Multidisciplinary Treatment Protocol Improves Time to Vascular Involvement in Patients With Acute Mesenteric Ischemia

Acute mesenteric ischemia (AMI) remains a highly morbid disease. Delays in treatment result in extended duration of ischemic time and poor outcomes. The objective of this study was to evaluate the implementation of an institutional protocol aimed to educate and engage relevant care providers to expedite the diagnosis and treatment of patients with AMI. All patients who underwent any surgery for AMI from a multi-center hospital system between January 2010 and November 2023 were investigated. The AMI treatment protocol was disseminated to first-line care providers (ie, EM, Medicine, Acute Care Surgery) across the hospital system January 2021 (Fig 1). Patients presenting before and after protocol implementation were compared. A retrospective review of demographic and postoperative data was performed. Effect of protocol on early vascular consultation (day of presentation) and early revascularization (≤12 hours from presentation) were analyzed. Total length of bowel resection, development of short gut syndrome, and major postoperative outcomes including 30-day mortality were analyzed. Of a total of 245 patients that were analyzed, 196 patients were treated pre-protocol, and 49 patients were treated post-protocol.. The majority of patients in the post-protocol group received an early vascular consultation (75.5% vs 58.1%; P = .01) (Fig 2). Of the patients who received an early vascular consultation, more patients had an early revascularization (100% vs 87%; P = .03). While not statistically significant, time to revascularization was lower in the post-protocol group (452 vs 657 minutes; P = .12). Length of bowel resected was also shorter in the post-protocol group, although not statistically significant (62 vs 76 centimeters; P = .12). OR case time did not significantly increase in the post-protocol group (181 vs 162 minutes; P = .31). There were no differences in postoperative sepsis, cardiac or renal injury, respiratory failure, or development of short gut syndrome. Thirty-day mortality did not differ (P = .56). Of the 12 patients in the post-protocol group who did not have a timely vascular consultation, length of small bowel resected was longer, though not statistically significant (91 vs 50 cm; P = .09). Time to revascularization also trended longer (560 vs 417 minutes; P = .13). The implementation of a protocol for management of AMI resulted in reduced time to vascular consultation and revascularization. Despite systemic dissemination of the protocol, 25% of AMI patients did not receive a timely vascular consultation. Further development of the protocol should include multisite diffusion and automatic code activation as soon as the radiographic diagnosis is made. Fig 2Proportion of patients receiving early (≤12 hours) revascularization in pre- or post-protocol patients.