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van de Voort JC, Kessel B, Borger van der Burg BLS, DuBose JJ, Hörer TM, Hoencamp R. Consensus on resuscitative endovascular balloon occlusion of the aorta in civilian (prehospital) trauma care: A Delphi study. J Trauma Acute Care Surg 2024; 96:921-930. [PMID: 38227678 DOI: 10.1097/ta.0000000000004238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) could prevent lethal exsanguination and support cardiopulmonary resuscitation. In prehospital trauma and medical emergency settings, a small population with high mortality rates could potentially benefit from early REBOA deployment. However, its use in these situations remains highly disputed. Since publication of the first Delphi study on REBOA, in which consensus was not reached on all addressed topics, new literature has emerged. The aim of this study was to establish consensus on the use and implementation of REBOA in civilian prehospital settings for noncompressible truncal hemorrhage and out-of-hospital cardiac arrest as well as for various in-hospital settings. METHODS A Delphi study consisting of three rounds of questionnaires was conducted based on a review of recent literature. REBOA experts with different medical specialties, backgrounds, and work environments were invited for the international panel. Consensus was reached when a minimum of 75% of panelists responded to a question and at least 75% (positive) or less than 25% (negative) of these respondents agreed on the questioned subject. RESULTS Panel members reached consensus on potential (contra)indications, physiological thresholds for patient selection, the use of ultrasound and practical, and technical aspects for early femoral artery access and prehospital REBOA. CONCLUSION The international expert panel agreed that REBOA can be used in civilian prehospital settings for temporary control of noncompressible truncal hemorrhage, provided that personnel are properly trained and protocols are established. For prehospital REBOA and early femoral artery access, consensus was reached on (contra)indications, physiological thresholds and practical aspects. The panel recommends the initiation of a randomized clinical trial investigating the use of prehospital REBOA for noncompressible truncal hemorrhage. LEVEL OF EVIDENCE Therapeutic/Care Management; Level V.
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Affiliation(s)
- Jan C van de Voort
- From the Department of Surgery (J.C.vdV., B.L.S.B.vdB., R.H.), Alrijne Hospital, Leiderdorp; Trauma Research Unit, Department of Trauma Surgery (J.C.vdV., R.H.), Erasmus University Medical Center, Rotterdam, The Netherlands; Division of General Surgery and Trauma (B.K.), Hillel Yaffe Medical Center, Hadera; Rappaport Faculty of Medicine (B.K.), Technion-Israel Institute of Technology, Haifa, Israel; Defense Healthcare Organization (B.L.S.B.vdB., R.H.), Ministry of Defense, Utrecht, The Netherlands; Department of Surgery and Perioperative Care (J.J.DB.), Dell School of Medicine, University of Texas, Austin, Texas; Department of Surgery, Faculty of Medicine and Health (T.M.H.), and Department of Cardiothoracic and Vascular Surgery (T.M.H.), Faculty of Medicine and Health, Örebro Hospital and University, Örebro, Sweden
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Hoshi H, Endo A, Yamamoto R, Yamakawa K, Suzuki K, Akutsu T, Morishita K. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma and its performance in Japan over the past 18 years: a nationwide descriptive study. World J Emerg Surg 2024; 19:19. [PMID: 38822409 PMCID: PMC11140856 DOI: 10.1186/s13017-024-00548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used to control massive hemorrhages. Although there is no consensus on the efficacy of REBOA, it remains an option as a bridging therapy in non-trauma centers where trauma surgeons are not available. To better understand the current landscape of REBOA application, we examined changes in its usage, target population, and treatment outcomes in Japan, where immediate hemostasis procedures sometimes cannot be performed. METHODS This retrospective observational study used the Japan Trauma Data Bank data. All cases in which REBOA was performed between January 2004 and December 2021 were included. The primary outcome was the in-hospital mortality rate. We analyzed mortality trends over time according to the number of cases, number of centers, severity of injury, and overall and subgroup mortality associated with REBOA usage. We performed a logistic analysis of mortality trends over time, adjusting for probability of survival based on the trauma and injury severity score. RESULTS Overall, 2557 patients were treated with REBOA and were deemed eligible for inclusion. The median age of the participants was 55 years, and male patients constituted 65.3% of the study population. Blunt trauma accounted for approximately 93.0% of the cases. The number of cases and facilities that used REBOA increased until 2019. While the injury severity score and revised trauma score did not change throughout the observation period, the hospital mortality rate decreased from 91.3 to 50.9%. The REBOA group without severe head or spine injuries showed greater improvement in mortality than the all-patient group using REBOA and all-trauma patient group. The greatest improvement in mortality was observed in patients with systolic blood pressure ≥ 80 mmHg. The adjusted odds ratios for hospital mortality steadily declined, even after adjusting for the probability of survival. CONCLUSIONS While there was no significant change in patient severity, mortality of patients treated with REBOA decreased over time. Further research is required to determine the reasons for these improvements in trauma care.
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Affiliation(s)
- Hiromasa Hoshi
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Akira Endo
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan.
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medicine and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan.
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Kazuma Yamakawa
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Keisuke Suzuki
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medicine and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Tomohiro Akutsu
- Department of Acute Critical Care Medicine, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki, 300-0028, Japan
| | - Koji Morishita
- Department of Acute Critical Care and Disaster Medicine, Graduate School of Medicine and Dental Sciences, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
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Zhao Z, Wang J, Niu J, Dong S, Shi J, Yan T, Guo W, Yang R, Tang X. The clinical effectiveness and safety of Zone III REBOA for resection of sacropelvic tumors in patients older than 70 years. World J Surg Oncol 2024; 22:120. [PMID: 38702816 PMCID: PMC11067248 DOI: 10.1186/s12957-024-03398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND REBOA is a method used to manage bleeding during surgery involving sacropelvic tumors. Nevertheless, studies on the use of REBOA among elderly people are lacking. The aim of this research was to investigate the efficacy and safety of Zone III REBOA in patients aged more than 70 years. METHODS A comparative study was conducted using case-control methods. A group of patients, referred to as Group A, who were younger than 70 years was identified and paired with a comparable group of patients, known as Group B, who were older than 70 years. Continuous monitoring of physiological parameters was conducted, and blood samples were collected at consistent intervals. RESULTS Totally, 188 participants were enrolled and received REBOA. Among the 188 patients, seventeen were aged more than 70 years. By implementing REBOA, the average amount of blood loss was only 1427 ml. Experiments were also conducted to compare Group A and Group B. No notable differences were observed in terms of demographic variables, systolic blood pressure (SBP), arterial pH, lactate levels, blood creatinine levels, potassium levels, or calcium levels at baseline. Additionally, after the deflation of the REBOA, laboratory test results, which included arterial pH, lactate, potassium concentration, calcium concentration, and blood creatinine concentration, were not significantly different (P > 0.05). CONCLUSION This study indicated that in selected patients aged more than 70 years can achieve satisfactory hemodynamic and metabolic stability with Zone III REBOA. LEVEL OF EVIDENCE Therapeutic study, Level III.
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Affiliation(s)
- Zhiqing Zhao
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Jichuan Wang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Jianfang Niu
- Department of Orthopedic Surgery, Peking University First Hospital, Beijing, China
| | - Sen Dong
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Jingtian Shi
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Taiqiang Yan
- Department of Orthopedic Surgery, Peking University First Hospital, Beijing, China.
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
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Smith MC, Medvecz AJ, Smith MR, Streams JR, Dennis BM. Computed tomography scanning is feasible in select patients with REBOA catheter deployment. Injury 2024; 55:111387. [PMID: 38360518 DOI: 10.1016/j.injury.2024.111387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Rapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock. METHODS We queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days. RESULTS 61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days. DISCUSSION We demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael C Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA.
| | - Andrew J Medvecz
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Melissa R Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Jill R Streams
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
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Li RF, Gong XF, Xu HB, Lin JT, Zhang HG, Suo ZJ, Wu JL. Age affects vascular morphology and predictiveness of anatomical landmarks for aortic zones in trauma patients: implications for resuscitative endovascular balloon occlusion of the aorta. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02512-z. [PMID: 38656432 DOI: 10.1007/s00068-024-02512-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/30/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Understanding the vascular morphology is fundamental for resuscitative endovascular balloon occlusion of the aorta. This study aimed to evaluate the effect of aging on length and diameter of aorta and iliac arteries in trauma patients, and to investigate the predictiveness of anatomical landmarks for aortic zones. METHODS A total of 235 patients in a regional trauma center registry from September 1, 2018, to January 3, 2024, participated in the study. Reconstruction of computed tomography was applied to the torso area. The marginal diameter and length of aorta and iliac arteries were measured. Anatomical landmark distances and aortic marginal lengths were compared. RESULTS The length and diameter of aorta and iliac arteries increased with age, and a tortuous and enlarged morphology was observed in older patients. There was a good regression between age and diameter of the aorta. Neither the jugular notch, the xiphisternal joint, nor the umbilicus could reliably represent specific margins of aortic zones. The distance between the mid-sternum and femoral artery (427 ± 25 to 442 ± 25 mm for right, and 425 ± 28 to 440 ± 26 mm for left) was predictive for zone 1 in all groups. The distance between the lower one-third junction of the xiphisternum to the umbilicus and femoral artery (232 ± 19 to 240 ± 17 mm for right, and 229 ± 20 to 237 ± 19 mm for left) was predictive for zone 3 aorta. CONCLUSION Aging increases the length and diameter of aorta and iliac arteries, with a tortuous and enlarged morphology in geriatric populations. The mid-sternum and the lower one-third junction of the xiphisternum to the umbilicus were predictive landmarks for zone 1 and zone 3, respectively.
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Affiliation(s)
- Rui-Fa Li
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Xue-Fang Gong
- Department of Pulmonary and Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Hong-Bo Xu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Jin-Tuan Lin
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Hai-Gang Zhang
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Zhi-Jun Suo
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Jing-Lan Wu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China.
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Yu B, Cho J, Kang BH, Kim K, Kim DH, Chang SW, Jung PY, Heo Y, Kang WS. Nomogram for predicting in-hospital mortality in trauma patients undergoing resuscitative endovascular balloon occlusion of the aorta: a retrospective multicenter study. Sci Rep 2024; 14:9164. [PMID: 38644449 PMCID: PMC11033263 DOI: 10.1038/s41598-024-59861-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024] Open
Abstract
Recently, resuscitative endovascular balloon occlusion of the aorta (REBOA) had been introduced as an innovative procedure for severe hemorrhage in the abdomen or pelvis. We aimed to investigate risk factors associated with mortality after REBOA and construct a model for predicting mortality. This multicenter retrospective study collected data from 251 patients admitted at five regional trauma centers across South Korea from 2015 to 2022. The indications for REBOA included patients experiencing hypovolemic shock due to hemorrhage in the abdomen, pelvis, or lower extremities, and those who were non-responders (systolic blood pressure (SBP) < 90 mmHg) to initial fluid treatment. The primary and secondary outcomes were mortality due to exsanguination and overall mortality, respectively. After feature selection using the least absolute shrinkage and selection operator (LASSO) logistic regression model to minimize overfitting, a multivariate logistic regression (MLR) model and nomogram were constructed. In the MLR model using risk factors selected in the LASSO, five risk factors, including initial heart rate (adjusted odds ratio [aOR], 0.99; 95% confidence interval [CI], 0.98-1.00; p = 0.030), initial Glasgow coma scale (aOR, 0.86; 95% CI 0.80-0.93; p < 0.001), RBC transfusion within 4 h (unit, aOR, 1.12; 95% CI 1.07-1.17; p < 0.001), balloon occlusion type (reference: partial occlusion; total occlusion, aOR, 2.53; 95% CI 1.27-5.02; p = 0.008; partial + total occlusion, aOR, 2.04; 95% CI 0.71-5.86; p = 0.187), and post-REBOA systolic blood pressure (SBP) (aOR, 0.98; 95% CI 0.97-0.99; p < 0.001) were significantly associated with mortality due to exsanguination. The prediction model showed an area under curve, sensitivity, and specificity of 0.855, 73.2%, and 83.6%, respectively. Decision curve analysis showed that the predictive model had increased net benefits across a wide range of threshold probabilities. This study developed a novel intuitive nomogram for predicting mortality in patients undergoing REBOA. Our proposed model exhibited excellent performance and revealed that total occlusion was associated with poor outcomes, with post-REBOA SBP potentially being an effective surrogate measure.
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Affiliation(s)
- Byungchul Yu
- Traumatology, Gachon University College of Medicine, Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Jayun Cho
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou School of Medicine, Suwon, Republic of Korea
| | - Kyounghwan Kim
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, 65, Doryeong-ro, Jeju-si, Jeju-do, Republic of Korea
| | - Dong Hun Kim
- Division of Trauma Surgery, Department of Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Pil Young Jung
- Department of Trauma and Acute Care Surgery, Yonsei University Wonju Severance Christian Hospital, Wonju, Republic of Korea
| | - Yoonjung Heo
- Division of Trauma Surgery, Department of Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Wu Seong Kang
- Department of Trauma Surgery, Jeju Regional Trauma Center, Cheju Halla General Hospital, 65, Doryeong-ro, Jeju-si, Jeju-do, Republic of Korea.
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Grechenig P, Hallmann B, Eibinger NR, Koutp A, Zajic P, Höfler G, Puchwein P. Percutaneous ultrasound-guided versus open cut-down access to femoral vessels for the placement of a REBOA catheter. Sci Rep 2024; 14:9111. [PMID: 38643229 PMCID: PMC11032382 DOI: 10.1038/s41598-024-59778-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 04/15/2024] [Indexed: 04/22/2024] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be useful in treating exsanguinating trauma patients. This study seeks to compare rates of success, complications and time required for vascular access between ultrasound-guidance and surgical cut-down for femoral sheath insertion as a prospective observational case control study. Participating clinicians from either trauma surgery or anesthesiology were allocated to surgical cut-down or percutaneous ultrasound-guided puncture on a 1:1 ratio. Time spans to vessel identification, successful puncture, and balloon inflation were recorded. 80 study participants were recruited and allocated to 40 open cut-down approaches and 40 percutaneous ultrasound-guided approaches. REBOA catheter placement was successful in 18/40 cases (45%) using a percutaneous ultrasound guided technique and 33/40 times (83%) using the open cut-down approach (p < 0.001). Median times [in seconds] compared between percutaneous ultrasound-guided puncture and surgical cut-down were 36 (18-73) versus 117(56-213) for vessel visualization (p < 0.001), 136 (97-175) versus 183 (156-219) for vessel puncture (p < 0.001), and 375 (240-600) versus 288 (244-379) for balloon inflation (p = 0.08) overall. Access to femoral vessels for REBOA catheter placement is safer when performed by cut-down and direct visualization but can be performed faster by an ultrasound-guided technique when vessels can be identified clearly and rapidly.
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Affiliation(s)
- Peter Grechenig
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - Barbara Hallmann
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Nicolas Rene Eibinger
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - Amir Koutp
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
| | - Paul Zajic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Gerald Höfler
- Diagnostic and Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - Paul Puchwein
- Department of Orthopedics and Trauma Surgery, Medical University of Graz, Graz, Austria
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Treffalls RN, DuBose JJ, Brenner M, Piccinini A, Inaba K, Scalea TM, Moore LJ, Kauvar DS. Outcomes Associated With Aortic Balloon Occlusion Time in Patients With Zone 1 Resuscitative Endovascular Balloon Occlusion of the Aorta. J Surg Res 2024; 296:256-264. [PMID: 38295713 DOI: 10.1016/j.jss.2023.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 12/08/2023] [Accepted: 12/29/2023] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) has the potential to cause clinically relevant systemic ischemic burden with long durations of aortic occlusion (AO). We aimed to examine the association between balloon occlusion time and clinical complications and mortality outcomes in patients undergoing zone 1 REBOA. METHODS A retrospective cohort analysis of American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acuteregistry patients with Zone 1 REBOA between 2013 and 2022 was performed. Patients with cardiopulmonary resuscitation on arrival or who did not survive past the emergency department were excluded. Total AO times were categorized as follows: <15 min, 15-30 min, 31-60 min, and >60 min. Clinical and procedural variables and in-hospital outcomes were compared across groups using bivariate and multivariate regression analyses. RESULTS There were 327 cases meeting inclusion criteria (n = 51 < 15 min, 83 15-30 min, 98 31-60 min, and 95 > 60 min, respectively). AO >60 min had higher admission lactate (8 ± 6; P = 0.004) compared to all other time groups, but injury severity score, heart rate, and systolic blood pressure were similar. Group average times from admission to definitive hemorrhage control ranged from 82 to 103 min and were similar across groups (85 min in AO >60 group). Longer AO times were associated with greater red blood cell, fresh frozen plasma transfusions (P < 0.001), and vasopressor use (P = 0.001). Mortality was greatest in the >60 min group (73%) versus the <15 min, 15-30 min, and 31-60 min groups (53%, 43%, and 45%, P < 0.001). With adjustment for injury severity score, systolic blood pressure, and lactate, AO >60 min had greater mortality (OR 3.7, 95% CI 1.6-9.4; P < 0.001) than other AO duration groups. Among 153 survivors, AO >60 min had a higher rate of multiple organ failure (15.4%) compared to the other AO durations (0%, 0%, and 4%, P = 0.02). There were no differences in amputation rates (0.7%) or spinal cord ischemia (1.4%). acute kidney injury was seen in 41% of >60 min versus 21%, 27%, and 33%, P = 0.42. CONCLUSIONS Though greater preocclusion physiologic injury may have been present, REBOA-induced ischemic insult was correlated with poor patient outcomes, specifically, REBOA inflation time >60 min had higher rates of mortality and multiple organ failure. Minimizing AO duration should be prioritized, and AO should not delay achieving definitive hemostasis. Partial REBOA may be a solution to extend safe AO time and deserves further study.
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Affiliation(s)
| | - Joseph J DuBose
- Department of Surgery, University of Texas Dell School of Medicine, Austin, Texas
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Alice Piccinini
- Department of Surgery, Los Angelos County + University of Southern California Hospital, Los Angelos, California
| | - Kenji Inaba
- Department of Surgery, Los Angelos County + University of Southern California Hospital, Los Angelos, California
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Laura J Moore
- Department of Surgery, University of Texas McGovern Medical School, Houston, Texas
| | - David S Kauvar
- Vascular Surgery Service, Brooke Army Medical Center, Houston, Texas; Department of Surgery, Uniformed Services University, Bethesda, Maryland.
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Kontopodis N, Tosounidis T, Kehagias E, Kouraki A, Tzirakis K, Ioannou CV. Concomitant vascular and orthopedic trauma: 10 points to consider. J Clin Orthop Trauma 2024; 51:102407. [PMID: 38681997 PMCID: PMC11053217 DOI: 10.1016/j.jcot.2024.102407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/01/2024] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
Although vascular injuries complicate only 1-2% of patients with orthopedic trauma, they may be encountered in a much higher rate of around 10 % in injuries around the knee and elbow joints following both fractures and dislocations. In case of vascular involvement, specific diagnostic and therapeutic challenges arise and there is a higher risk for significant morbidity (i.e. limb loss) or mortality. In the absence of randomized data, diagnostic and therapeutic algorithms are not always straightforward and clinical practice may be based on experience and local protocols rather than firm evidence. With this article we intend to review available literature regarding concomitant skeletal and vascular trauma in order to provide concise information and clear guidelines of when to operate with least investigations and when to go for a full spectrum of investigations in the absence of hard clinical signs. Additionally, other aspects concerning the manipulation of these patients are discussed, such as the indications of primary amputation, the potential role of endovascular techniques and the value of the Resuscitative Endovascular Balloon Occlusion of the Aorta. In summary, this scoping review summarizes current practices in the diagnostic and therapeutic management of patients with concomitant orthopedic and vascular injuries, discusses different treatment strategies and gives a practical perspective for implementation on every day practice.
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Affiliation(s)
- Nikolaos Kontopodis
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Theodoros Tosounidis
- Orthopedic Department, University of Crete-Medical School, Heraklion, Crete, Greece
| | - Elias Kehagias
- Interventional Radiology Unit, University of Crete-Medical School, Heraklion, Crete, Greece
| | | | - Konstantinos Tzirakis
- Department of Mechanical Engineering, Hellenic Mediterranean University, Heraklion, Crete, Greece
| | - Christos V. Ioannou
- Vascular Surgery Department, University of Crete-Medical School, Heraklion, Crete, Greece
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Abel B, Mares J, Hutzler J, Parajuli B, Kurada L, White JM, Propper BW, Stewart IJ, Burmeister DM. The degree of aortic occlusion in the setting of trauma alters the extent of acute kidney injury associated with mitochondrial preservation. Am J Physiol Renal Physiol 2024; 326:F669-F679. [PMID: 38450433 DOI: 10.1152/ajprenal.00323.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/09/2024] [Accepted: 02/24/2024] [Indexed: 03/08/2024] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to control noncompressible hemorrhage not addressed with traditional tourniquets. However, REBOA is associated with acute kidney injury (AKI) and subsequent mortality in severely injured trauma patients. Here, we investigated how the degree of aortic occlusion altered the extent of AKI in a porcine model. Female Yorkshire-cross swine (n = 16, 68.1 ± 0.7 kg) were anesthetized and had carotid and bilateral femoral arteries accessed for REBOA insertion and distal and proximal blood pressure monitoring. Through a laparotomy, a 6-cm liver laceration was performed and balloon inflation was performed in zone 1 of the aorta for 90 min, during which animals were randomized to target distal mean arterial pressures of 25 or 45 mmHg via balloon volume adjustment. Blood draws were taken at baseline, end of occlusion, and time of death, at which point renal tissues were harvested 6 h after balloon deflation for histological and molecular analyses. Renal blood flow was lower in the 25-mmHg group (48.5 ± 18.3 mL/min) than in the 45-mmHg group (177.9 ± 27.2 mL/min) during the occlusion phase, which recovered and was not different after balloon deflation. AKI was more severe in the 25-mmHg group, as evidenced by circulating creatinine, blood urea nitrogen, and urinary neutrophil gelatinase-associated lipocalin. The 25-mmHg group had increased tubular necrosis, lower renal citrate synthase activity, increased tissue and circulating syndecan-1, and elevated systemic inflammatory cytokines. The extent of renal ischemia-induced AKI is associated with the magnitude of mitochondrial biomass and systemic inflammation, highlighting potential mechanistic targets to combine with partial REBOA strategies to prevent AKI.NEW & NOTEWORTHY Large animal models of ischemia-reperfusion acute kidney injury (IR-AKI) are lacking. This report establishes a titratable IR-AKI model in swine in which a balloon catheter can be used to alter distal pressures experienced by the kidney, thus controlling renal blood flow. Lower blood flow results in greater renal dysfunction and structural damage, as well as lower mitochondrial biomass, elevated systemic inflammation, and vascular dysfunction.
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Affiliation(s)
- Biebele Abel
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Incorporated, Bethesda, Maryland, United States
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland, United States
| | - John Mares
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Incorporated, Bethesda, Maryland, United States
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland, United States
| | - Justin Hutzler
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Incorporated, Bethesda, Maryland, United States
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland, United States
| | - Babita Parajuli
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | - Lalitha Kurada
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Incorporated, Bethesda, Maryland, United States
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | - Joseph M White
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Brandon W Propper
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland, United States
- Department of Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
| | - Ian J Stewart
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
| | - David M Burmeister
- Department of Surgery, Uniformed Services University of the Health Science, Bethesda, Maryland, United States
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, United States
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Leeper WR, James N. Trauma Bay Evaluation and Resuscitative Decision-Making. Surg Clin North Am 2024; 104:293-309. [PMID: 38453303 DOI: 10.1016/j.suc.2024.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
The reader of this article will now have the ability to reflect on all aspects of high-quality trauma bay care, from resuscitation to diagnosis and leadership to debriefing. Although there is no replacement for experience, both clinically and in a simulation environment, trauma clinicians are encouraged to make use of this article both as a primer at the beginning of a trauma rotation and a reference text to revisit after difficult cases in the trauma bay. Also, periods of reflection seem appropriate in the busy but, of course, rewarding career in trauma care.
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Affiliation(s)
- William Robert Leeper
- Department of Surgery, Western University, Victoria Campus, London Health Sciences Center, Room E2-215, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Division of Critical Care, Department of Surgery, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Nicholas James
- London Health Sciences Center, Victoria Campus, Room E2-214, 800 Commissioners Road East, London, Ontario N6A 5W9, Canada; Trauma Program at London Health Sciences Center, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
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12
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Jansen JO, MacLennan GS, Campbell MK. Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients With Exsanguinating Hemorrhage-Reply. JAMA 2024; 331:981-982. [PMID: 38502076 DOI: 10.1001/jama.2024.0285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Graeme S MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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13
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Kamijo K, Matsumura Y. Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients With Exsanguinating Hemorrhage. JAMA 2024; 331:978-979. [PMID: 38502080 DOI: 10.1001/jama.2024.0291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Affiliation(s)
- Kyosuke Kamijo
- Department of Gynecology, Nagano Municipal Hospital, Nagano, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency and Psychiatry Medical Center, Chiba, Japan
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Tullos A, Wunnava S, Medina D, Sheahan C, Chawla A, Torrance B, Brooke A, Donovan M, Palit T, Sheahan M. Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center. J Vasc Surg 2024:S0741-5214(24)00499-3. [PMID: 38493898 DOI: 10.1016/j.jvs.2024.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to manage severe hemorrhagic shock. Popularized in medical care during military conflicts, the concept has emerged as a lifesaving technique that is utilized around the United States. Literature on risks of REBOA placement, especially vascular injuries, are not well-reported. Our goal was to assess the incidence of vascular injury from REBOA placement and the risk factors associated with injury and death among these patients at our institution. METHODS We performed a retrospective cohort study of all patients who underwent REBOA placement between September 2017 and June 2022 at our Level 1 Trauma Center. The primary outcome variable was the presence of an injury related to REBOA insertion or use. Secondary outcomes studied were limb loss, the need for dialysis, and mortality. Data were analyzed using descriptive statistics, χ2, and t-tests as appropriate for the variable type. RESULTS We identified 99 patients who underwent REBOA placement during the study period. The mean age of patients was 43.1 ± 17.2 years, and 67.7% (67/99) were males. The majority of injuries were from blunt trauma (79.8%; 79/99). Twelve of the patients (12.1%; 12/99) had a vascular injury related to REBOA placement. All but one required intervention. The complications included local vessel injury (58.3%; 7/12), distal embolization (16.7%; 2/12), excessive bleeding requiring vascular consult (8.3%; 1/12), pseudoaneurysm requiring intervention (8.3%; 1/12), and one incident of inability to remove the REBOA device (8.3%; 1/12). The repairs were performed by vascular surgery (75%; 9/12), interventional radiology (16.7%; 2/12), and trauma surgery (8.3%; 1/12). There was no association of age, gender, race, and blunt vs penetrating injury to REBOA-related complications. Mortality in this patient population was high (40.4%), but there was no association with REBOA-related complications. Ipsilateral limb loss occurred in two patients with REBOA-related injuries, but both were due to their injuries and not to REBOA-related ischemia. CONCLUSIONS Although vascular complications are not unusual in REBOA placement, there does not appear to be an association with limb loss, dialysis, or mortality if they are addressed promptly. Close coordination between vascular surgeons and trauma surgeons is essential in patients undergoing REBOA placement.
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Affiliation(s)
- Amanda Tullos
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Sanjay Wunnava
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Daniela Medina
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Claudie Sheahan
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Amit Chawla
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Bruce Torrance
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Amadis Brooke
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Melissa Donovan
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Tapash Palit
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Malachi Sheahan
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA.
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Studer AN, Young JC, Cook JT, Grimaldo FH, Wickman DA, Zarow GJ, Spalding CN. A Novel REBOA Training Curriculum for Emergency Medicine Residents: A Pilot Study. J Emerg Med 2024:S0736-4679(24)00075-1. [PMID: 38821848 DOI: 10.1016/j.jemermed.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 01/14/2024] [Accepted: 03/06/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a potentially life-saving intervention to treat noncompressible torso hemorrhage. Traditionally, REBOA use has been limited to surgeons. However, emergency physicians are often the first point-of-contact and are well-versed in obtaining rapid vascular access and damage control resuscitation, making them ideal candidates for REBOA training. STUDY OBJECTIVES To fill this gap, we designed and evaluated a REBOA training curriculum for emergency medicine (EM) residents. METHODS Participants enrolled in an accredited 4-year EM residency program (N = 11) completed a 12-hour REBOA training course. Day 1 included lectures, case studies, and hands-on training using REBOA task trainers and perfused cadavers. Day 2 included additional practice and competency evaluations. Assessments included a 25-item written knowledge exam, decision-making on case studies, REBOA placement success, and time-to-placement. Participants returned at 4 months to assess long-term retention. Data were analyzed using t-tests and nonparametric statistics at p < 0.05. RESULTS Scores on a 25-item multiple choice test significantly increased from pre-training (65% ± 5%) to post-training (92% ± 1%), p < 0.001. On Day 2, participants scored 100% on correct recognition of REBOA indications and scored 100% on correct physical placement of REBOA. Exit surveys indicated increased preparedness, confidence, and support for incorporating this course into EM training. Most importantly, REBOA knowledge, correct recognition of REBOA indications, and correct REBOA placement skills were retained by the majority of participants at 4 months. CONCLUSION This course effectively teaches EM residents the requisite skills for REBOA competence and proper placement. This study could be replicated at other facilities with larger, more diverse samples, aiming to expand the use of REBOA in emergency physicians and reducing preventable deaths in trauma.
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Affiliation(s)
- Amanda N Studer
- Department of Emergency Medicine, Naval Medicine Center San Diego, San Diego, CA.
| | - Jocelyn C Young
- Department of Emergency Medicine, Naval Medicine Center San Diego, San Diego, CA
| | - Jeffrey T Cook
- Department of Emergency Medicine, Naval Medicine Center San Diego, San Diego, CA
| | - Felipe H Grimaldo
- Department of Emergency Medicine, Naval Medicine Center San Diego, San Diego, CA
| | - Danielle A Wickman
- Department of Emergency Medicine, Naval Medicine Center San Diego, San Diego, CA
| | | | - Carmen N Spalding
- Department of Emergency Medicine, Bioskills/Simulation Training Center, Naval Medicine Center San Diego, San Diego, CA
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16
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Epstein L, Grigorian A, Matsushima K, Nahmias J, Dilday J, Demetriades D. Propensity Score Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta: Zone-1 Versus Zone-3 Resuscitative Endovascular Balloon Occlusion of the Aorta Odds of Mortality. J Surg Res 2024; 295:660-665. [PMID: 38104529 DOI: 10.1016/j.jss.2023.11.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/07/2023] [Accepted: 11/12/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION There are two zones for the placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients: above the mesenteric vessels (Zone-1) or below the renal arteries (Zone-3). Zone-1 REBOA diverts blood away from the visceral organs which leads to a systemic inflammatory response and reperfusion injury. We hypothesized that patients undergoing Zone-1 REBOA placement had a higher odds of mortality. METHODS The 2017-2019 Trauma Quality Improvement Program database was queried for patients undergoing either Zone-1 or Zone-3 REBOA. We excluded all patients with prehospital cardiac arrest. We compared Zone-1 versus Zone-3 REBOA using a 1:2 propensity-score model, matching for age, mechanism, sex, hypotension, tachycardia, blunt solid organ injury grade, pelvic fracture, and injuries to the aorta, iliac artery, iliac vein, and inferior vena cava. RESULTS We matched 130 Zone-1 REBOA patients to 260 Zone-3 REBOA patients. There were no statistically significant differences in the matched variables (P > 0.05). Compared to Zone-3 REBOA, patients with Zone-1 REBOA who survived ≥48 h had similar rates of acute kidney injury (18.6% versus 10.9%, P = 0.19). Zone-1 REBOA patients had a higher mortality rate (71.4% versus 48.8%, P = 0.002) and mortality odds ratio (OR) (OR 1.85, OR 1.18-2.89, P = 0.007). Zone-1 REBOA remained associated with a higher odds of mortality after controlling for traumatic brain injury and injury severity score (OR 1.86, OR 1.18-2.92, P = 0.007). CONCLUSIONS Compared to Zone-3, using a REBOA in Zone-1 is associated with higher odds of mortality. The use of REBOA Zone-1 deployment should be done with caution.
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Affiliation(s)
- Larissa Epstein
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California.
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California
| | - Joshua Dilday
- Department of Surgery, University of Southern California, Los Angeles, California
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17
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Fontenelle Ribeiro Junior MA, Salman SM, Al-Qaraghuli SM, Makki F, Abu Affan RA, Mohseni SR, Brenner M. Complications associated with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review. Trauma Surg Acute Care Open 2024; 9:e001267. [PMID: 38347890 PMCID: PMC10860083 DOI: 10.1136/tsaco-2023-001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/22/2023] [Indexed: 02/15/2024] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become part of the arsenal to temporize patients in shock from severe hemorrhage. REBOA is used in trauma to prevent cardiovascular collapse by preserving heart and brain perfusion and minimizing distal hemorrhage until definitive hemorrhage control can be achieved. Significant side effects, including death, ischemia and reperfusion injuries, severe renal and lung damage, limb ischemia and amputations have all been reported. The aim of this article is to provide an update on complications related to REBOA. REBOA has emerged as a critical intervention for managing severe hemorrhagic shock, aiming to temporize patients and prevent cardiovascular collapse until definitive hemorrhage control can be achieved. However, this life-saving procedure is not without its challenges, with significant reported side effects. This review provides an updated overview of complications associated with REBOA. The most prevalent procedure-related complication is distal embolization and lower limb ischemia, with an incidence of 16% (range: 4-52.6%). Vascular and access site complications are also noteworthy, documented in studies with incidence rates varying from 1.2% to 11.1%. Conversely, bleeding-related complications exhibit lower documentation, with incidence rates ranging from 1.4% to 28.6%. Pseudoaneurysms are less likely, with rates ranging from 2% to 14%. A notable incidence of complications arises from lower limb compartment syndrome and lower limb amputation associated with the REBOA procedure. Systemic complications include acute kidney failure, consistently reported across various studies, with incidence rates ranging from 5.6% to 46%, representing one of the most frequently documented systemic complications. Infection and sepsis are also described, with rates ranging from 2% to 36%. Pulmonary-related complications, including acute respiratory distress syndrome and multisystem organ failure, occur in this population at rates ranging from 7.1% to 17.5%. This comprehensive overview underscores the diverse spectrum of complications associated with REBOA.
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Affiliation(s)
| | | | | | - Farah Makki
- Medicine, University of Sharjah, Sharjah, UAE
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18
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Alremeithi R, Tran QK, Quintana MT, Shahamatdar S, Pourmand A. Approach to traumatic cardiac arrest in the emergency department: a narrative literature review for emergency providers. World J Emerg Med 2024; 15:3-9. [PMID: 38188559 PMCID: PMC10765073 DOI: 10.5847/wjem.j.1920-8642.2023.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 07/28/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Traumatic cardiac arrest (TCA) is a major contributor to mortality and morbidity in all age groups and poses a significant burden on the healthcare system. Although there have been advances in treatment modalities, survival rates for TCA patients remain low. This narrative literature review critically examines the indications and effectiveness of current therapeutic approaches in treating TCA. METHODS We performed a literature search in the PubMed and Scopus databases for studies published before December 31, 2022. The search was refined by combining search terms, examining relevant study references, and restricting publications to the English language. Following the search, 943 articles were retrieved, and two independent reviewers conducted a screening process. RESULTS A review of various studies on pre- and intra-arrest prognostic factors showed that survival rates were higher when patients had an initial shockable rhythm. There were conflicting results regarding other prognostic factors, such as witnessed arrest, bystander cardiopulmonary resuscitation (CPR), and the use of prehospital or in-hospital epinephrine. Emergency thoracotomy was found to result in more favorable outcomes in cases of penetrating trauma than in those with blunt trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides an advantage to emergency thoracotomy in terms of occupational safety for the operator as an alternative in managing hemorrhagic shock. When implemented in the setting of aortic occlusion, emergency thoracotomy and REBOA resulted in comparable mortality rates. Veno-venous extracorporeal life support (V-V ECLS) and veno-arterial extracorporeal life support (V-A ECLS) are viable options for treating respiratory failure and cardiogenic shock, respectively. In the context of traumatic injuries, V-V ECLS has been associated with higher rates of survival to discharge than V-A ECLS. CONCLUSION TCA remains a significant challenge for emergency medical services due to its high morbidity and mortality rates. Pre- and intra-arrest prognostic factors can help identify patients who are likely to benefit from aggressive and resource-intensive resuscitation measures. Further research is needed to enhance guidelines for the clinical use of established and emerging therapeutic approaches that can help optimize treatment efficacy and ameliorate survival outcomes.
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Affiliation(s)
- Rashed Alremeithi
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Quincy K. Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore 21201, USA
- Program in Trauma, the R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore 21201, USA
| | - Megan T. Quintana
- Center for Trauma and Critical Care, Department of Surgery, the George Washington University School of Medicine & Health Sciences, Washington DC 20037, USA
| | - Soroush Shahamatdar
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
| | - Ali Pourmand
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC 20037, USA
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Vrancken SM, de Vroome M, van Vledder MG, Halm JA, Van Lieshout EMM, Borger van der Burg BLS, Hoencamp R, Verhofstad MHJ, van Waes OJF. Non-compressible truncal and junctional hemorrhage: A retrospective analysis quantifying potential indications for advanced bleeding control in Dutch trauma centers. Injury 2024; 55:111183. [PMID: 37981519 DOI: 10.1016/j.injury.2023.111183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/06/2023] [Accepted: 11/03/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Truncal and junctional hemorrhage is the leading cause of potentially preventable deaths in trauma patients. To reduce this mortality, the application of advanced bleeding control techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), junctional tourniquets, Foley catheters, or hemostatic agents should be optimized. This study aimed to identify trauma patients with non-compressible truncal and junctional hemorrhage (NCTJH) who might benefit from advanced bleeding control techniques during initial trauma care. We hypothesized that there is a substantial cohort of Dutch trauma patients that can possibly benefit from advanced bleeding control techniques. METHODS Adult trauma patients with an Abbreviated Injury Scale ≥3 in the torso, neck, axilla, or groin region, who were presented between January 1st, 2014 and December 31st, 2018 to two Dutch level-1 trauma centers, were identified from the Dutch Trauma Registry. Potential indications for advanced bleeding control in patients with NCTJH were assessed by an expert panel of three trauma surgeons based on injury characteristics, vital signs, response to resuscitation, and received treatment. RESULTS In total, 1719 patients were identified of whom 249 (14.5 %) suffered from NCTJH. In 153 patients (60.6 %), hemorrhagic shock could have been mitigated or prevented with advanced bleeding control techniques. This group was younger and more heavily injured: median age of 40 versus 48 years and median ISS 33 versus 22 as compared to the entire cohort. The mortality rate in these patients was 31.8 %. On average, each of the included level-1 trauma centers treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial. CONCLUSIONS More than half of included Dutch trauma patients with NCTJH may benefit from in-hospital application of advanced bleeding control techniques, such as REBOA, during initial trauma care. Widespread implementation of these techniques in the Dutch trauma system may contribute to reduction of mortality and morbidity from non-compressible truncal and junctional hemorrhage.
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Affiliation(s)
- Suzanne M Vrancken
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Trauma Research Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.
| | - Matthijs de Vroome
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jens A Halm
- Trauma Research Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands; Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Oscar J F van Waes
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands
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20
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Aoki M, Matsumura Y, Izawa Y, Hayashi Y. Ultrasound assessment is useful for evaluating balloon volume of resuscitative endovascular balloon occlusion of the aorta. Eur J Trauma Emerg Surg 2023; 49:2479-2484. [PMID: 37430175 DOI: 10.1007/s00068-023-02309-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Endovascular balloon occlusion of the aorta (EBOA) increases proximal arterial pressure but may also induce life-threatening ischemic complications. Although partial REBOA (P-REBOA) mitigates distal ischemia, it requires invasive monitoring of femoral artery pressure for titration. In this study, we aimed to titrate P-REBOA to prevent high-degree P-REBOA using ultrasound assessment of femoral arterial flow. METHODS Proximal (carotid) and distal (femoral) arterial pressures were recorded, and perfusion velocity of distal arterial pressures was measured by pulse wave Doppler. Systolic and diastolic peak velocities were measured among all ten pigs. Total REBOA was defined as a cessation of distal pulse pressure, and maximum balloon volume was documented. The balloon volume (BV) was titrated at 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the perfusion velocity of distal arterial pressures were recorded. RESULTS Proximal blood pressure increased with increasing BV. Distal pressure decreased with increasing BV, and distal pressure sharply decreased by > 80% of BV. Both systolic and diastolic velocities of the distal arterial pressure decreased with increasing BV. Diastolic velocity could not be recorded when the BV of REBOA was > 80%. CONCLUSION The diastolic peak velocity in the femoral artery disappeared when %BV was > 80%. Evaluation of the femoral artery pressure by pulse wave Doppler may predict the degree of P-REBOA without invasive arterial monitoring.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan.
| | - Yoshimitsu Izawa
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Yosuke Hayashi
- Department of Emergency and Critical Care Medicine, Japan Red Cross Narita Hospital, Narita, Japan
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21
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DeClerk AC, Helmer SD, Quinn KR, Haan JM. Evaluation of Resuscitative Endovascular Balloon Occlusion of the Aorta Complications in a Community-Based Trauma Center. Am Surg 2023; 89:5505-5511. [PMID: 36803133 DOI: 10.1177/00031348231157810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of management of noncompressible torso hemorrhage in trauma patients. Increased utilization has shown increased vascular complications and mortality. This study aimed to evaluate complications of REBOA placement in a community trauma setting. METHODS A 3-year retrospective review was performed of all trauma patients that underwent REBOA placement. Data collection included demographics, injury characteristics, complications, and mortality. RESULTS Twenty-three patients were included, and the overall mortality was 65.2%. Most patients suffered blunt trauma (73.9%), and median ISS and TRISS (survival probability) were 24 and 42.2%, respectively. The median time to REBOA placement was 22 minutes, and hemorrhagic control was achieved in all patients. The most common complication was acute kidney injury at 34.8%. There was one complication associated with placement that required vascular intervention but did not lead to limb amputation. CONCLUSION Resuscitative endovascular balloon occlusion of the aorta was shown to have higher rates of acute kidney injury, similar rates of vascular injury, and lower rate of limb complications compared to published literature. Resuscitative endovascular balloon occlusion of the aorta remains a useful tool for trauma resuscitation without the fear of increased complications.
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Affiliation(s)
- Andrew C DeClerk
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Stephen D Helmer
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Karson R Quinn
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - James M Haan
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
- Department of Trauma Services, Ascension Via Christi Hospital Saint Francis, Wichita, KS, USA
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22
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Marsden M, Lendrum R, Davenport R. Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta. Curr Opin Crit Care 2023; 29:689-695. [PMID: 37861182 DOI: 10.1097/mcc.0000000000001106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. RECENT FINDINGS While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. SUMMARY Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.
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Affiliation(s)
- Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- Academic Department of Military Surgery and Trauma, Research and Clinical Innovation, Birmingham
| | - Robert Lendrum
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- London's Air Ambulance
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
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Jansen JO, Hudson J, Cochran C, MacLennan G, Lendrum R, Sadek S, Gillies K, Cotton S, Kennedy C, Boyers D, Ferry G, Lawrie L, Nath M, Wileman S, Forrest M, Brohi K, Harris T, Lecky F, Moran C, Morrison JJ, Norrie J, Paterson A, Tai N, Welch N, Campbell MK. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA 2023; 330:1862-1871. [PMID: 37824132 PMCID: PMC10570916 DOI: 10.1001/jama.2023.20850] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/23/2023] [Indexed: 10/13/2023]
Abstract
Importance Bleeding is the most common cause of preventable death after trauma. Objective To determine the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) when used in the emergency department along with standard care vs standard care alone on mortality in trauma patients with exsanguinating hemorrhage. Design, Setting, and Participants Pragmatic, bayesian, randomized clinical trial conducted at 16 major trauma centers in the UK. Patients aged 16 years or older with exsanguinating hemorrhage were enrolled between October 2017 and March 2022 and followed up for 90 days. Intervention Patients were randomly assigned (1:1 allocation) to a strategy that included REBOA and standard care (n = 46) or standard care alone (n = 44). Main Outcomes and Measures The primary outcome was all-cause mortality at 90 days. Ten secondary outcomes included mortality at 6 months, while in the hospital, and within 24 hours, 6 hours, or 3 hours; the need for definitive hemorrhage control procedures; time to commencement of definitive hemorrhage control procedures; complications; length of stay; blood product use; and cause of death. Results Of the 90 patients (median age, 41 years [IQR, 31-59 years]; 62 [69%] were male; and the median Injury Severity Score was 41 [IQR, 29-50]) randomized, 89 were included in the primary outcome analysis because 1 patient in the standard care alone group declined to provide consent for continued participation and data collection 4 days after enrollment. At 90 days, 25 of 46 patients (54%) had experienced all-cause mortality in the REBOA and standard care group vs 18 of 43 patients (42%) in the standard care alone group (odds ratio [OR], 1.58 [95% credible interval, 0.72-3.52]; posterior probability of an OR >1 [indicating increased odds of death with REBOA], 86.9%). Among the 10 secondary outcomes, the ORs for mortality and the posterior probabilities of an OR greater than 1 for 6-month, in-hospital, and 24-, 6-, or 3-hour mortality were all increased in the REBOA and standard care group, and the ORs were increased with earlier mortality end points. There were more deaths due to bleeding in the REBOA and standard care group (8 of 25 patients [32%]) than in standard care alone group (3 of 18 patients [17%]), and most occurred within 24 hours. Conclusions and Relevance In trauma patients with exsanguinating hemorrhage, a strategy of REBOA and standard care in the emergency department does not reduce, and may increase, mortality compared with standard care alone. Trial Registration isrctn.org Identifier: ISRCTN16184981.
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Affiliation(s)
- Jan O. Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
- Center for Injury Science, University of Alabama at Birmingham
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Sam Sadek
- Royal London Hospital, London, England
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Gillian Ferry
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mintu Nath
- Medical Statistics Team, University of Aberdeen, Aberdeen, Scotland
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
| | - Karim Brohi
- Queen Mary University of London, London, England
| | - Tim Harris
- Barts Health NHS Trust, Royal London Hospital, St Bartholomew’s Hospital, London, England
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, England
| | - Chris Moran
- Nottingham University Hospital Trust, Nottingham, England
| | - Jonathan J. Morrison
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, Scotland
| | | | - Nigel Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, England
| | - Nick Welch
- Patient and public involvement representative in England
| | - Marion K. Campbell
- Health Services Research Unit, University of Aberdeen, Aberdeen, Scotland
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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25
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Bhogadi SK, Colosimo C, Hosseinpour H, Nelson A, Rose MI, Calvillo AR, Anand T, Ditillo M, Magnotti LJ, Joseph B. The undisclosed disclosures: The dollar-outcome relationship in resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2023; 95:726-730. [PMID: 37316993 DOI: 10.1097/ta.0000000000004080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Despite its rapid evolution, resuscitative endovascular balloon occlusion of the aorta (REBOA) remains a controversial intervention that continues to generate active research. Proper conflict of interest (COI) disclosure helps to ensure that research is conducted objectively, without bias. We aimed to identify the accuracy of COI disclosures in REBOA research. METHODS Literature search was performed using the keyword "REBOA" on PubMed. Studies on REBOA with at least one American author published between 2017 and 2022 were identified. The Centers for Medicare and Medicaid Services Open Payments database was used to extract information regarding payments to the authors from the industry. This was compared with the COI section reported in the manuscripts. Conflict of interest disclosure was defined as inaccurate if the authors failed to disclose any amount of money received from the industry. Descriptive statistics were performed. RESULTS We reviewed a total of 524 articles, of which 288 articles met the inclusion criteria. At least one author received payments in 57% (165) of the articles. Overall, 59 authors had a history of payment from the industry. Conflict of interest disclosure was inaccurate in 88% (145) of the articles where the authors received payment. CONCLUSION Conflict of interest reports are highly inaccurate in REBOA studies. There needs to be standardization of reporting of conflicts of interest to avoid potential bias. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Sai Krishna Bhogadi
- From the Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, College of Medicine, University of Arizona, Tucson, Arizona
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26
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Brede JR, Rehn M. The end of balloons? Our take on the UK-REBOA trial. Scand J Trauma Resusc Emerg Med 2023; 31:69. [PMID: 37908007 PMCID: PMC10619299 DOI: 10.1186/s13049-023-01142-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality. MAIN BODY In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study. CONCLUSION The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Prinsesse Kristinas Gate 3, 7006, Trondheim, Norway.
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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27
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Walters S, Cuthbert R, Ward J, Arshad H, Culpan P, Perkins Z, Tai N, Bates P. Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2971-2979. [PMID: 36922411 DOI: 10.1007/s00590-023-03516-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures. METHODS This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h. RESULTS Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta-REBOA, Interventional Radiology-IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036). Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS). CONCLUSION Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.
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Affiliation(s)
- Samuel Walters
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK.
| | - Rory Cuthbert
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Jonathan Ward
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Homa Arshad
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Paul Culpan
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Zane Perkins
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Nigel Tai
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Peter Bates
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
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28
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Guan Y, Chen P, Zhou H, Hong J, Yan Y, Wang Y. Common complications and prevention strategies for resuscitative endovascular balloon occlusion of the aorta: A narrative review. Medicine (Baltimore) 2023; 102:e34748. [PMID: 37653766 PMCID: PMC10470747 DOI: 10.1097/md.0000000000034748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered a key measure of treatment due to its use in stabilizing patients in shock through temporary inflow occlusion for noncompressible torso hemorrhage as well as its supportive role in myocardial and cerebral perfusion. Although its clinical efficacy in trauma has been widely recognized, concerns over related complications, such as vascular access and ischemia-reperfusion, are on the rise. This paper aims to investigate complications associated with REBOA and identify current and emerging prevention or mitigation strategies through a literature review based on human or animal data. Common complications associated with REBOA include ischemia/reperfusion injuries, vessel injuries, venous thromboembolism, and worsening proximal bleeding. REBOA treatment outcomes can be improved substantially with the help of precise selection of patients, better visualization tools, improvement in balloon catheters, blockage strategies, and medication intervention measures. Better understanding of REBOA-related complications and further research on the strategies to mitigate the occurrence of such complications will be of vital importance for the optimization of the clinical outcomes in patients.
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Affiliation(s)
- Yi Guan
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Pinghao Chen
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Hao Zhou
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Jiaxiang Hong
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Yanggang Yan
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Yong Wang
- Department of Emergency, Hainan Clinical Research Center for Acute and Critical Diseases, the Second Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Interventional Radiology and Vascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Haikou, China
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Uchida K, Deguchi R, Himura H, Yoshitake H, Kawamoto A, Saoyama Y, Miyashita M, Nishimura T, Yamamoto H, Mizobata Y. Combined computed tomography and C-arm resuscitation room system (CTCARM) is associated with decreased time to definitive hemostasis and reduces preperitoneal pelvic packing maneuvers in severe pelvic trauma. Trauma Surg Acute Care Open 2023; 8:e001153. [PMID: 37583617 PMCID: PMC10423830 DOI: 10.1136/tsaco-2023-001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/23/2023] [Indexed: 08/17/2023] Open
Abstract
Objectives Severe pelvic fracture concomitant with massive bleeding is potentially lethal, and intervention for hemorrhage control still depends on institutional supplies. With the recent installation of a CT and C-arm combined resuscitation room system (CTCARM) for treatment of trauma patients in our institution, the strategic process and options for hemorrhage control after pelvic fracture have changed. We retrospectively reviewed the procedures we performed and their outcomes. Methods The CTCARM was installed in our trauma resuscitation room in April 2020. Patients who were diagnosed as having pelvic fracture and underwent interventional radiology for hemorrhage control within 2.5 hours after arrival were compared before and after CTCARM installation. We reviewed the time process for hemorrhage control, treatment options performed, blood products used and their outcomes. Results Included in this study were 56 patients treated between 2016 and 2022, of whom 36 patients were treated before (original group) and 20 patients after CTCARM installation (CTCARM group). Patient characteristics and vital signs at admission were not statistically different. Preperitoneal pelvic packing was performed significantly more frequently in the original group (p<0.01), whereas resuscitative endovascular balloon occlusion of the aorta use was much more frequent in the CTCARM group (p=0.02). Although the times from admission to first angiography (p=0.014) and to complete hemostasis (p=0.02) were significantly shorter in the CTCARM group, mortality was not statistically different. Four preventable trauma deaths occurred in the original group, but there were none in the CTCARM group. Six unexpected survivors were observed in the original group and four in the CTCARM group. Conclusions Although the CTCARM had no direct effects on patient mortality for now, it has allowed us to accelerate the treatment time process, shorten preperitoneal pelvic packing procedural time, and potentially avoid subsequent preventable trauma deaths. Level of evidence Level IV.
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Affiliation(s)
- Kenichiro Uchida
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ryo Deguchi
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hoshi Himura
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroyuki Yoshitake
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Kawamoto
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yuki Saoyama
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Masahiro Miyashita
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Tetsuro Nishimura
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiromasa Yamamoto
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasumitsu Mizobata
- Department of Traumatology and Critical Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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30
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Cambronero GE, Sanin GD, Patel NTP, Ganapathy AS, Lane MR, Patterson JW, Niebler JAP, Johnson MA, Rahbar E, Jordan JE, Neff LP, Williams TK. Automated partial resuscitative endovascular balloon occlusion of the aorta reduces blood loss and hypotension in a highly lethal porcine liver injury model. J Trauma Acute Care Surg 2023; 95:205-212. [PMID: 37038255 DOI: 10.1097/ta.0000000000003962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND Partial and intermittent resuscitative endovascular balloon occlusion of the aorta (pREBOA and iREBOA, respectively) are lifesaving techniques designed to extend therapeutic duration, mitigate ischemia, and bridge patients to definitive hemorrhage control. We hypothesized that automated pREBOA balloon titration compared with automated iREBOA would reduce blood loss and hypotensive episodes over a 90-minute intervention phase compared with iREBOA in an uncontrolled liver hemorrhage swine model. METHODS Twenty-four pigs underwent an uncontrolled hemorrhage by liver transection and were randomized to automated pREBOA (n = 8), iREBOA (n = 8), or control (n = 8). Once hemorrhagic shock criteria were met, controls had the REBOA catheter removed and received transfusions only for hypotension. The REBOA groups received 90 minutes of either iREBOA or pREBOA therapy. Surgical hemostasis was obtained, hemorrhage volume was quantified, and animals were transfused to euvolemia and then underwent 1.5 hours of automated critical care. RESULTS The control group had significantly higher mortality rate (5 of 8) compared with no deaths in both REBOA groups, demonstrating that the liver injury is highly lethal ( p = 0.03). During the intervention phase, animals in the iREBOA group spent a greater proportion of time in hypotension than the pREBOA group (20.7% [16.2-24.8%] vs. 0.76% [0.43-1.14%]; p < 0.001). The iREBOA group required significantly more transfusions than pREBOA (21.0 [20.0-24.9] mL/kg vs. 12.1 [9.5-13.9] mL/kg; p = 0.01). At surgical hemostasis, iREBOA had significantly higher hemorrhage volumes compared with pREBOA (39.2 [29.7-44.95] mL/kg vs. 24.7 [21.6-30.8] mL/kg; p = 0.04). CONCLUSION Partial REBOA animals spent significantly less time at hypotension and had decreased transfusions and blood loss. Both pREBOA and iREBOA prevented immediate death compared with controls. Further refinement of automated pREBOA is necessary, and controller algorithms may serve as vital control inputs for automated transfusion. LEVEL OF EVIDENCE Therapeutic/Care Management; Level III.
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Affiliation(s)
- Gabriel E Cambronero
- From the Department of General Surgery (G.E.C., G.D.S., N.T.P.P., A.S.G., J.A.P.N., L.P.N.) and Department of Vascular and Endovascular Surgery (M.R.L., J.W.P., T.K.W.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina; Division of Emergency Medicine (M.A.J.), University of Utah School of Medicine, Salt Lake City, Utah; Department of Biomedical Engineering (E.R.), Wake Forest University School of Medicine; and Department of Cardiothoracic Surgery (J.E.J.), Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina
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31
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Schmitt J, Gurney J, Aries P, Danguy Des Deserts M. Advances in trauma care to save lives from traumatic injury: A narrative review. J Trauma Acute Care Surg 2023; 95:285-292. [PMID: 36941236 DOI: 10.1097/ta.0000000000003960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
ABSTRACT Recent advances on trauma management from the prehospital setting to in hospital care led to a better surviving severe trauma rate. Mortality from exsanguination remains the first preventable mortality. Damage-control resuscitation and surgery are evolving and thus some promising concepts are developing. Transfusion toolkit is brought on the prehospital scene while temporary bridge to hemostasis may be helpful. Panel transfusion products allow an individualized ratio assumed by fresh frozen or lyophilized plasma, fresh or cold-stored whole blood, fibrinogen, four-factor prothrombin complex concentrates. Growing interest is raising in whole blood transfusion, resuscitative endovascular balloon occlusion of the aorta use, hybrid emergency room, viscoelastic hemostatic assays to improve patient outcomes. Microcirculation, traumatic endotheliopathy, organ failures and secondary immunosuppression are point out since late deaths are increasing and may deserve specific treatment.As each trauma patient follows his own course over the following days after trauma, trauma management may be seen through successive, temporal, and individualized aims.
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Affiliation(s)
- Johan Schmitt
- From the Intensive Care Unit, Military Teaching Hospital Clermont Tonnerre (S.J., A.P., D.D.D.M.), Brest, France; US Army Institute of Surgical Research (G.J.), San Antonio, Texas; and Joint Trauma System, DoD Center of Excellence for Trauma (G.J.), San Antonio, Texas
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Gong SC, Park JE, Kang S, An S, Kim MJ, Kim K, Shin IS. Preperitoneal Pelvic Packing versus Angioembolization for Patients with Hemodynamically Unstable Pelvic Fractures with Pelvic Bleeding: A Single-Centered Retrospective Study. Healthcare (Basel) 2023; 11:1784. [PMID: 37372902 DOI: 10.3390/healthcare11121784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/24/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023] Open
Abstract
The aim of this study was to compare the outcomes of preperitoneal pelvic packing (PPP) and angioembolization (AE) for patients with equivocal vital signs after initial resuscitation. This single-centered retrospective study included information from the database of a regional trauma center from April 2014 to December 2022 for patients with pelvic fractures with a systolic blood pressure of 80-100 mmHg after initial fluid resuscitation. The patients' characteristics, outcomes, and details of AE after resuscitative endovascular balloon occlusion of the aorta (REBOA) placed in zone III were collected. The follow-up duration was from hospital admission to discharge. A total of 65 patients were enrolled in this study. Their mean age was 59.2 ± 18.1 years, and 40 were males. We divided the enrolled patients into PPP (n = 43) and AE (n = 22) groups. The median time from emergency department (ED) to procedure and the median duration of ED stay were significantly longer in the AE group than in the PPP group (p ≤ 0.001 for both). The median mechanical ventilation (MV) duration was significantly shorter (p = 0.046) in the AE group. The number of patients with complications, overall mortality, and mortality due to hemorrhage did not differ between the two groups. Three patients (13.6%) were successfully treated with AE after REBOA. AE may be beneficial for patients with hemodynamically unstable pelvic fractures who show equivocal vital signs after initial fluid resuscitation in terms of reducing the MV duration and incidence of infectious complications.
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Affiliation(s)
- Seong Chan Gong
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Ji Eun Park
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Sooyeon Kang
- Department of Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Sanghyun An
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Myoung Jun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - Kwangmin Kim
- Graduate School, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
| | - In Sik Shin
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea
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Harfouche MN, Feliciano DV, Kozar RA, DuBose JJ, Scalea TM. A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database. J Am Coll Surg 2023; 236:1208-1216. [PMID: 36847370 DOI: 10.1097/xcs.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.
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Affiliation(s)
- Melike N Harfouche
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - David V Feliciano
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Rosemary A Kozar
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Joseph J DuBose
- Dell Medical School, University of Texas at Austin, Austin, TX (DuBose)
| | - Thomas M Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
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Cralley AL, Moore EE, Sauaia A, Carani PH, Schaid TR, DeBot M, Fragoso M, Ghasabyan A, Hansen K, Cohen MJ, Silliman CC, Fox CJ. REBOA for the Treatment of Blast Polytrauma: Zone 3 Provides Cerebral Perfusion, Attenuates Organ Dysfunction and Reperfusion Coagulopathy Compared to Zone 1 in a Swine Model. J Trauma Acute Care Surg 2023; 94:718-724. [PMID: 36749658 PMCID: PMC10133017 DOI: 10.1097/ta.0000000000003894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a lifesaving therapy for hemorrhagic shock following pelvic/lower extremity injuries in military settings. However, Zone 1 aortic occlusion (AO; above the celiac artery), while providing brain/cardiac perfusion, may induce/worsen visceral ischemia and organ dysfunction. In contrast, AO Zone 3 (below the renal arteries) provides abdominal perfusion potentially minimizing ischemia/reperfusion injury. We hypothesized that, compared with AO Zone 1, AO Zone 3 provides neuro/cardioprotection while minimizing visceral ischemia and reperfusion coagulopathy after severe traumatic hemorrhage due to pelvic/lower extremity injuries. METHODS Fifty-kilogram male Yorkshire swine underwent a blast polytrauma injury followed by a resuscitation protocol with randomization to no AO (No AO, n = 6) or AO with REBOA at Zone 1 (AO Zone 1; n = 6) or Zone 3 (AO Zone 3; n = 4). Vital signs and intracranial pressure (ICP) were monitored for 240 minutes. Citrate native and tissue plasminogen activator challenge thrombelastography, prothrombin time, creatinine, lipase, total bilirubin, troponin, and enzyme-linked immunosorbent assays protein levels were measured at set intervals. RESULTS Both AO groups had significant increases in mean arterial pressure during aortic occlusion. All three groups had significant increases in ICP, but final ICP in the No AO group (26 ± 5.8 mm Hg) was significantly elevated compared with AO Zone 1 (17 ± 5.2 mm Hg) and AO Zone 3 (16 ± 4.2 mm Hg) ( p < 0.01). The final mean troponin in the No AO group (4.10 ± 5.67 ng/mL) was significantly higher than baseline (0.03 ± 0.02 ng/mL, p < 0.05), while the two AO groups had no significant changes ( p > 0.05). AO Zone 1 was the only group associated with hyperfibrinolysis ( p < 0.05) and significantly increased prothrombin time ( p < 0.05). Only AO Zone 1 group had significantly higher markers of organ damage. CONCLUSION Compared with AO Zone 1, AO Zone 3 provided similar neuro/cardioprotection but with less organ dysfunction and coagulopathy. This study suggests that Zone 3 REBOA may be preferable over Zone 1 for treating military relevant blast polytrauma with minimal intra-abdominal and chest trauma, but further clinical investigation is warranted.
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Affiliation(s)
- Alexis L Cralley
- From the Department of Surgery (A.L.C., E.E.M., A.S., T.R.S., M.D., M.F., A.G., M.J.C., C.C.S.), School of Medicine, University of Colorado; Ernest E Moore Shock Trauma Center at Denver Health (E.E.M.), Denver; Department of Health Systems, Management and Policy (A.S.), School of Public Health, University of Colorado Denver, Aurora, Colorado; Faculdade Israelita de Ciências da Saúde Albert Einstein (P.H.C.), Hospital Israelita Albert Einstein, São Paulo, Brazil; University of Colorado School of Medicine Proteomics Core Facility (K.H.) and Department of Pediatrics (C.C.S.), School of Medicine, University of Colorado Denver, Aurora; Vitalant Research Division (C.C.S.), Denver, Colorado; and Department of Vascular Surgery (C.J.F.), School of Medicine, University of Maryland, Baltimore, Maryland
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Balch JA, Loftus TJ, Efron PA, Mohr AM, Upchurch GR, Smith RS. Survival and neurologic outcomes following aortic occlusion for trauma and hemorrhagic shock in a hybrid operating room. World J Emerg Surg 2023; 18:21. [PMID: 36959585 PMCID: PMC10035182 DOI: 10.1186/s13017-023-00484-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 02/20/2023] [Indexed: 03/25/2023] Open
Abstract
BACKGROUND Outcomes following aortic occlusion for trauma and hemorrhagic shock are poor, leading some to question the clinical utility of aortic occlusion in this setting. This study evaluates neurologically intact survival following resuscitative endovascular balloon occlusion of the aorta (REBOA) versus resuscitative thoracotomy at a center with a dedicated trauma hybrid operating room with angiographic capabilities. METHODS This retrospective cohort analysis compared patients who underwent zone 1 aortic occlusion via resuscitative thoracotomy (n = 13) versus REBOA (n = 13) for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock (systolic blood pressure less than 90 mmHg despite volume resuscitation) at a level 1 trauma center with a dedicated trauma hybrid operating room. The primary outcome was survival to hospital discharge. The secondary outcome was neurologic status at hospital discharge, assessed by Glasgow Coma Scale (GCS) scores. RESULTS Overall median age was 40 years, 27% had penetrating injuries, and 23% had pre-hospital closed-chest cardiopulmonary resuscitation. In both cohorts, median injury severity scores and head-abbreviated injury scores were 26 and 2, respectively. The resuscitative thoracotomy cohort had lower systolic blood pressure on arrival (0 [0-75] vs. 76 [65-99], p = 0.009). Hemorrhage control (systolic blood pressure 100 mmHg without ongoing vasopressor or transfusion requirements) was obtained in 77% of all REBOA cases and 8% of all resuscitative thoracotomy cases (p = 0.001). Survival to hospital discharge was greater in the REBOA cohort (54% vs. 8%, p = 0.030), as was discharge with GCS 15 (46% vs. 0%, p = 0.015). CONCLUSIONS Among patients undergoing aortic occlusion for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock at a center with a dedicated, trauma hybrid operating room, nearly half of all patients managed with REBOA had neurologically intact survival. The high death rate in resuscitative thoracotomy and differences in patient cohorts limit direct comparison.
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Affiliation(s)
- Jeremy A Balch
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Tyler J Loftus
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Philip A Efron
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - Gilbert R Upchurch
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA
| | - R Stephen Smith
- Department of Surgery, University of Florida Health, PO Box 100108, Gainesville, FL, 32610-0108, USA.
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Wu YT, Lewis MR, Arase M, Demetriades D. Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated with Increased Risk of Extremity Compartment Syndrome. World J Surg 2023; 47:796-802. [PMID: 36371514 DOI: 10.1007/s00268-022-06832-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/28/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a temporizing procedure to control intra-abdominal or pelvic bleeding. Theoretically, occlusion of the aorta and the resulting ischemia-reperfusion of the lower extremities may increase the risk of extremity compartment syndrome (CS). To date, no study has addressed systematically the incidence and risk factors of CS following REBOA intervention. The purpose of this study was to address this knowledge gap. METHODS Adult trauma patients from the American College of Surgeons Trauma Quality Improvement Program (ACS-TQIP) database (2016-2019) were included. Patients who received REBOA within 4 h of admission were compared to patients without REBOA after propensity score matching for demographics, vital signs on admission, comorbidities, injury severity of different body regions, pelvic and lower extremity fractures, vascular trauma to the lower extremities, fixation for fractures, angioembolization (AE) for pelvis, preperitoneal pelvic packing (PPP), laparotomy, and venous thromboembolism (VTE) prophylaxis. The primary outcomes were rates of lower extremity CS and fasciotomy and acute kidney injury (AKI). Secondary outcomes included mortality. RESULTS There were 534 patients who received REBOA matched with 1043 patients without REBOA. Overall, patients in the REBOA group had significantly higher rates of CS than no REBOA patients [5.4% vs 1.1%, p < 0.001, OR: 5.39]. The risk of CS remained significantly higher in the subgroups of patients with or without pelvic or lower extremity fractures, as well as in the subgroup of patients with associated extremity vascular injury [11.2% vs 1.5%, p < 0.001, OR: 8.12].The fasciotomy and AKI rates were significantly higher in the REBOA group (5.8% vs 1.2%, p < 0.001 and 12.9% vs 7.4%, p< 0.001 respectively). CONCLUSION REBOA use is associated with a higher risk of lower extremity CS, fasciotomy and AKI, especially in patients with associated lower extremity vascular injuries. These complications should be taken into account when considering REBOA use, and close observation for this complication should always be part of the routine monitoring.
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Affiliation(s)
- Yu-Tung Wu
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Meghan R Lewis
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA
| | - Miharu Arase
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA
| | - Demetrios Demetriades
- Division of Trauma, Emergency Surgery, Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Los Angeles, CA, 90033, USA.
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Kenawy DM, Elsisy M, Abdel-Rasoul M, Koppert TL, Garcia-Neuer MI, Chun Y, Tillman BW. A dumbbell rescue stent graft facilitates clamp-free repair of aortic injury in a porcine model. JVS Vasc Sci 2023; 4:100100. [PMID: 37021144 PMCID: PMC10068254 DOI: 10.1016/j.jvssci.2023.100100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023] Open
Abstract
Objective Noncompressible torso hemorrhage is a high-mortality injury. We previously reported improved outcomes with a retrievable rescue stent graft to temporize aortic hemorrhage in a porcine model while maintaining distal perfusion. A limitation was that the original cylindrical stent graft design prohibited simultaneous vascular repair, given the concern for suture ensnarement of the temporary stent. We hypothesized that a modified, dumbbell-shaped design would preserve distal perfusion and also offer a bloodless plane in the midsection, facilitating repair with the stent graft in place and improve the postrepair hemodynamics. Methods In an Institutional Animal Care and Use Committee-approved terminal porcine model, a custom retrievable dumbbell-shaped rescue stent graft (dRS) was fashioned from laser-cut nitinol and polytetrafluoroethylene covering and compared with aortic cross-clamping. Under anesthesia, the descending thoracic aorta was injured and then repaired with cross-clamping (n = 6) or dRS (n = 6). Angiography was performed in both groups. Operations were divided into phases: (1) baseline, (2) thoracic injury with either cross-clamp or dRS deployed, and (3) recovery, after which the clamp or dRS were removed. Target blood loss was 22% to simulate class II or III hemorrhagic shock. Shed blood was recovered with a Cell Saver and reinfused for resuscitation. Renal artery flow rates were recorded at baseline and during the repair phase and reported as a percentage of cardiac output. Phenylephrine pressor requirements were recorded. Results In contrast with cross-clamped animals, dRS animals demonstrated both operative hemostasis and preserved flow beyond the dRS angiographically. Recovery phase mean arterial pressure, cardiac output, and right ventricular end-diastolic volume were significantly higher in dRS animals (P = .033, P = .015, and P = .012, respectively). Whereas distal femoral blood pressures were absent during cross-clamping, among the dRS animals, the carotid and femoral MAPs were not significantly different during the injury phase (P = .504). Cross-clamped animals demonstrated nearly absent renal artery flow, in contrast with dRS animals, which exhibited preserved perfusion (P<.0001). Femoral oxygen levels (partial pressure of oxygen) among a subset of animals further confirmed greater distal oxygenation during dRS deployment compared with cross-clamping (P = .006). After aortic repair and clamp or stent removal, cross-clamped animals demonstrated more significant hypotension, as demonstrated by increased pressor requirements over stented animals (P = .035). Conclusions Compared with aortic cross-clamping, the dRS model demonstrated superior distal perfusion, while also facilitating simultaneous hemorrhage control and aortic repair. This study demonstrates a promising alternative to aortic cross-clamping to decrease distal ischemia and avoid the unfavorable hemodynamics that accompany clamp reperfusion. Future studies will assess differences in ischemic injury and physiological outcomes. Clinical Relevance Noncompressible aortic hemorrhage remains a high-mortality injury, and current damage control options are limited by ischemic complications. We have previously reported a retrievable stent graft to allow rapid hemorrhage control, preserved distal perfusion, and removal at the primary repair. The prior cylindrical stent graft was limited by the inability to suture the aorta over the stent graft owing to risk of ensnarement. This large animal study explored a dumbbell retrievable stent with a bloodless plane to allow suture placement with the stent in place. This approach improved distal perfusion and hemodynamics over clamp repair and heralds the potential for aortic repair while avoiding complications.
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Affiliation(s)
- Dahlia M. Kenawy
- Division of Vascular Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Moataz Elsisy
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Tanner L. Koppert
- Division of Vascular Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Youngjae Chun
- Swanson School of Engineering, University of Pittsburgh, Pittsburgh, PA
| | - Bryan W. Tillman
- Division of Vascular Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Chien CY, Lewis MR, Dilday J, Biswas S, Luo Y, Demetriades D. Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study. Am J Surg 2023; 225:414-419. [PMID: 36253317 DOI: 10.1016/j.amjsurg.2022.09.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.
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Affiliation(s)
- Chih-Ying Chien
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Joshua Dilday
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Subarna Biswas
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Yong Luo
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Trauma Center & Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States.
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Qasim Z. Resuscitative Endovascular Balloon Occlusion of the Aorta. Emerg Med Clin North Am 2023; 41:71-88. [DOI: 10.1016/j.emc.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Carlsen MIS, Aalberg NK, Sandø AD, Skrede S, Gisvold SE, Uleberg O. The use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a pregnant woman with a ruptured splenic aneurysm and haemorrhagic shock: A case report. Acta Anaesthesiol Scand 2023; 67:230-232. [PMID: 36357321 PMCID: PMC10099586 DOI: 10.1111/aas.14172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022]
Affiliation(s)
| | | | | | - Solveig Skrede
- Department Gynaecology and Obstetrics, St. Olav's University Hospital, Trondheim, Norway
| | - Sven Erik Gisvold
- Department of Anaesthesia and Intensive Care, St. Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Oddvar Uleberg
- Department of Emergency Medicine and Pre-hospital services, St. Olav's University Hospital, Trondheim, Norway
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Cralley AL, Vigneshwar N, Moore EE, Dubose J, Brenner ML, Sauaia A. Zone 1 Endovascular Balloon Occlusion of the Aorta vs Resuscitative Thoracotomy for Patient Resuscitation After Severe Hemorrhagic Shock. JAMA Surg 2023; 158:140-150. [PMID: 36542395 PMCID: PMC9856952 DOI: 10.1001/jamasurg.2022.6393] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/27/2022] [Indexed: 12/24/2022]
Abstract
Importance Aortic occlusion (AO) is a lifesaving therapy for the treatment of severe traumatic hemorrhagic shock; however, there remains controversy whether AO should be accomplished via resuscitative thoracotomy (RT) or via endovascular balloon occlusion of the aorta (REBOA) in zone 1. Objective To compare outcomes of AO via RT vs REBOA zone 1. Design, Setting, and Participants This was a comparative effectiveness research study using a multicenter registry of postinjury AO from October 2013 to September 2021. AO via REBOA zone 1 (above celiac artery) was compared with RT performed in the emergency department of facilities experienced in both procedures and documented in the prospective multicenter Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry. Propensity score matching (PSM) with exact institution matching was used, in addition to subgroup multivariate analysis to control for confounders. The study setting included the ED, where AO via RT or REBOA was performed, and participants were adult trauma patients 16 years or older. Exposures AO via REBOA zone 1 vs RT. Main Outcomes and Measures The primary outcome was survival. Secondary outcomes were ventilation-free days (VFDs), intensive care unit (ICU)-free days, discharge Glasgow Coma Scale score, and Glasgow Outcome Score (GOS). Results A total of 991 patients (median [IQR] age, 32 [25-48] years; 808 male individuals [81.9%]) with a median (IQR) Injury Severity Score of 29 (18-50) were included. Of the total participants, 306 (30.9%) had AO via REBOA zone 1, and 685 (69.1%) had AO via RT. PSM selected 112 comparable patients (56 pairs). REBOA zone 1 was associated with a statistically significant lower mortality compared with RT (78.6% [44] vs 92.9% [52]; P = .03). There were no significant differences in VFD greater than 0 (REBOA, 18.5% [10] vs RT, 7.1% [4]; P = .07), ICU-free days greater than 0 (REBOA, 18.2% [10] vs RT, 7.1% [4]; P = .08), or discharge GOS of 5 or more (REBOA, 7.5% [4] vs RT, 3.6% [2]; P = .38). Multivariate analysis confirmed the survival benefit of REBOA zone 1 after adjustment for significant confounders (relative risk [RR], 1.25; 95% CI, 1.15-1.36). In all subgroup analyses (cardiopulmonary resuscitation on arrival, traumatic brain injury, chest injury, pelvic injury, blunt/penetrating mechanism, systolic blood pressure ≤60 mm Hg on AO initiation), REBOA zone 1 offered an either similar or superior survival. Conclusions and Relevance Results of this comparative effectiveness research suggest that REBOA zone 1 provided better or similar survival than RT for patients requiring AO postinjury. These findings provide the ethically necessary equipoise between these therapeutic approaches to allow the planning of a randomized controlled trial to establish the safety and effectiveness of REBOA zone 1 for AO in trauma resuscitation.
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Affiliation(s)
- Alexis L. Cralley
- Department of Surgery, School of Medicine, University of Colorado, Denver
| | - Navin Vigneshwar
- Department of Surgery, School of Medicine, University of Colorado, Denver
| | - Ernest E. Moore
- Department of Surgery, School of Medicine, University of Colorado, Denver
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, Colorado
| | - Joseph Dubose
- Department of Surgery, School of Medicine, University of Texas, Austin
| | - Megan L. Brenner
- Department of Surgery, University of California, Riverside School of Medicine, Moreno Valley
| | - Angela Sauaia
- Department of Surgery, School of Medicine, University of Colorado, Denver
- Department of Health Systems, Management and Policy, School of Public Health, University of Colorado Denver, Aurora
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Balch JA, Loftus TJ, Efron PA, Mohr AM, Upchurch GR, Smith RS. Survival and neurologic outcomes following aortic occlusion for trauma and hemorrhagic shock in a hybrid operating room. RESEARCH SQUARE 2023:rs.3.rs-2459030. [PMID: 36711502 PMCID: PMC9882656 DOI: 10.21203/rs.3.rs-2459030/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Outcomes following aortic occlusion for trauma and hemorrhagic shock are poor, leading some to question the clinical utility of aortic occlusion in this setting. This study evaluates neurologically intact survival following resuscitative endovascular balloon occlusion of the aorta (REBOA) vs. resuscitative thoracotomy at a center with a dedicated trauma hybrid operating room with angiographic capabilities. Methods: This retrospective cohort analysis compared patients who underwent zone 1 aortic occlusion via resuscitative thoracotomy (n=13) vs. REBOA (n=13) for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock (systolic blood pressure less than 90 mmHg despite volume resuscitation) at a level 1 trauma center with a dedicated, trauma hybrid operating room. The primary outcome was survival to hospital discharge. The secondary outcome was neurologic status at hospital discharge, assessed by Glasgow Coma Scale (GCS) scores. Results: Overall median age was 40 years, 27% had penetrating injuries, and 23% had pre-hospital closed-chest cardiopulmonary resuscitation. In both cohorts, median Injury Severity Scores and head Abbreviated Injury Scores were 26 and 2, respectively. The resuscitative thoracotomy cohort had lower systolic blood pressure on arrival (0 [0-75] vs. 76 [65-99], p=0.009). Hemorrhage control (systolic blood pressure 100 mmHg without ongoing vasopressor or transfusion requirements) was obtained in 77% of all REBOA cases and 8% of all resuscitative thoracotomy cases (p=0.001). Survival to hospital discharge was greater in the REBOA cohort (54% vs. 8%, p=0.030), as was discharge with GCS 15 (46% vs. 0%, p=0.015). Conclusions: Among patients undergoing aortic occlusion for blunt or non-thoracic, penetrating trauma and refractory hemorrhagic shock at a center with a dedicated, trauma hybrid operating room, nearly half of all patients managed with REBOA had neurologically intact survival. The high death rate in resuscitative thoracotomy and differences in patient cohorts limit direct comparison.
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Partial vs Full Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a Swine Model of Raised Intracranial Pressure and Hemorrhagic Shock. J Am Coll Surg 2023; 236:241-252. [PMID: 36519920 DOI: 10.1097/xcs.0000000000000403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Partial resuscitative endovascular balloon occlusion of the aorta (pREBOA) is a potential method to mitigate the ischemia observed in full REBOA (fREBOA). However, the effect of pREBOA on cerebral perfusion in the setting of raised intracranial pressure (rICP) is unknown. The aim was to evaluate the effects of no REBOA (nREBOA) vs pREBOA vs fREBOA on cerebral perfusion in a swine model of rICP and hemorrhagic shock. STUDY DESIGN Anesthetized swine (n = 18) underwent instrumentation. Controlled hemorrhage was performed over 30 minutes. rICP was achieved using an intracranial Fogarty catheter inflated to achieve an ICP of 20 mmHg. Animals underwent intervention for 30 minutes, followed by resuscitation. The primary outcome was cerebral perfusion measured by ICP (millimeters of mercury), cerebral perfusion pressure (CPP; millimeters of mercury), and cerebral blood flow (CBF; milliliters per minute per 100 g) derived from CT perfusion. The secondary outcomes included hemodynamics and lactate (millimoles per liter). RESULTS The peak ICP of pREBOA animals (22.7 ± 2.5) was significantly lower than nREBOA and fREBOA. pREBOA CPP was significantly higher compared with nREBOA and fREBOA during resuscitation. The pREBOA CBF was greater during intervention and resuscitation compared with nREBOA (p < 0.001). Systolic blood pressure was similar between pREBOA and fREBOA, and coronary perfusion was significantly greater in pREBOA. fREBOA had significantly higher lactate during the intervention (9.3 ± 1.3) and resuscitation (8.9 ± 3.5) compared with nREBOA and pREBOA. CONCLUSION pREBOA produced greater cerebral perfusion, as demonstrated by more favorable CPP, CBF, and ICP values. fREBOA was associated with metabolic derangement and diminished pressure during resuscitation. pREBOA is superior to fREBOA in a swine model and should be considered over fREBOA for aortic occlusion.
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Ko HJ, Koo HF, Al-Saadi N, Froghi S. A comparison of mortality and indicators of treatment success of resuscitative endovascular balloon occlusion of aorta (REBOA): a systematic review and meta-analysis. Indian J Thorac Cardiovasc Surg 2023; 39:27-36. [PMID: 36590045 PMCID: PMC9794671 DOI: 10.1007/s12055-022-01413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022] Open
Abstract
Background Emergency resuscitative thoracotomy (RT) is a recognised method of controlling non-compressible torso haemorrhage (NCTH) often in adjunct to emergency surgery. Recently, there is much debate regarding resuscitative endovascular balloon occlusion of aorta (REBOA) on its role in civilian trauma cases in controlling NCTH. This study aims to provide an updated review on in-hospital mortality rates in patients who underwent REBOA versus RT and standard care without REBOA (non-REBOA) and to identify the potential indicators of REBOA survival. Methods Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to perform the study. All adult trauma cases were included, while pre-hospital, military and non-English studies were excluded. A literature search was done on studies from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. A significance level of p < 0.05 was used. Results Twenty-five studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01, 0.12-0.26). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62, 0.46-3.53). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (- 40.57 min, p < 0.01) and injury severity score (- 8.50, p < 0.01). Conclusions REBOA has a potential for wider application in civilian settings, with our study demonstrating lower in-hospital mortality compared to RT. Prospective multi-centre studies are needed for further evaluation of the indications and feasibility of REBOA.Level of Evidence + Study Type: Level IV. Systematic review with meta-analysis. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-022-01413-3.
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Affiliation(s)
- Ho Juen Ko
- University College London, London, UK
- Department of HPB & Liver Transplantation, Division of Surgery & Interventional Sciences, Royal Free Hospital, Pond Street, Hampstead, NW2 2QG London UK
| | | | - Nina Al-Saadi
- Vascular Surgery Glenfield Hospital UHL NHS Trust, Leicester, UK
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 334] [Impact Index Per Article: 167.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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46
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 95] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Polcz JE, Ronaldi AE, Madurska M, Bedocs P, Leung LY, Burmeister DM, White PW, Rasmussen TE, White JM. Next-Generation REBOA (Resuscitative Endovascular Balloon Occlusion of the Aorta) Device Precisely Achieves Targeted Regional Optimization in a Porcine Model of Hemorrhagic Shock. J Surg Res 2022; 280:1-9. [PMID: 35939866 DOI: 10.1016/j.jss.2022.06.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 05/13/2022] [Accepted: 06/04/2022] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Limitations such as time-dependent distal ischemia have slowed the adoption of resuscitative endovascular balloon occlusion of the aorta (REBOA) for noncompressible hemorrhage. Next-generation REBOA technologies may allow for controlled partial flow, known as targeted regional optimization, to reduce distal ischemia. We aimed to characterize the efficacy of one such catheter in a porcine model of lethal hemorrhagic shock. METHODS Noncompressible hemorrhage from an iliac injury was induced in anesthetized swine (Sus scrofa) (70-90 kg), targeting 30% total blood volume. Animals were then randomized to partial aortic occlusion (PO) with targeted distal mean arterial pressure (MAP) of 35-40 mm of mercury (mm Hg) and complete aortic occlusion (CO) (n = 8 per group) for 90 min. All groups were then resuscitated during a two-h critical care (CC) phase, with flow rate and MAP recorded continuously at the distal infrarenal aorta and proximal carotid artery, and analyzed with two-way repeated measures analysis of variance with S-N-K post-hoc test. RESULTS During aortic occlusion, MAP distal to the balloon was consistently maintained at 35.8 ± 0.3 mm Hg in the PO group compared to 27.1 ± 0.3 mm Hg in the CO group (P < 0.05), which also corresponded to higher flow rates (202.9 ± 4.8 mL/min PO versus 25.9 ± 0.8 mL/min CO; P < 0.05). MAP proximal to the balloon was significantly higher with CO versus PO (109.2 ± 2.3 mm Hg versus 85.2 ± 2.3 mm Hg; P < 0.05). During the CC phase, distal aortic flow and MAP were not significantly different between groups. However, creatinine returned to baseline levels by the end of the study in the PO group, but not the CO group. One animal died in the CO group, whereas none died in the PO group. CONCLUSIONS This is the first examination of the next-generation pREBOA-PRO in a porcine model of lethal hemorrhagic shock. We show technical feasibility of this technique to precisely achieve targeted regional optimization without device failure or complication. The ability to titrate balloon inflation and thus distal flow/pressure may extend the therapeutic window of REBOA by mitigating distal ischemia.
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Affiliation(s)
- Jeanette E Polcz
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Alley E Ronaldi
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Marta Madurska
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland; R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Peter Bedocs
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Lai Yee Leung
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland; Henry M. Jackson Foundation, Bethesda, Maryland
| | - David M Burmeister
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Paul W White
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Todd E Rasmussen
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Joseph M White
- Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland.
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Wu YT, Nichols C, Chien CY, Lewis MR, Demetriades D. REBOA in trauma and the risk of venous thromboembolic complications: A matched-cohort study. Am J Surg 2022; 225:1091-1095. [DOI: 10.1016/j.amjsurg.2022.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
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Patterson JT, Wier J, Gary JL. Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury. J Bone Joint Surg Am 2022; 104:1821-1829. [PMID: 35939780 DOI: 10.2106/jbjs.22.00252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury. METHODS Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay. RESULTS In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching. CONCLUSIONS PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Julian Wier
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
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Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
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