This protocol addresses the patient with non-occlusive mesenteric ischemia in whom initial intensive medical therapy has not restored adequate mesenteric perfusion — evidenced by failure of the serum lactate to clear or normalize.

Previous Treatment — Failure Condition

Initial management included treatment of the underlying precipitating cause along with fluid resuscitation, electrolyte correction, nasogastric decompression, and broad-spectrum antibiotics. Cardiac output was optimized using dobutamine, low-dose dopamine, or milrinone, with elimination of vasopressors. Systemic anticoagulation was provided with unfractionated heparin, and catheter-directed papaverine hydrochloride was infused into the superior mesenteric artery and/or continuous intravenous prostaglandin E1 was administered. The trigger for escalation to the next line is failure to achieve improvement in mesenteric perfusion, reflected by persistent or worsening serum lactate rather than clearance toward normalization.

Next-Line Approach

When peritoneal signs develop or mesenteric perfusion cannot be restored through medical means, this protocol defines a surgical intervention for managing frankly infarcted bowel. The complete procedural regimen — including operative approach, damage-control considerations, and the timing of re-evaluation — is available in full via the link below.

References

DOI: 10.1186/s13017-022-00443-x

Infarcted bowel should be resected promptly.
If a patient presents with peritoneal signs, an exploratory laparotomy is required for resection of frankly necrotic bowel.
Damage control surgery is an important adjunct, given the critical state of these patients.
Most often, re-exploration should be accomplished within 24–48 h and decisions regarding anastomosis, stoma, or additional resection can be made with plans for sequential abdominal closure.

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Non-occlusive Mesenteric Ischemia When Serum Lactate Fails to Normalize After Medical Management

References