based on the clinical presentation and established biphasic computed tomography criteria. Clinical and biochemical data were obtained 24 hours before, at the time, and 24 hours after diagnosis. Results: Patients were 60.5 (49.3-73) years old and had multiple comorbidities. Most of them were diagnosed with septic shock requiring high doses of norepinephrine (NE: 0.382 [0.249-0.627] μg/kg/min). The Sequential Organ Failure Assessment (SOFA) score was 18 (16-20). A decrease in oxygenation (Pao2/Fio2), pH, and bicarbonate and an increase in international normalized ratio, lactate, bilirubin, leucocyte count, and NE dose were early indicators of NOMI. Median SOFA score significantly increased in the last 24 hours before diagnosis of NOMI (16 vs 18, P < .0001). Overall, 28-day mortality was 75% (81% nonintervention vs 64% intervention cohort; P = .579). Median SOFA scores 24 hours after intervention increased by +5% in the nonintervention group and decreased by 5.5% in the intervention group ( P = .0059). Conclusions: Our data suggest that NOMI is a detrimental disease associated with progressive organ failure and a high mortality. Local intra-arterial prostaglandin application might hold promise as a rescue treatment strategy. These data encourage future randomized controlled trials are desirable.

Non-occlusive mesenteric ischemia (NOMI): evaluation of 2D-perfusion angiography (2D-PA) for early treatment response assessment

“…Non-occlusive mesenteric ischemia (NOMI) was first described by Ende in 1958 in patients with severe heart failure [1]. Since then, NOMI is recognized as a substantial cause of acute mesenteric ischemia characterized by a combination of splanchnic vasoconstriction and the absence of embolic or atherosclerotic-thrombotic occlusion of the mesenteric arteries [2][3][4]. Risk factors for NOMI include cardiovascular and chronic kidney disease, administration of vasoconstrictive medications or drugs (e.g., digoxin, vasopressor therapy, cocaine, methamphetamine abuse), recent major surgery, sepsis, and shock [3,4].…”

“…Since then, NOMI is recognized as a substantial cause of acute mesenteric ischemia characterized by a combination of splanchnic vasoconstriction and the absence of embolic or atherosclerotic-thrombotic occlusion of the mesenteric arteries [2][3][4]. Risk factors for NOMI include cardiovascular and chronic kidney disease, administration of vasoconstrictive medications or drugs (e.g., digoxin, vasopressor therapy, cocaine, methamphetamine abuse), recent major surgery, sepsis, and shock [3,4]. Overall, NOMI accounts for 5-15% of acute mesenteric ischemia cases [2,3] and is associated with high mortality rates ranging between 50 and 93%, primarily due to its association with severe comorbidities [3,5,6].…”

“…Risk factors for NOMI include cardiovascular and chronic kidney disease, administration of vasoconstrictive medications or drugs (e.g., digoxin, vasopressor therapy, cocaine, methamphetamine abuse), recent major surgery, sepsis, and shock [3,4]. Overall, NOMI accounts for 5-15% of acute mesenteric ischemia cases [2,3] and is associated with high mortality rates ranging between 50 and 93%, primarily due to its association with severe comorbidities [3,5,6]. Contrary to well-known symptoms of acute occlusive arterial mesenteric ischemia, clinical signs of NOMI are often unspecific [3,4,7].…”

“…Overall, NOMI accounts for 5-15% of acute mesenteric ischemia cases [2,3] and is associated with high mortality rates ranging between 50 and 93%, primarily due to its association with severe comorbidities [3,5,6]. Contrary to well-known symptoms of acute occlusive arterial mesenteric ischemia, clinical signs of NOMI are often unspecific [3,4,7]. Moreover, the symptoms may be masked due to intubation and sedation of the critically ill patients, potentially leading to a delayed diagnosis [3,4,[7][8][9][10][11].…”

“…Contrary to well-known symptoms of acute occlusive arterial mesenteric ischemia, clinical signs of NOMI are often unspecific [3,4,7]. Moreover, the symptoms may be masked due to intubation and sedation of the critically ill patients, potentially leading to a delayed diagnosis [3,4,[7][8][9][10][11]. Laboratory tests (e.g., elevated serum lactate) in combination with increasing need of vasoconstrictive medications strengthen the clinical suspicion of non-occlusive mesenteric ischemia [3,4].…”