Management of ischaemic bowel in the ICU patient

PURPOSE OF REVIEW: Acute mesenteric ischaemia is an uncommon but often fatal condition frequently requiring intensive care management. This review discusses the multidisciplinary management of subtypes of acute mesenteric ischaemia, emphasizing the specific challenges of nonocclusive mesenteric ischaemia (NOMI) in the ICU. RECENT FINDINGS: While multidisciplinary approach and early revascularisation have improved outcomes in arterial occlusive acute mesenteric ischaemia, diagnostic and therapeutic strategies for NOMI remain challenging. Similarities and differences in diagnosis and management of patients with NOMI and of occlusive subtypes of acute mesenteric ischaemia are outlined. In the absence of evidence, we suggest that optimizing hemodynamic stability, with a focus on achieving euvolemia, maintaining adequate cardiac output and ensuring adequate vascular tone, may help prevent or limit nonocclusive bowel ischemia. Equally important is treating the underlying cause of hemodynamic instability (such as sepsis, cardiac dysfunction or hypovolemia). In patients admitted to ICU after revascularisation and/or bowel resection, limitation of progression of intestinal damage is the target, while addressing progression of bowel necrosis when it occurs, requires well established multidisciplinary teamwork. SUMMARY: Managing acute mesenteric ischaemia in the ICU extends beyond restoring mesenteric blood flow, it requires simultaneous correction of the systemic insult driving and/or driven by ischemia, and timely surgical intervention both when bowel viability is salvageable or already lost. Different subtypes of acute mesenteric ischaemia have some differences in diagnosis and management.