We are constantly taught as residents that we need to act quickly in toxic C-Diff colitis, and if we don't get their colon in a bucket before they start to spiral downward, then it's too late to do anything.
However, I think it's less clear than that in real life. The main reason is that often we don't have an accurate clinical picture. The patient the OP briefly described sounded like he wasn't properly worked up or managed...sometimes placing appropriate lines and giving appropriate fluids and antibiotics can quickly reduce the need for "max pressors," and we'll find that the patient wasn't as far gone as it seemed.
Also, I've seen a couple patients get super sick from C-diff, including multiple pressors, who respond dramatically to colectomy and recover after source control. Patient selection is obviously important...one of these was a 25yo post-partum female who could take insults better than an old man with cardiomyopathy.
It's tough to say for sure based on the OP's description what to do next. If the patient is truly past the point where he would benefit from surgery, then it's appropriate to do nothing, and I've recommended this before, even when it's a tough situation (45 yo HIV+ mother of 2 comes to mind). However, often I feel obligated to get some more information before giving up. It doesn't take long to drop in some lines, see how hypotensive the patient truly is, and see if he is fluid responsive.
I'm sure many SDNers are familiar with the newer literature supporting loop ileostomy with Vanco through the efferent loop....I've never been brave enough to do it, but I'm definitely intrigued.....after all, how much of our quoted high morbidity and mortality come from the procedure itself?
