NOMI: Association with the Use of Different Vasoconstrictors in Cardiac Surgery

Background: Nonocclusive mesenteric ischemia (NOMI) is a serious postoperative complication in cardiac and vascular surgery that is rare, but accompanied by a very high mortality rate. The pathophysiology is not yet fully understood and the diagnosis remains difficult. Lactatemia is the widely used as a marker, but is a late occurring, low sensitive and weakly specific surrogate. Here, we identified clinical risk parameters to enable preventive therapeutic options.

Method: We analyzed 634 consecutive all comers intensive care patients (age 68.7 ± 11.1 years, 69.9% male) in elective, urgent or emergent cardiac surgery for the development of NOMI or lactatemia. NOMI positive patients were propensity score matched to patients undergoing cardiac surgery without lactatemia. Risk factors for the development of NOMI were analyzed by uni-/multivariate regression analysis and ROC analysis.

Results: NOMI patients suffered preoperatively from hyperlipoproteinemia (p = 0.041), had multi-valvular disease (p = 0.047) and underwent multi-valvular operation (mitral + tricuspid; p < 0.001), had significantly more often coronary artery bypass graft surgery (0.031), exhibited postoperative renal failure (GFR < 30; p < 0.01), needed postoperative dialysis (p < 0.001), were treated with vasopressin (p < 0.001), and died (p < 0.001) during intensive care therapy. Cardiac reoperation increased NOMI probability by the factor 2,018 (1,078/2,018/3,375; p = 0.028), vasopressin therapy by the factor 5,203 (2,726; 5,203; 9.93; p < 0.001); In particular, a combination therapy of norepinephrine with vasopressin promotes for NOMI. Vasopressin therapy was positively predictive of NOMI (ROC = 0.74; p < 0.001). The threshold for therapy with vasopressin in our cohort to induce NOMI in combination with norepinephrine is 0.5 I.E./h (sensitivity: 0.617; specificity: 0.831; Youden-Index: 0.45).

Conclusion: Contrary to current therapy recommendations, therapy with vasopressin, especially in combination with other vasoconstrictors, can induce NOMI and should be carefully dosed and closely monitored. Patients at risk are in particular cardiac reoperations, combined valve operations and dialysis patients.

Publication History

Article published online:
28 January 2023