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Brauer SK, Musy AA, Schneider S, Trottmann FN, Kaderli N, Vetter C, Surbek D, Schindewolf M, Gerber AL, Stotz M, Hautz W, Zdanowicz JA. Using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a Rescue Strategy in Severe Postpartum Hemorrhage: A Case Report. Diagnostics (Basel) 2024; 14:1980. [PMID: 39272763 PMCID: PMC11394129 DOI: 10.3390/diagnostics14171980] [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: 06/29/2024] [Revised: 09/03/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024] Open
Abstract
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Routine treatment of PPH includes uterotonics, tranexamic acid, curettage, uterine (balloon) tamponade, compression sutures, uterine artery ligation, and, if available, transcatheter arterial embolization (TAE). In cases of severe PPH refractory to standard medical and surgical management, hysterectomy is usually the ultima ratio, and is equally associated with a higher rate of complications. In addition, this sudden loss of fertility, especially in young women, can be devastating. Here, we report a case of a 29-year-old woman who suffered from severe PPH with a blood loss > 1500 mL and hemodynamic instability after delivery of her first baby at a smaller hospital. She was consequently successfully treated with resuscitative endovascular balloon occlusion of the aorta (REBOA) by first placing a balloon catheter into the infra-renal aorta and subsequent TAE after failure of all other available treatment options prior to hysterectomy. TAE has been suggested in PPH treatment to avoid hysterectomies and thus to preserve patients' reproductive function. If hemodynamic stabilization cannot be achieved with mass transfusion, REBOA seems to be an effective rescue strategy with which to achieve hemodynamic stabilization and gain additional time for embolization. Although REBOA is already recommended in several PPH guidelines, this approach seems relatively unknown in German-speaking countries.
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Affiliation(s)
- Sophie-Kristin Brauer
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Alexandre Athanasios Musy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Sophie Schneider
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Fabienne Nicole Trottmann
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Nina Kaderli
- Department of Obstetrics, Spital Emmental, 3400 Burgdorf, Switzerland
| | - Christian Vetter
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Marc Schindewolf
- Department of Angiology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Anna Lea Gerber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Manuela Stotz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Jarmila A Zdanowicz
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Li X, Xie N, Zhou T, Yang B. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Field Setting: A Case Report From China. J Trauma Nurs 2024; 31:272-277. [PMID: 39250556 DOI: 10.1097/jtn.0000000000000803] [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: 09/11/2024]
Abstract
BACKGROUND The widespread use of agricultural machinery in China has increased the incidence of agricultural machinery-related injuries, posing challenges to on-site medical rescue. This study explores resuscitative endovascular balloon occlusion of the aorta (REBOA) as a life-saving intervention for a patient with severe trauma from agricultural machinery. CASEPRESENTATION This study reviews the emergency medical response for a 70-year-old male who suffered machinery entanglement injuries in an agricultural field in western China. The intervention involved a tiered multidisciplinary medical response, including the implementation of REBOA. CONCLUSION This case demonstrates the successful use of REBOA in the prehospital setting in China. While prehospital REBOA use is rare, it is increasingly reported in both military and civilian contexts in austere environments in different countries. Further research is required to validate the feasibility and efficacy of REBOA as a prehospital resuscitation strategy.
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Affiliation(s)
- Xixi Li
- Author Affiliations: Department of Nursing, Suining Central Hospital, Suining, Sichuan Province, China (Li, Xie, and Zhou); and Emergency Center, Suining Central Hospital, Suining, Sichuan Province, China (Yang)
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Jansen JO, Hudson J, Kennedy C, Cochran C, MacLennan G, Gillies K, Lendrum R, Sadek S, Boyers D, Ferry G, Lawrie L, Nath M, Cotton S, Wileman S, Forrest M, Brohi K, Harris T, Lecky F, Moran C, Morrison JJ, Norrie J, Paterson A, Tai N, Welch N, Campbell MK. The UK resuscitative endovascular balloon occlusion of the aorta in trauma patients with life-threatening torso haemorrhage: the (UK-REBOA) multicentre RCT. Health Technol Assess 2024; 28:1-122. [PMID: 39259521 DOI: 10.3310/ltyv4082] [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: 09/13/2024] Open
Abstract
Background The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis. Objective To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department. Design Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone. Setting United Kingdom Major Trauma Centres. Participants Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta. Interventions Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta. Main outcome measures Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon. Data sources Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data). Results Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%). Limitations The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates. Conclusions This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful. Future work The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required. Trial registration This trial is registered as ISRCTN16184981. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
- Division of Trauma and Acute Care Surgery, Department of Surgery, The University of Alabama at Birmingham, Birmingham, USA
| | - Jemma Hudson
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Charlotte Kennedy
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | | | | | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Gillian Ferry
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Louisa Lawrie
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mintu Nath
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Seonaidh Cotton
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Samantha Wileman
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Mark Forrest
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Karim Brohi
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | | | | | | | | | - Nick Welch
- Patient and Public Involvement Representative, London, UK
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Deicke K, Ajouri J, Lorbeer S, Feisel-Schwickardi G, Kranke P, Dimpfl M, Sönmez C, Dimpfl T, Muellenbach RM. [Resuscitative endovascular balloon occlusion of the aorta (REBOA) for cesarean section in two patients with placenta accreta spectrum disorder]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01436-y. [PMID: 39093362 DOI: 10.1007/s00101-024-01436-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/12/2024] [Accepted: 06/23/2024] [Indexed: 08/04/2024]
Affiliation(s)
- K Deicke
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, ECMO-Zentrum, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland
| | - J Ajouri
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, ECMO-Zentrum, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland
| | - S Lorbeer
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland
| | - G Feisel-Schwickardi
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland
| | - P Kranke
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland
| | - M Dimpfl
- Frauenklinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - C Sönmez
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland
| | - Th Dimpfl
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland
| | - R M Muellenbach
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, ECMO-Zentrum, Klinikum Kassel, Mönchebergstr. 41-43, 34125, Kassel, Deutschland.
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Martínez Hernández A, Chorro R, Climent A, Lazaro-Paulina FG, Martínez García V. Has the balloon really burst? Analysis of "the UK-REBOA randomized clinical trial". Am J Surg 2024; 234:62-67. [PMID: 38670836 DOI: 10.1016/j.amjsurg.2024.04.016] [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: 02/19/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Uncontrolled hemorrhagic shock is a leading cause of early death after injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents a paradigm shift in achieving hemodynamic stability and its implementation still remain controversial in different settings. The recently published UK-REBOA Randomized Clinical Trial aimed to determine the effectiveness of REBOA in patients with hemorrhagic shock, concluding its increased mortality compared with standard care alone. METHODS An adjustment of the statistical analysis was performed and a comprehensive analysis was proposed to address the study's limitations and demonstrate that these conclusions cannot be considered as benchmarks. RESULTS Primary and secondary outcomes were analyzed using Bayesian logistic regression and generalized linear models suitable for the outcome distribution. No statistically significant differences were observed between the two groups for the primary outcome (p-value 0.3341) nor in most of the secondary outcomes. The results of the principal stratum analyses (to account for intercurrent events) also did not show significant differences after the statistical analysis tests. CONCLUSION It cannot be stated that REBOA increases mortality compared with standard care alone in trauma patients with exsanguinating hemorrhage. Further studies and adequate simulation training programs in REBOA are critical to its successful implementation within a trauma system and to identify the optimum settings and patients.
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Affiliation(s)
- Andreu Martínez Hernández
- Department of General and Visceral Surgery, General University Hospital, Castellon, Spain; Department of Medicine, Jaume I University, Castellon, Spain; Prehospital Critical Care Training Group, Javea, Spain.
| | - Rosanna Chorro
- Emergency Medicine Department, Mayo Clinic, Rochester, MN, USA; Prehospital Critical Care Training Group, Javea, Spain
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Ahmed N, Kuo YH. Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) And Mortality in Hemorrhagic Shock Associated with Severe Pelvic Fracture: a National Data Analysis. BMC Emerg Med 2024; 24:104. [PMID: 38910235 PMCID: PMC11194952 DOI: 10.1186/s12873-024-01020-y] [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: 08/21/2023] [Accepted: 06/07/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND The purpose of the study was to evaluate the mortality of patients who received Resuscitative Endovascular Balloon Occlusion of The Aorta (REBOA) in severe pelvic fracture with hemorrhagic shock. METHODS The American College of Surgeon Trauma Quality Improvement Program (ACS-TQIP) database for the calendar years 2017-2019 was accessed for the study. The study included all patients aged 15 years and older who sustained severe pelvic fractures, defined as an injury with an abbreviated injury scale (AIS) score of ≥ 3, and who presented with the lowest systolic blood pressure (SBP) of < 90 mmHg. Patients with severe brain injury were excluded from the study. Propensity score matching was used to compare the patients who received REBOA with similar characteristics to patients who did not receive REBOA. RESULTS Out of 3,186 patients who qualified for the study, 35(1.1%) patients received REBOA for an ongoing hemorrhagic shock with severe pelvic fracture. The propensity matching created 35 pairs of patients. The pair-matched analysis showed no significant differences between the group who received REBOA and the group that did not receive REBOA regarding patients' demography, injury severity, severity of pelvic fractures, lowest blood pressure at initial assessment and laparotomies. There was no significant difference found between REBOA versus no REBOA group in overall in-hospital mortality (34.3% vs. 28.6, P = 0.789). CONCLUSION Our study did not identify any mortality advantage in patients who received REBOA in hemorrhagic shock associated with severe pelvic fracture compared to a similar cohort of patients who did not receive REBOA. A larger sample size prospective study is needed to validate our results. CASE-CONTROL RETROSPECTIVE STUDY Level of Evidence IV.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma & Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, USA.
- Hackensack Meridian School of Medicine, Nutley, NJ, USA.
| | - Yen-Hong Kuo
- Office of Research Administration, Hackensack Meridian Health Research Institute, Nutley, NJ, USA
- Department of Medical Sciences, Hackensack Meridian School of Medicine, Nutley, NJ, USA
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Malkoc A, GnanaDev R, Shoemaker H, Guan A, Kim SU, Glover K, Woodward B, Schwartz S. The novel use of resuscitative endovascular balloon occlusion of the aorta for uncontrolled bleeding in a surgically inaccessible abdomen: The ruptured proper hepatic artery in a frozen abdomen. Trauma Case Rep 2024; 51:101002. [PMID: 38835529 PMCID: PMC11148511 DOI: 10.1016/j.tcr.2024.101002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 06/06/2024] Open
Abstract
Hemorrhage is among the leading causes of death for trauma patients. Adjunct techniques used to control bleeding include use of aortic cross clamping, application of a pelvic binder, rapidly expanding hemostatic sponges, and extra-peritoneal packing. Additionally, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can provide life-saving proximal control for patients with massive internal hemorrhage. This study concerns a patient treated with Zone 1 REBOA for class IV hemorrhagic shock from a spontaneous common hepatic artery rupture. REBOA was performed at bedside in the Surgical Intensive Care Unit (SICU) prior to definitive selective embolization. A healthy 28-year-old male suffered a grade 4 liver laceration and pancreatic head transection with associated duodenal injury after a high-speed motor vehicle collision. On arrival, the patient required a damage control laparotomy with multiple reoperations for management of his intra-abdominal injuries. By hospital day 11, significant visceral adhesions resulted in a frozen abdomen. On hospital day 20, the patient developed massive hematemesis, hematochezia, and class IV hemorrhagic shock. Vascular surgery was called to bedside in the SICU to perform REBOA. The patient received massive transfusion protocol while a 12 Fr sheath was inserted, and an aortic occlusion balloon was inflated in Zone 1 allowing for hemodynamic stabilization for transport and definitive management in the angiography suite. This case reports a novel use of REBOA, at bedside in the SICU, for the management of a massive gastrointestinal bleed in a patient with frozen abdomen. In this case, REBOA allowed us to achieve temporary hemodynamic stability prior to definitive control in the angiography suite. Bedside use of REBOA in the SICU prevented certain exsanguination and death.
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Affiliation(s)
- Aldin Malkoc
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Raja GnanaDev
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Hailey Shoemaker
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, CA, USA
| | - Angel Guan
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - So Un Kim
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Keith Glover
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Brandon Woodward
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
| | - Samuel Schwartz
- The Division of Vascular Surgery, Department of Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA 92324, USA
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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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Deser SB, Arapi B, Tel Ustunisik C, Bitargil M, Yuksel A. REBOA Improves Outcomes in Hybrid Surgery for Ruptured Abdominal Aortic Aneurysms. Ann Vasc Surg 2024; 100:8-14. [PMID: 38122969 DOI: 10.1016/j.avsg.2023.10.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/01/2023] [Accepted: 10/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Despite advancements in diagnostic methods and emergency interventions, mortality rates of ruptured abdominal aortic aneurysm (rAAA) continue to remain high. To address this issue, the resuscitative endovascular balloon occlusion of the aorta (REBOA) technique has been designed to provide temporary control of bleeding. We aimed to compare the impact of the REBOA technique during open aortic surgery for rAAA. METHODS Between January 2014 and November 2021, 53 consecutive patients (46 males, 7 females; mean age 71.9 ± 7.9 years; range 51-89 years) who underwent emergency open aortic surgery for rAAA were retrospectively analyzed. Patients were divided into REBOA (21 patients) and non-REBOA (32 patients) groups. The primary outcomes were postoperative 24-hr and 30-day mortality. The secondary outcomes were intensive care unit (ICU) stay, in-hospital stay, bleeding, postoperative renal failure, bowel ischemia, and transient ischemic attack (TIA)/stroke rate. RESULTS The REBOA group showed a significant reduction in mortality rates at both 24 hr (9.5% vs. 37.5%, P = 0.029) and 30 days (14.2% vs. 43.7%, P = 0.035) compared to the non-REBOA group. In-hospital stay (12.8 ± 3.48 vs. 15.6 ± 4.74 days, P = 0.02) and ICU stay (2.42 ± 2.08 vs. 5.09 ± 5.79 days, P = 0.048) were shorter among the REBOA group. Total procedure time and bleeding were reduced among the REBOA group without significant differences in terms of postoperative renal failure, bowel ischemia, and TIA/stroke rate. CONCLUSIONS The REBOA group demonstrated significantly improved survival rates compared to the non-REBOA group, without a significant difference in complication rates. REBOA is considered a less invasive option compared to the traditional method for open aortic cross-clamping. This study demonstrated that the use of REBOA may be considered as a first-line treatment option for open surgery in cases of rAAA particularly when an off-the-shelf endovascular aneurysm repair device is not suitable.
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Affiliation(s)
- Serkan Burc Deser
- Department of Cardiovascular Surgery, Institute of Cardiology, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Berk Arapi
- Department of Cardiovascular Surgery, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Cigdem Tel Ustunisik
- Department of Cardiovascular Surgery, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Macit Bitargil
- Department of Cardiovascular Surgery, Acibadem Hospital, Istanbul, Turkey
| | - Ahmet Yuksel
- Department of Cardiovascular Surgery, City Hospital, Bursa, Turkey
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Shum-Tim L, Bichara-Allard S, Hopkins B, AlShahwan N, Hanley S, Manzano-Nunez R, Garcia AF, Deckelbaum D, Grushka J, Razek T, Fata P, Khwaja K, McKendy K, Jastaniah A, Wong EG. Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2024; 96:499-509. [PMID: 37478348 DOI: 10.1097/ta.0000000000004109] [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: 07/23/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. METHODS We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. RESULTS Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%). CONCLUSION This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
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Affiliation(s)
- Lukas Shum-Tim
- From the Division of Trauma Surgery (L.S.-T., S.B.-A., B.H., N.A.S., D.D., J.G., T.R., P.F., K.K., K.M.K., A.J., E.G.W.), McGill University, Montreal; Division of Vascular Surgery (S.H.), McGill University, Gatineau, QC, Canada; Department of Surgery, (NAS) King Saud University; Clinical Research Unit, Hospital del Mar Medical Research Institute (IMIM), (R.M.-N.), Barcelona, Spain; and Department of Surgery (A.F.G.), Fundación Valle del Lili, Cali, Colombia
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11
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Paran M, McGreevy D, Hörer TM, Khan M, Dudkiewicz M, Kessel B. International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma. Surgeon 2024; 22:37-42. [PMID: 37652801 DOI: 10.1016/j.surge.2023.08.001] [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: 04/29/2023] [Revised: 08/05/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy. METHODS This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database. RESULTS One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta. CONCLUSIONS Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.
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Affiliation(s)
- Maya Paran
- Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Isral, Affiliated with Sackler School of Medicine, Tel-Aviv University, Tel-aviv, Israel.
| | - David McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of General Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mansoor Khan
- Brighton and Sussex Medical School, Brighton, UK
| | - Mickey Dudkiewicz
- Hillel Yaffe Medical Center, Affiliated with The Rappaport Medical School, Technion, Haifa, Israel
| | - Boris Kessel
- Division of General Surgery and Trauma, Hillel Yaffe Medical Center, Affiliated with The Rappaport Medical School, Technion, Haifa, Israel
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Wanhainen A, Van Herzeele I, Bastos Goncalves F, Bellmunt Montoya S, Berard X, Boyle JR, D'Oria M, Prendes CF, Karkos CD, Kazimierczak A, Koelemay MJW, Kölbel T, Mani K, Melissano G, Powell JT, Trimarchi S, Tsilimparis N, Antoniou GA, Björck M, Coscas R, Dias NV, Kolh P, Lepidi S, Mees BME, Resch TA, Ricco JB, Tulamo R, Twine CP, Branzan D, Cheng SWK, Dalman RL, Dick F, Golledge J, Haulon S, van Herwaarden JA, Ilic NS, Jawien A, Mastracci TM, Oderich GS, Verzini F, Yeung KK. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2024; 67:192-331. [PMID: 38307694 DOI: 10.1016/j.ejvs.2023.11.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 90.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 02/04/2024]
Abstract
OBJECTIVE The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy. METHODS The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence. RESULTS A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed. CONCLUSION The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.
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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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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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Haugland H, Gamberini L, Hoareau GL, Haenggi M, Greif R, Brede JR. Resuscitative endovascular balloon occlusion of the aorta in out-of-hospital cardiac arrest - A Delphi consensus study for uniform data collection. Resusc Plus 2023; 16:100485. [PMID: 37859631 PMCID: PMC10583171 DOI: 10.1016/j.resplu.2023.100485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/25/2023] [Indexed: 10/21/2023] Open
Abstract
Background Evolving research on resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct treatment for out-of-hospital cardiac arrest mandates uniform recording and reporting of data. A consensus on which variables need to be collected may enable comparing and merging data from different studies. We aimed to establish a standard set of variables to be collected and reported in future REBOA studies in out-of-hospital cardiac arrest. Methods A four-round stepwise Delphi consensus process first asked experts to propose without restraint variables for future REBOA research in out-of-hospital cardiac arrest. The experts then reviewed the variables on a 5-point Likert scale and ≥75% agreement was defined as consensus. First authors of published papers on REBOA in out-of-hospital cardiac arrest over the last five years were invited to join the expert panel. Results The data were collected between May 2022 and December 2022. A total of 28 experts out of 34 primarily invited completed the Delphi process, which developed a set of 31 variables that might be considered as a supplement to the Utstein style reporting of research in out-of-hospital cardiac arrest. Conclusions This Delphi consensus process suggested 31 variables that enable future uniform reporting of REBOA in out-of-hospital cardiac arrest.
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Affiliation(s)
- Helge Haugland
- St. Olav’s University Hospital, Trondheim, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Lorenzo Gamberini
- Department of Anesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | | | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robert Greif
- University of Bern, Bern Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
- ERC ResearchNet, Niel, Belgium
| | - Jostein Rødseth Brede
- St. Olav’s University Hospital, Trondheim, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
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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: 48] [Impact Index Per Article: 48.0] [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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Haering D, Meador H, Lynch E, Lauria M, Garchar E, Braude D. Management of Postpartum Hemorrhage in Critical Care Transport. Air Med J 2023; 42:488-495. [PMID: 37996188 DOI: 10.1016/j.amj.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 11/25/2023]
Abstract
Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.
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Affiliation(s)
- Donald Haering
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM.
| | - Hallie Meador
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Lynch
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Michael Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Garchar
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Darren Braude
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Trauma Emerg Surg 2023; 49:2031-2046. [PMID: 37430174 PMCID: PMC10520188 DOI: 10.1007/s00068-023-02271-3] [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: 07/12/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment, and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage, resuscitative endovascular balloon occlusion and resuscitative thoracotomy, pericardiocentesis, needle decompression, and thoracostomy. CONCLUSIONS Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition, and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well-organised team using crew resource management, but also on an institutional safety culture embedded in everyday practice through continuous education, training, and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr-University Bochum, Minden, Germany.
| | - Janusz Andres
- Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland
| | - Bernd W Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Luca Brazzi
- The Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Edoardo De Robertis
- The Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Sharon Einav
- The Intensive Care Unit, Shaare Zedek Medical Center, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Carl Gwinnutt
- The Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK
| | - Bahar Kuvaki
- The Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey
| | - Pawel Krawczyk
- The Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Matthew D McEvoy
- The Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Pieter Mertens
- The Department of Anaesthesiology, Antwerp University Hospital, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Vivek K Moitra
- Division of Critical Care Anesthesiology, The Department of Anesthesiology, Columbia University, Columbia, NY, USA
| | - Jose Navarro-Martinez
- The Anesthesiology Department, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), Biomedical Research (ISABIAL), Alicante, Spain
| | - Mark E Nunnally
- The Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Michael O Connor
- The Department of Anesthesiology & Critical Care, University of Chicago, Chicago, IL, USA
| | - Marcus Rall
- The Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany
| | - Kurt Ruetzler
- The Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jan Schmitz
- Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Karl Thies
- The Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Bethel, Germany
| | - Jonathan Tilsed
- The Department of Surgery, Hull University Teaching Hospitals, Hull, UK
| | - Mauro Zago
- General & Emergency Surgery Division, The Department of Surgery, A. Manzoni Hospital, Milan, Italy
| | - Arash Afshari
- The Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark
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Hinkelbein J, Andres J, Böttiger BW, Brazzi L, De Robertis E, Einav S, Gwinnutt C, Kuvaki B, Krawczyk P, McEvoy MD, Mertens P, Moitra VK, Navarro-Martinez J, Nunnally ME, O'Connor M, Rall M, Ruetzler K, Schmitz J, Thies K, Tilsed J, Zago M, Afshari A. Cardiac arrest in the perioperative period: a consensus guideline for identification, treatment, and prevention from the European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery. Eur J Anaesthesiol 2023; 40:724-736. [PMID: 37218626 DOI: 10.1097/eja.0000000000001813] [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: 05/24/2023]
Abstract
INTRODUCTION Cardiac arrest in the operating room is a rare but potentially life-threatening event with mortality rates of more than 50%. Contributing factors are often known, and the event is recognised rapidly as patients are usually under full monitoring. This guideline covers the perioperative period and is complementary to the European Resuscitation Council (ERC) guidelines. MATERIAL AND METHODS The European Society of Anaesthesiology and Intensive Care and the European Society for Trauma and Emergency Surgery jointly nominated a panel of experts to develop guidelines for the recognition, treatment and prevention of cardiac arrest in the perioperative period. A literature search was conducted in MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials. All searches were restricted to publications from 1980 to 2019 inclusive and to the English, French, Italian and Spanish languages. The authors also contributed individual, independent literature searches. RESULTS This guideline contains background information and recommendation for the treatment of cardiac arrest in the operating room environment, and addresses controversial topics such as open chest cardiac massage (OCCM), resuscitative endovascular balloon occlusion (REBOA) and resuscitative thoracotomy, pericardiocentesis, needle decompression and thoracostomy. CONCLUSION Successful prevention and management of cardiac arrest during anaesthesia and surgery requires anticipation, early recognition and a clear treatment plan. The ready availability of expert staff and equipment must also be taken into consideration. Success not only depends on medical knowledge, technical skills and a well organised team using crew resource management but also on an institutional safety culture embedded in everyday practice through continuous education, training and multidisciplinary co-operation.
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Affiliation(s)
- Jochen Hinkelbein
- From the University Department of Anaesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, University Hospital Ruhr-University Bochum, Minden, Germany (JH), Department of Anaesthesiology and Intensive Care Medicine, Medical Faculty and University Hospital of Cologne, Cologne, Germany (BWB, JS), Department of Anaesthesiology and Intensive Therapy, Jagiellonian University Medical College, Krakow, Poland (JA), Department of Surgical Sciences, University of Turin, Turin (LB), Division of Anaesthesia, Analgesia and Intensive Care, Department of Medicine and Surgery, University of Perugia, Italy (EdR), Intensive Care Unit, Shaare Zedek Medical Center and Hebrew University Faculty of Medicine, Jerusalem, Israel (SE), Department of Anaesthesia, Salford Royal NHS Foundation Trust, Salford, UK (CG), Department of Anesthesiology and Reanimation, Dokuz Eylül University, İzmir, Turkey (BK), Department of Anesthesiology and Intensive Care Medicine, Jagiellonian University Medical College, Krakow, Poland (PK), Department of Anaesthesiology, Antwerp University Hospital, Edegem, Belgium (PM), Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee (MDM), Division of Critical Care Anesthesiology, Department of Anesthesiology, Columbia University, New York, USA (VKM), Anesthesiology Department, Dr Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISAB), and Biomedical Research (ISABIAL), Alicante, Spain (JN-M), Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York (MEN), Department of Anesthesiology & Critical Care, University of Chicago, Illinois, USA (MO'C), Institute for Patient Safety and Simulation Team Training InPASS, Reutlingen, Germany (MR), Departments of General Anesthesiology and Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (KR), Department of Anaesthesiology and Critical Care, EvKB, OWL University Medical Center, Bielefeld University, Campus Bielefeld-Bethel, Germany (KT), Department of Surgery, Hull University Teaching Hospitals, Hull, UK (JT), General & Emergency Surgery Division, Department of Surgery, A. Manzoni Hospital, Milan, Italy (MZ) and Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet, Denmark and Department of Clinical Medicine, University of Copenhagen, Denmark (AA)
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Troisi N, Bertagna G, Torri L, Canovaro F, D’Oria M, Adami D, Berchiolli R. The Management of Ruptured Abdominal Aortic Aneurysms: An Ongoing Challenge. J Clin Med 2023; 12:5530. [PMID: 37685601 PMCID: PMC10488063 DOI: 10.3390/jcm12175530] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND despite improvements in the diagnosis and treatment of elective AAAs, ruptured abdominal aortic aneurysms (RAAAs) continue to cause a substantial number of deaths. The choice between an open or endovascular approach remains a challenge, as does postoperative complications in survivors. The aim of this manuscript is to offer an overview of the contemporary management of RAAA patients, with a focus on preoperative and intraoperative factors that could help surgeons provide more appropriate treatment. METHODS we performed a search on MEDLINE, Embase, and Scopus from 1 January 1985 to 1 May 2023 and reviewed SVS and ESVS guidelines. A total of 278 articles were screened, but only those with data available on ruptured aneurysms' incidence and prevalence, preoperative scores, and mortality rates after emergency endovascular or open repair for ruptured AAA were included in the narrative synthesis. Articles were not restricted due to the designs of the studies. RESULTS the centralization of RAAAs has improved outcomes after both surgical and endovascular repair. Preoperative mortality risk scores and knowledge of intraoperative factors influencing mortality could help surgeons with decision-making, although there is still no consensus about the best treatment. Complications continue to be an issue in patients surviving intervention. CONCLUSIONS RAAA still represents a life-threatening condition, with high mortality rates. Effective screening and centralization matched with adequate preoperative risk-benefit assessment may improve outcomes.
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Affiliation(s)
- Nicola Troisi
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Giulia Bertagna
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Lorenzo Torri
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Francesco Canovaro
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Mario D’Oria
- Vascular Surgery Unit, Azienda Sanitaria Universitaria Giuliano Isontina, 34148 Trieste, Italy;
| | - Daniele Adami
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
| | - Raffaella Berchiolli
- Vascular Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy; (G.B.); (L.T.); (F.C.); (D.A.); (R.B.)
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Foley MP, Walsh SR, Doolan N, Vulliamy P, McMonagle M, Aylwin C. Editor's Choice - Systematic Review and Meta-Analysis of Lower Extremity Vascular Complications after Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): An Inevitable Concern? Eur J Vasc Endovasc Surg 2023; 66:103-118. [PMID: 36796674 DOI: 10.1016/j.ejvs.2023.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/24/2023] [Accepted: 02/10/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporise non-compressible torso haemorrhage. Recent data have suggested that vascular access complications secondary to REBOA placement are higher than initially anticipated. This updated systematic review and meta-analysis aimed to determine the pooled incidence rate of lower extremity arterial complications after REBOA. DATA SOURCES PubMed, Scopus, Embase, conference abstract listings, and clinical trial registries. REVIEW METHODS Studies including more than five adults undergoing emergency REBOA for exsanguinating haemorrhage that reported access site complications were eligible for inclusion. A pooled meta-analysis of vascular complications was performed using the DerSimonian-Laird weights for the random effects model, presented as a Forest plot. Further meta-analyses compared the relative risk of access complications between different sheath sizes, percutaneous access techniques, and indications for REBOA. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. RESULTS No randomised controlled trials were identified, and the overall study quality was poor. Twenty-eight studies including 887 adults were identified. REBOA was performed for trauma in 713 cases. The pooled proportion rate of vascular access complications was 8.6% (95% confidence interval 4.97 - 12.97), with substantial heterogeneity (I2 = 67.6%). There was no significant difference in the relative risk of access complications between 7 and > 10 F sheaths (p = .54), or between ultrasound guided and landmark guided access (p = .081). However, traumatic haemorrhage was associated with a significantly higher risk of complications compared with non-traumatic haemorrhage (p = .034). CONCLUSION This updated meta-analysis aimed to be as comprehensive as possible considering the poor quality of source data and high risk of bias. It suggested that lower extremity vascular complications were higher than originally suspected after REBOA. While the technical aspects did not appear to impact the safety profile, a cautious association could be drawn between REBOA use for traumatic haemorrhage and a higher risk of arterial complications.
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Affiliation(s)
- Megan Power Foley
- Department of Vascular Surgery, University College Hospital Galway, Galway, Ireland; Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK.
| | - Stewart R Walsh
- Lambe Institution for Translational Research, National University of Ireland Galway, Galway, Ireland; National Surgical Research Support Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Nathalie Doolan
- Department of Vascular Surgery, University College Hospital Galway, Galway, Ireland
| | - Paul Vulliamy
- Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK
| | | | - Christopher Aylwin
- Blizard Institute for Trauma Sciences, Queen Mary University of London, London, UK; Department of Trauma Surgery, Imperial College London, London, UK
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Engberg M, Mikkelsen S, Hörer T, Lindgren H, Søvik E, Frendø M, Svendsen MB, Lönn L, Konge L, Russell L, Taudorf M. Learning insertion of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) catheter: Is clinical experience necessary? A prospective trial. Injury 2023; 54:1321-1329. [PMID: 36907823 DOI: 10.1016/j.injury.2023.02.048] [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: 12/02/2022] [Revised: 02/08/2023] [Accepted: 02/22/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging and potentially life-saving procedure, necessitating qualified operators in an increasing number of centres. The procedure shares technical elements with other vascular access procedures using the Seldinger technique, which is mastered by doctors not only in endovascular specialties but also in trauma surgery, emergency medicine, and anaesthesiology. We hypothesised that doctors mastering the Seldinger technique (experienced anaesthesiologist) would learn the technical aspects of REBOA with limited training and remain technically superior to doctors unfamiliar with the Seldinger technique (novice residents) given similar training. METHODS This was a prospective trial of an educational intervention. Three groups of doctors were enroled: novice residents, experienced anaesthesiologists, and endovascular experts. The novices and the anaesthesiologists completed 2.5 h of simulation-based REBOA training. Their skills were tested before and 8-12 weeks after training using a standardised simulated scenario. The endovascular experts, constituting a reference group, were equivalently tested. All performances were video recorded and rated by three blinded experts using a validated assessment tool for REBOA (REBOA-RATE). Performances were compared between groups and with a previously published pass/fail cutoff. RESULTS Sixteen novices, 13 board-certified specialists in anaesthesiology, and 13 endovascular experts participated. Before training, the anaesthesiologists outperformed the novices by 30 percentage points of the maximum REBOA-RATE score (56% (SD 14.0) vs 26% (SD 17%), p<0.01). After training, there was no difference in skills between the two groups (78% (SD 11%) vs 78 (SD 14%), p = 0.93). Neither group reached the endovascular experts' skill level (89% (SD 7%), p<0.05). CONCLUSION For doctors mastering the Seldinger technique, there was an initial inter-procedural transfer of skills advantage when performing REBOA. However, after identical simulation-based training, novices performed equally well to anaesthesiologists, indicating that vascular access experience is not a prerequisite to learning the technical aspects of REBOA. Both groups would need more training to reach technical proficiency.
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Affiliation(s)
- Morten Engberg
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Søren Mikkelsen
- The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark; The Prehospital Research Unit, Region of Southern Denmark, Odense University Hospital, Odense, Denmark; Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Tal Hörer
- Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Life Science, Örebro University Hospital, Örebro, Sweden
| | - Hans Lindgren
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Department of Surgery, Section of Interventional Radiology, Helsingborg Hospital, Helsingborg, Sweden
| | - Edmund Søvik
- Department of Radiology and Nuclear Medicine, St. Olavs University Hospital, Trondheim, Norway
| | - Martin Frendø
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Plastic and Reconstructive Surgery, Copenhagen University Hospital Herlev, Denmark
| | - Morten Bo Svendsen
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark
| | - Lars Lönn
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Radiology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lene Russell
- Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education, the Capital Region of Denmark; Department of Anaesthesiology and Intensive Care, Copenhagen University Hospital Gentofte, Denmark
| | - Mikkel Taudorf
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Radiology, Copenhagen University Hospital Rigshospitalet, Denmark
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REBOA: Expanding Applications From Traumatic Hemorrhage to Obstetrics and Cardiopulmonary Resuscitation, From the AJR Special Series on Emergency Radiology. AJR Am J Roentgenol 2023; 220:16-22. [PMID: 35920708 DOI: 10.2214/ajr.22.27932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged over the past decade as a technique to control life-threatening hemorrhage and treat hemorrhagic shock, being increasingly used to treat noncompressible traumatic torso hemorrhage. Reports during this time also support the use of a REBOA device for an expanding range of indications including nontraumatic abdominal hemorrhage, postpartum hemorrhage, placenta accreta spectrum (PAS) disorder, and cardiopulmonary resuscitation (CPR). The strongest available evidence supports REBOA as a lifesaving adjunct to definitive surgical management in trauma and as a method to help avoid hysterectomy in select patients with postpartum hemorrhage or PAS disorder. In comparison with initial descriptions of complete REBOA inflation, techniques for partial REBOA inflation have been introduced to achieve hemodynamic stability while minimizing adverse events relating to reperfusion injuries. Fluoroscopy-free REBOA has been described in various settings, including trauma, obstetrics, and out-of-hospital cardiac arrest. As the use of REBOA expands outside the trauma setting and into nontraumatic abdominal hemorrhage, obstetrics, and CPR, it is imperative for radiologists to become familiar with this technology, its proper placement, and its potential adverse sequelae.
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Johnson GGRJ, Dhaliwal S, Launcelott S, Hyun E, Helewa R, Shariff F, Hochman D. Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review. Int Med Case Rep J 2022; 15:761-768. [PMID: 36597475 PMCID: PMC9805738 DOI: 10.2147/imcrj.s372294] [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: 04/26/2022] [Accepted: 10/29/2022] [Indexed: 12/29/2022] Open
Abstract
Background Ruptured middle colic artery aneurysm is extremely uncommon. Diagnosis can be challenging, as symptomatology can be attributed to more common abdominal pathologies. Due to the rarity of this condition, only case reports are available to inform management. Case Presentation We present the case of a 72-year-old woman with a ruptured middle colic artery aneurysm presenting with signs and symptoms more suggestive of acute calculous cholecystitis. Her co-existing bleed was confirmed on CT angiogram. Coil embolization was initially attempted unsuccessfully. She underwent laparotomy, a middle colic artery ligation, and extended right hemicolectomy with intra-aortic balloon placement for emergency proximal vascular control. Post-operatively, she had a re-bleed that was successfully managed with covered stent placement in the proximal superior mesenteric artery after an unsuccessful re-attempt at coil embolization. Her apparent associated cholecystitis was managed with antibiotics and resolved uneventfully. Conclusion A middle colic artery aneurysm can be challenging to diagnose and treat. Management options include endovascular techniques, open surgery, or a combination approach. Intra-aortic balloon placement for emergency vascular control is a novel approach that could avoid hemorrhage when intra-abdominal vascular access is challenging.
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Affiliation(s)
- Garrett G R J Johnson
- Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada,Clinician Investigator Program, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Surinder Dhaliwal
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sebastian Launcelott
- Department of Surgery, Section of Vascular Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Hyun
- Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ramzi Helewa
- Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Farhana Shariff
- Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Hochman
- Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Manitoba, Canada,Correspondence: David Hochman, Department of Surgery, Section of General Surgery, University of Manitoba, 343 Tache Avenue, Winnipeg, Manitoba, R2H 2A5, Canada, Tel +1 204-925-9592, Fax +1 204-231-2283, Email
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Man With Cardiac Arrest. Ann Emerg Med 2022; 80:568-578. [DOI: 10.1016/j.annemergmed.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/10/2022] [Accepted: 06/08/2022] [Indexed: 11/18/2022]
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Slot SAS, van Oostendorp SE, Schoonmade LJ, Geeraedts LMG. The role of REBOA in patients in traumatic cardiac arrest subsequent to hemorrhagic shock: a scoping review. Eur J Trauma Emerg Surg 2022; 49:693-707. [PMID: 36335515 PMCID: PMC10175493 DOI: 10.1007/s00068-022-02154-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022]
Abstract
Abstract
Purpose
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a useful adjunct in treatment of patients in severe hemorrhagic shock. Hypothetically, REBOA could benefit patients in traumatic cardiac arrest (TCA) as balloon occlusion of the aorta increases afterload and may improve myocardial performance leading to return of spontaneous circulation (ROSC). This scoping review was conducted to examine the effect of REBOA on patients in TCA.
Methods
This scoping review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) Statement. PubMed, EMBASE.com and the Web of Science Core Collection were searched. Articles were included if they reported any data on patients that underwent REBOA and were in TCA. Of the included articles, data regarding SBP, ROSC and survival were extracted and summarized.
Results
Of 854 identified studies, 26 articles met criteria for inclusion. These identified a total of 785 patients in TCA that received REBOA (presumably less because of potential overlap in patients). This review shows REBOA elevates mean SBP in patients in TCA. The achievement of ROSC after REBOA deployment ranged from 18.2% to 67.7%. Survival to discharge ranged from 3.5% to 12.1%.
Conclusion
Overall, weak evidence is available on the use of REBOA in patients in TCA. This review, limited by selection bias, indicates that REBOA elevates SBP and may benefit ROSC and potentially survival to discharge in patients in TCA. Extensive further research is necessary to further clarify the role of REBOA during TCA.
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Irahara T, Oishi D, Tsuda M, Kajita Y, Mori H, Terashima T, Tanabe S, Hattori M, Kuge Y, Takeyama N. Combined, converted, and prophylactic use of resuscitative endovascular balloon occlusion of the aorta for severe torso trauma: a retrospective study. Acute Med Surg 2022; 9:e792. [PMID: 36203855 PMCID: PMC9525620 DOI: 10.1002/ams2.792] [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: 02/05/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used as an intra‐aortic balloon occlusion in Japan; however, protocols for its effective use in different conditions have not been established. This study aimed to summarize the strategies of REBOA use in severe torso trauma. Methods Twenty‐nine cases of REBOA for torso trauma treated at our hospital over 5 years were divided into hemodynamically unstable (HU) (n = 12), cardiac arrest (CA) (n = 13), and hemodynamically stable (HS) (n = 4) groups. We retrospectively examined patient characteristics, trauma mechanism, injury site, severity score, intervention type, and survival rates at 24 h in each group. Results In the HU group, 9 and 3 patients survived and died within 24 h, respectively; time to intervention (56.6 versus 130.7 min, P = 0.346) tended to be shorter and total occlusion time (40.2 versus 337.7 min, P = 0.009) was significantly shorter in survivors than in nonsurvivors. In the CA group, 10 patients were converted from resuscitative thoracotomy with aortic cross‐clamp (RTACC); one patient survived. All four patients in the HS group survived, having received prophylactic REBOA. Conclusion The efficacy of REBOA for severe torso trauma depends on the patient's condition. If the patients are hemodynamically unstable, time to intervention and total occlusion time could correlate with survival. The combined use of REBOA with definitive hemostasis could improve outcomes. Conversion from RTACC in the cardiac arrest patients and prophylactic use in the hemodynamically stable patients can be one of the potentially effective options, although further studies are needed.
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Affiliation(s)
- Takayuki Irahara
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Dai Oishi
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Masanobu Tsuda
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Yuka Kajita
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Hisatake Mori
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Tsuguaki Terashima
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Subaru Tanabe
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Miyuki Hattori
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Yuuji Kuge
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Naoshi Takeyama
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
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Jansen JO, Cochran C, Boyers D, Gillies K, Lendrum R, Sadek S, Lecky F, MacLennan G, Campbell MK. The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial). Trials 2022; 23:384. [PMID: 35550642 PMCID: PMC9097076 DOI: 10.1186/s13063-022-06346-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. METHODS Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. DISCUSSION This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. TRIAL REGISTRATION ISRCTN16184981.
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Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
- Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, 35294, USA.
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Sam Sadek
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Stonko DP, Edwards J, Abdou H, Elansary NN, Lang E, Savidge SG, Hicks CW, Morrison JJ. The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA. Front Physiol 2022; 13:871073. [PMID: 35615678 PMCID: PMC9125334 DOI: 10.3389/fphys.2022.871073] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/04/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is used for aortic control in hemorrhagic shock despite little quantification of its mechanism of resuscitation or cardiac injury. The goal of this study was to use pressure-volume (PV) loop analysis and direct coronary blood flow measurements to describe the physiologic changes associated with the clinical use of REBOA. Methods: Swine underwent surgical and vascular access to measure left ventricular PV loops and left coronary flow in hemorrhagic shock and subsequent placement of occlusive REBOA, partial REBOA, and no REBOA. PV loop characteristics and coronary flow are compared graphically with PV loops and coronary waveforms, and quantitatively with measures of the end systolic and end pressure volume relationship, and coronary flow parameters, with accounting for multiple comparisons. Results: Hemorrhagic shock was induced in five male swine (mean 53.6 ± 3.6 kg) as demonstrated by reduction of stroke work (baseline: 3.1 vs. shock: 1.2 L*mmHg, p < 0.01) and end systolic pressure (ESP; 109.8 vs. 59.6 mmHg, p < 0.01). ESP increased with full REBOA (178.4 mmHg; p < 0.01), but only moderately with partial REBOA (103.0 mmHg, p < 0.01 compared to shock). End systolic elastance was augmented from baseline to shock (1.01 vs. 0.39 ml/mmHg, p < 0.01) as well as shock compared to REBOA (4.50 ml/mmHg, p < 0.01) and partial REBOA (3.22 ml/mmHg, p = 0.01). Percent time in antegrade coronary flow decreased in shock (94%-71.8%, p < 0.01) but was rescued with REBOA. Peak flow increased with REBOA (271 vs. shock: 93 ml/min, p < 0.01) as did total flow (peak: 2136, baseline: 424 ml/min, p < 0.01). REBOA did not augment the end diastolic pressure volume relationship. Conclusion: REBOA increases afterload to facilitate resuscitation, but the penalty is supraphysiologic coronary flows and imposed increase in LV contractility to maintain cardiac output. Partial REBOA balances the increased afterload with improved aortic system compliance to prevent injury.
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Affiliation(s)
- David P. Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Noha N. Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Eric Lang
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Samuel G. Savidge
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan J. Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,*Correspondence:Jonathan J. Morrison,
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Yamamoto R, Alarhayem A, Muir MT, Jenkins DH, Eastridge BJ, Shapiro ML, Cestero RF. Gaining or wasting time? Influence of time to operating room on mortality after temporary hemostasis using resuscitative endovascular balloon occlusion of the aorta. Am J Surg 2022; 224:125-130. [DOI: 10.1016/j.amjsurg.2022.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 01/24/2022] [Accepted: 03/31/2022] [Indexed: 11/01/2022]
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Inaba K, Alam HB, Brasel KJ, Brenner M, Brown CVR, Ciesla DJ, de Moya MA, DuBose JJ, Moore EE, Moore LJ, Sava JA, Vercruysse GA, Martin MJ. A Western Trauma Association critical decisions algorithm: Resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2022; 92:748-753. [PMID: 34686636 DOI: 10.1097/ta.0000000000003438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kenji Inaba
- From the Division of Trauma and Surgical Critical Care (K.I., M.J.M.), Department of Surgery, University of Southern California, Los Angeles, California; Department of Surgery (H.B.A.), Northwestern University, Chicago, Illinois; Department of Surgery (K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (M.B.), University of California Riverside, Riverside, California; Department of Surgery (C.V.R.B., J.J.D.), University of Texas at Austin, Austin, Texas; Department of Surgery (D.J.C.), University of South Florida, Tampa, Florida; Department of Surgery (M.A.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado; Department of Surgery (L.J.M.), University of Texas, McGovern Medical School, Houston, Houston, Texas; Department of Surgery (J.A.S.), MedStar Washington Hospital, Washington, DC; and Department of Surgery (G.A.V.), University of Michigan, Ann Arbor, Michigan
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Llompart-Pou JA, Chico-Fernández M. Traumatic critical hemorrhage. Future challenges. Med Intensiva 2022; 46:217-220. [PMID: 35210173 DOI: 10.1016/j.medine.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/12/2021] [Accepted: 04/15/2021] [Indexed: 06/14/2023]
Affiliation(s)
- J A Llompart-Pou
- Servei de Medicina Intensiva, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Balearic Islands, Spain.
| | - M Chico-Fernández
- Unidad de Cuidados Intensivos de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, Spain
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Granieri S, Frassini S, Cimbanassi S, Bonomi A, Paleino S, Lomaglio L, Chierici A, Bruno F, Biondi R, Di Saverio S, Khan M, Cotsoglou C. Impact of resuscitative endovascular balloon occlusion of the aorta (REBOA) in traumatic abdominal and pelvic exsanguination: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:3561-3574. [DOI: 10.1007/s00068-022-01955-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 03/13/2022] [Indexed: 12/29/2022]
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Brede JR, Søvik E, Rehn M. Resuscitative endovascular balloon occlusion of the aorta: the postpartum haemorrhage perspective. Crit Care 2022; 26:57. [PMID: 35277189 PMCID: PMC8917633 DOI: 10.1186/s13054-022-03942-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
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The Role of Prehospital REBOA for Hemorrhage Control in Civilian and Military Austere Settings: A Systematic Review. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2010006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite the success of prehospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in combat and civilian settings, the prevalence of complications and the lack of conclusive evidence has led to uncertainty and controversy. Therefore, this systematic review aimed to evaluate the role of prehospital REBOA for hemorrhage control in trauma populations. We systematically searched Cochrane, Ovid MEDLINE, EMBASE and Google Scholar for all relevant studies that investigated the efficacy of prehospital REBOA on trauma patients with massive hemorrhage. Primary outcome was evaluated by blood pressure elevation and secondary outcome was measured by 30-day mortality and complications. Our search identified 546 studies, but only six studies met the inclusion and exclusion criteria. Included studies were low to moderate quality due to limitations within the studies. However, all of the studies reported significant elevation of blood pressure and survival, demonstrating the potential benefits of REBOA. For example, the 30-day mortality rate reduced significantly after REBOA, but studies lacked long-term outcome assessments across the continuum of care. Due to the heterogeneity of the results, a meta-analysis was not possible. We conclude that prehospital REBOA is a feasible and effective resuscitative adjunct for shock patients with lethal non-compressible torso hemorrhage. However, due to the unclear causes of complications and the lack of high quality and homogeneous data, the effects of prehospital REBOA were not truly reflected and comparison between groups was not feasible. Thus, further high-quality studies are required to attest the causality between prehospital REBOA and outcomes.
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McGreevy DT, Björklund J, Nilsson KF, Hörer TM. Hemodynamic Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta in Hemodynamic Instability Secondary to Acute Cardiac Tamponade in a Porcine Model. Shock 2022; 57:291-297. [PMID: 34710883 DOI: 10.1097/shk.0000000000001875] [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: 11/26/2022]
Abstract
BACKGROUND The pre-hospital use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasing, although it remains controversial, in part because of suggested contraindications such as acute cardiac tamponade (ACT). As both the pre-hospital and in-hospital use of REBOA might potentially occur with concurrent ACT, knowledge of the hemodynamic effect of REBOA in this setting is crucial. This study, therefore, aimed at investigating the physiological effects of REBOA in hemodynamic instability secondary to ACT in a porcine model. We hypothesize that REBOA can temporarily increase systemic blood pressure and carotid blood flow, and prolong survival, in hemodynamic shock caused by ACT. METHODS Fourteen pigs (24-38 kg) underwent ACT, through true cardiac injury and hemorrhage into the pericardial space, and were allowed to hemodynamically deteriorate. At a systolic blood pressure (SBP) of 50 mm Hg (SBP50) they were randomized to total occlusion REBOA in zone 1 or to a control group. Survival, hemodynamic parameters, carotid blood flow (CBF), femoral blood flow (FBF), cardiac output (CO), end-tidal CO2, and arterial blood gas parameters were analyzed. RESULTS REBOA intervention was associated with a significant increase in SBP (50 mm Hg to 74 mm Hg, P = 0.016) and CBF (110 mL/min to 195 mL/min, P = 0.031), with no change in CO, compared to the control group. At 20 min after SBP50, the survival rate in the intervention group was 86% and in the control group 14%, with time to death being significantly longer in the intervention group. CONCLUSIONS This randomized animal study demonstrates that REBOA can help provide hemodynamic stabilization and prolong survival in hemodynamic shock provoked by ACT. It is important to stress that our study does not change the fact that urgent pericardiocentesis or cardiac surgery is, and should remain, the standard optimal treatment for ACT.Level of evidence: Prospective, randomized, experimental animal study. Basic science study, therapeutic.
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Affiliation(s)
- David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Janina Björklund
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Marchand LS, Sepehri A, Hannan ZD, Zaidi SM, Bangura AT, Morrison JJ, Manson TT, Slobogean GP, O’Hara NN, O’Toole RV. Pelvic Ring Injury Mortality: Are We Getting Better? J Orthop Trauma 2022; 36:81-86. [PMID: 34128497 PMCID: PMC8669037 DOI: 10.1097/bot.0000000000002210] [Citation(s) in RCA: 4] [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] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To determine if changes in pelvic trauma care and treatment protocols have affected overall mortality rates after pelvic ring injury. DESIGN Retrospective cohort study. SETTING Level I trauma center. PATIENTS/PARTICIPANTS A total of 3314 patients with pelvic ring injuries who presented to a single referral center from 1999 to 2018 were included in the study. INTERVENTION Pelvic ring management, years 1999-2006 versus years 2007-2018. MAIN OUTCOME MEASUREMENTS In hospital mortality. Other examined variables included change in patient demographics, fracture characteristics, date of injury, associated injuries, length of hospital stay, Abbreviated Injury Severity Score. RESULTS The composite mortality rate was 6.5% (214/3314). The earliest cohort presented a mortality rate of 9.1% [111/1224; 95% confidence interval (CI), 7.6%-10.8%] compared with the more recent cohort mortality rate of 4.9% (103/2090; 95% CI, 4.1%-5.9%). Overall mortality was significantly lower in the more recent period, a risk difference of 4.1% (95% CI, 2.3%-6.1%; P < 0.01). After adjusting for age and Abbreviated Injury Severity Score of the brain, chest, and abdomen, the mortality reduction was more pronounced with an adjusted risk difference of 6.4% (95% CI, 4.7%-8.1%; P < 0.01). CONCLUSION Significant improvement in the mortality rate of pelvic ring injuries has been demonstrated in recent years (4.9% vs. 9.1%) and the difference is even large when accounting for known confounders. Improvement appears to coincide chronologically with changes in trauma resuscitation and implementation of adjuvant treatments for managing patients with severe hemorrhagic shock. Although the exact benefit of each treatment awaits further research, these data might indicate improved care over time for these difficult patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Lucas S. Marchand
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aresh Sepehri
- University of British Columbia, Department of Orthopaedic Surgery, Vancouver, BC, Canada
| | - Zachary D. Hannan
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Syed M.R. Zaidi
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Abdulai T. Bangura
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nathan N. O’Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert V. O’Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
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Dahlquist A, Elander Degerstedt L, von Oelreich E, Brännström A, Gustavsson J, P Arborelius U, Günther M. Blast polytrauma with hemodynamic shock, hypothermia, hypoventilation and systemic inflammatory response: description of a new porcine model. Eur J Trauma Emerg Surg 2022; 48:401-409. [PMID: 32862315 PMCID: PMC7456397 DOI: 10.1007/s00068-020-01476-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 08/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE In the past decade blast injuries have become more prevalent. Blast trauma may cause extensive injuries requiring improved early resuscitation and prevention of haemorrhage. Randomized prospective trials are logistically and ethically challenging, and large animal models are important for further research efforts. Few severe blast trauma models have been described, which is why we aimed to establish a comprehensive polytrauma model in accordance with the criteria of the Berlin definition of polytrauma and with a survival time of > 2 h. Multiple blast injuries to the groin and abdomen were combined with hypoperfusion, respiratory and metabolic acidosis, hypoventilation, hypothermia and inflammatory response. The model was compared to lung contusion and haemorrhage. METHODS 16 landrace swine (mean weight 60.5 kg) were randomized to "control" (n = 5), "chest trauma/hem" by lung contusion and class II haemorrhage (n = 5), and "blast polytrauma" caused by multiple blast injuries to the groin and abdomen, class II haemorrhage, lipopolysaccharide (LPS) infusion and hypothermia 32 °C (n = 6). RESULTS The blast polytrauma group had an Injury Severity Score of 57 which resulted in haemodynamic shock, hypothermia, respiratory and metabolic acidosis and inflammatory response. The chest trauma/hem group had an Injury Severity Score of 9 and less profound physiologic effects. Physiologic parameters presented a dose-response relationship corresponding to the trauma levels. CONCLUSION A comprehensive blast polytrauma model fulfilling the Berlin polytrauma criteria, with a high trauma load and a survival time of > 2 h was established. A severe, but consistent, injury profile was accomplished enabling the addition of experimental interventions in future studies, particularly of immediate resuscitation efforts including whole blood administration, trauma packing and haemostasis.
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Affiliation(s)
- Albin Dahlquist
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Louise Elander Degerstedt
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Erik von Oelreich
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Brännström
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden
| | - Jenny Gustavsson
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ulf P Arborelius
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Günther
- Department of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, S1, 118 83, Stockholm, Sweden.
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Patel N, Harfouche M, Stonko DP, Elansary N, Scalea TM, Morrison JJ. Factors Associated With Increased Mortality in Severe Abdominopelvic Injury. Shock 2022; 57:175-180. [PMID: 34468423 DOI: 10.1097/shk.0000000000001851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Associated injuries are thought to increase mortality in patients with severe abdominopelvic trauma. This study aimed to identify clinical factors contributing to increased mortality in patients with severe abdominopelvic trauma, with the hypothesis that a greater number of concomitant injuries would result in increased mortality. METHODS This was a retrospective review of the Trauma Quality Improvement Program (TQIP) database of patients ≥ 18 years with severe abdominopelvic trauma defined as having an abdominal Abbreviated Injury Score (AIS) ≥ 3 with pelvic fractures and/or iliac vessel injury (2015-2017). Primary outcome was in-hospital mortality based on concomitant body region injuries. Secondary outcomes included mortality at 6 h, 6 to 24 h, and after 24 h based on concomitant injuries, procedures performed, and transfusion requirements. RESULTS A total of 185,257 patients were included in this study. Survivors had more severely injured body regions than non-survivors (4 vs. 3, P < 0.001). Among those who died within 6 h, 28.5% of patients required a thoracic procedure and 43% required laparotomy compared to 6.3% and 22.1% among those who died after 24 h (P < 0.001). Head AIS ≥ 3 was the only body region that significantly contributed to overall mortality (OR 1.26, P < 0.001) along with laparotomy (OR 3.02, P < 0.001), neurosurgical procedures (2.82, P < 0.001) and thoracic procedures (2.28, P < 0.001). Non-survivors who died in < 6 h and 6-24 h had greater pRBC requirements than those who died after 24 h (15.5 and 19.5 vs. 8 units, P < 0.001). CONCLUSION Increased number of body regions injured does not contribute to greater mortality. Uncontrolled noncompressible torso hemorrhage rather than the burden of concomitant injuries is the major contributor to the high mortality associated with severe abdominopelvic injury.
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Affiliation(s)
- Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Melike Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - David P Stonko
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland
| | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Nahmias J, Byerly S, Stein D, Haut ER, Smith JW, Gelbard R, Ziesmann M, Boltz M, Zarzaur B, Biffl WL, Brenner M, DuBose J, Fox C, Galante J, Martin M, Moore EE, Moore L, Morrison J, Norii T, Scalea T, Yeh DD. A core outcome set for resuscitative endovascular balloon occlusion of the aorta: A consensus based approach using a modified Delphi method. J Trauma Acute Care Surg 2022; 92:144-151. [PMID: 34554137 DOI: 10.1097/ta.0000000000003405] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The utilization of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma has grown exponentially in recent years. However, inconsistency in reporting of outcome metrics related to this intervention has inhibited the development of evidence-based guidelines for REBOA application. This study sought to attain consensus on a core outcome set (COS) for REBOA. METHODS A review of "landmark" REBOA articles was performed, and panelists (first and senior authors) were contacted for participation in a modified Delphi study. In round 1, panelists provided a list of potential core outcomes. In round 2, using a Likert scale (1 [not important] to 9 [very important]), panelists scored the importance of each potential outcome. Consensus for core outcomes was defined a priori as greater than 70% of scores receiving 7 to 9 and less than 15% of scores receiving 1 to 3. Feedback was provided after round 2, and a third round was performed to reevaluate variables not achieving consensus and allow a final "write-in" round by the experts. RESULTS From 17 identified panelists, 12 participated. All panelists (12 of 12, 100%) participated in each subsequent round. Panelists initially identified 34 unique outcomes, with two outcomes later added upon write-in request after round 2. From 36 total potential outcomes, 20 achieved consensus as core outcomes, and this was endorsed by 100% of the participants. CONCLUSION Panelists successfully achieved consensus on a COS for REBOA-related research. This REBOA-COS is recommended for all clinical trials related to REBOA and should help enable higher-quality study designs, valid aggregation of published data, and development of evidence-based practice management guidelines. LEVEL OF EVIDENCE Diagnostic test or criteria, level V. TRIAL REGISTRATION Core Outcomes in Trauma Surgery: Development of a Core Outcome Set for Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) http://www.comet-initiative.org/Studies/Details/1709.
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Affiliation(s)
- Jeffry Nahmias
- From the Department of Surgery (J.N.), University of California, Irvine, Orange, California; Department of Surgery (S.B.), University of Tennessee Health Science Campus, Memphis, Tennessee; Department of Surgery (D.S.), Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California; Division of Acute Care Surgery, Department of Surgery (E.R.H.), The Johns Hopkins University School of Medicine, Baltimore, Maryland; Hiram C. Polk Md Department of Surgery (J.W.S.), University of Louisville, Louisville, Kentucky; Division of Trauma and Acute Care Surgery, Department of Surgery (R.G.), University of Alabama at Birmingham, Boshell Building, Birmingham, Alabama; Department of Surgery (M.Z.), University of Manitoba, Winnipeg, Manitoba, Canada; Division of Trauma, Acute Care and Critical Care Surgery, Department of Surgery (Mel.B.), Penn State Hershey Medical Center, Hershey, Pennsylvania; Department of Surgery (B.Z.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Department of Surgery (W.L.B.), Scripps Clinic Medical Group, La Jolla, California; Department of Surgery (Meg.B.), University of California Riverside School of Medicine, Riverside CA; R Adams Cowley Shock Trauma Center (J.D., C.F., J.M., T.S.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (J.G.), University of California, Davis, Sacramento; Department of Surgery (M.M.), Scripps Mercy Hospital, San Diego, California; Ernest E Moore Shock Trauma Center at Denver Health (E.E.M.), University of Colorado Denver, Denver Colorado; Department of Surgery (L.M.), The University of Texas Health McGovern Medical School, Houston, Houston, Texas; Department of Emergency Medicine (T.N.), University of New Mexico Health Sciences Center, Albuquerque, New Mexico; Department of Traumatology and Acute Critical Medicine (T.N.), Osaka University Graduate School of Medicine, Osaka, Japan; and Department of Surgery (D.D.Y.), University of Miami Miller School of Medicine, Miami, Florida
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Hörer TM, Pirouzram A, Khan M, Brenner M, Cotton B, Duchesne J, Ferrada P, Kauvar D, Kirkpatrick A, Ordonez C, Perreira B, Roberts D. Endovascular Resuscitation and Trauma Management (EVTM)-Practical Aspects and Implementation. Shock 2021; 56:37-41. [PMID: 32080064 DOI: 10.1097/shk.0000000000001529] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT In recent years there has been a tremendous increase in hemorrhage control by endovascular methods. Traumatic and non-traumatic hemorrhage is being more frequently managed with endografts, embolization agents, and minimal invasive methods. These methods initially were used in hemodynamically stable patients only, whereas now these are being implemented in acute settings and hemodynamically unstable patients. The strategy of using endovascular and combined open-endo methods approach for hemodynamic instability in trauma and non-trauma patients has been named EVTM- EndoVascular resuscitation and Trauma Management. The EVTM concept will be presented in this article, describing how it is developed and used, as well as its limitations and future aspects.
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Affiliation(s)
- Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Life Science, Örebro University Hospital and University, Orebro, Sweden
| | - Artai Pirouzram
- Department of Cardiothoracic and Vascular Surgery, Linköping University Hospital, Linkoping, Sweden
| | - Mansoor Khan
- Department of Digestive Diseases, Brighton and Sussex University Hospitals, Brighton, UK
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California
| | - Bryan Cotton
- Department of Surgery, University of Texas Health Science Center, Houston, Texas
| | - Juan Duchesne
- Division Chief Acute Care Surgery, Department of Surgery Tulane, New Orleans, Louisiana
| | - Paula Ferrada
- VCU Surgery Trauma, Critical Care and Emergency Surgery, Richmond, Virginia
| | - David Kauvar
- Vascular Surgery Service, San Antonio Military Medical Center, San Antonio, Texas
| | - Andrew Kirkpatrick
- Regional Trauma Services Foothills Medical Centre, Calgary, Alberta, Canada
- Departments of Surgery, Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
- Canadian Forces Health Services, Calgary, Alberta, Canada
| | - Carlos Ordonez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Colombia
| | - Bruno Perreira
- Department of Surgery and Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Derek Roberts
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of Ottawa, The Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
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Park C, Grant J, Garigipati P, Kuhlenschmidt K, Black G, Bhat S, Abdelfattah K, Cripps M, Dumas RP. Resuscitative endovascular balloon occlusion of the aorta: simulation improves performance but may require interval training to prevent skill degradation. Eur J Trauma Emerg Surg 2021; 48:1955-1959. [PMID: 34731285 DOI: 10.1007/s00068-021-01815-9] [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: 07/27/2021] [Accepted: 10/25/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Surgical trainees are exposed to less procedures with increasing need for simulation. Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become increasingly implemented for hemorrhage control, yet most courses are catered to faculty level with little data on trainees. We propose that routine training in this critical procedure will improve trainee performance over time. METHODS This is a prospective, observational study at a level I trauma center involving a monthly trauma procedural program. Early in the month, trainees received hands-on REBOA training; at the end, trainees underwent standardized, class-based evaluation on a perfused trainer. Score percentages were recorded (0-100%). Endpoints included early, mid and late performance (2-12 months). Paired T-test and Pearson's coefficient were used to evaluate differences and strength of association between time between training and performance. RESULTS 25 trainees participated with 5 and 11 repeat learners in the PGY-2 and PGY-3 classes, respectively. Median early performance score was 62.5% (IQR 56-81) for PGY-2s and 91.6% (IQR 75-100) in PGY-3s. Pearson's coefficient between time between and training and score demonstrated a weak correlation in the PGY-2s (r2 = - 0.13), but was more pronounced in the PGY-3s (r2 = - 0.44) with an inflection point at 5 months. CONCLUSIONS Routine REBOA training in trainees is associated with improvement in performance within a short period of time. Skill degradation was most pronounced in trainees who did not receive training for more than 5 months. Trainees can be successfully trained in REBOA; however, this should be done at shorter intervals to prevent skill degradation.
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Affiliation(s)
- Caroline Park
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA.
| | - Jennifer Grant
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Priya Garigipati
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Kali Kuhlenschmidt
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - George Black
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Sneha Bhat
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Kareem Abdelfattah
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Michael Cripps
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
| | - Ryan P Dumas
- Division of Acute Care Surgery, Department of General Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Adams D, McDonald PL, Sullo E, Merkle AB, Nunez T, Sarani B, Shackelford SA, Bowyer MW, van der Wees P. Management of non-compressible torso hemorrhage of the abdomen in civilian and military austere/remote environments: protocol for a scoping review. Trauma Surg Acute Care Open 2021; 6:e000811. [PMID: 34746436 PMCID: PMC8527150 DOI: 10.1136/tsaco-2021-000811] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/30/2021] [Indexed: 11/04/2022] Open
Abstract
The management of non-compressible torso hemorrhage in military austere/remote environments is a leading cause of potentially preventable death in the prehospital/battlefield environment that has not shown a decrease in mortality in 26 years. Numerous conceptual innovations to manage non-compressible torso hemorrhage have been developed without proven effectiveness in this setting. This scoping review aims to assess the current literature to define non-compressible torso hemorrhage in civilian and military austere/remote environments, assess current innovations and the effectiveness of these innovations, assess the current knowledge gaps and potential future innovations in the management of non-compressible torso hemorrhage in civilian and military austere/remote environments, and assess the translational health science perspective of the current literature and its potential effect on public health. The Joanna Briggs Institute for evidence synthesis will guide this scoping review to completion. A nine-step development process, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist, will be used to enhance the methodological and reporting quality of this scoping review. The Participant, Concept, Context framework will broaden this scoping review's reach in developing a comprehensive search strategy. Thirty years will be explored to assess all relevant literature to ensure a thorough search. Two researchers will explore all the discovered literature and develop consensus on the selected literature included in this scoping review. The article will undergo review and data extraction for data analysis. The knowledge to action framework will guide the knowledge synthesis and creation of this scoping review. A narrative synthesis will systematically review and synthesize the collected literature to produce and explain a broad conclusion of the selected literature. Lastly, a consultation exercise in the form of qualitative interviews will be conducted to assess the thematic analysis results and validate the result of this scoping review. This scoping review will require Institutional Review Board approval for the expert consultation in the form of qualitative interviews. Consultants' identifying information will remain confidential. The collected and analyzed data from this scoping review will identify gaps in the literature to create an evidence-informed protocol for the management of non-compressible torso hemorrhage of the abdomen in civilian and military austere/remote environments. The results of this scoping review will be distributed in peer-reviewed journals and educational, medical presentations. Scoping Review Protocol, Level IV.
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Affiliation(s)
- Donald Adams
- Translational Health Science, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Paige L McDonald
- Clinical Research and Leadership Department, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Elaine Sullo
- Department of Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Alexander B Merkle
- Department of Surgery, Sutter Capital Pavilion, Sutter Health, Sacramento, California, USA
| | - Timothy Nunez
- Trauma and Acute Care Surgery, San Antonio Military Medical Center, San Antonio, Texas, USA
| | - Babak Sarani
- Trauma and Acute Care Surgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Stacy A Shackelford
- Joint Trauma System, Defense Center of Excellence for Trauma, San Antonio, Texas, USA
| | - Mark W Bowyer
- The Norman M Rich Department of Surgery, Uniformed Services University of the Health Sciences and Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Philip van der Wees
- Department of Clinical Research and Leadership, PhD program in Translational Health Sciences, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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Engberg M, Lönn L, Konge L, Mikkelsen S, Hörer T, Lindgren H, Søvik E, Svendsen MB, Frendø M, Taudorf M, Russell L. Reliable and valid assessment of procedural skills in resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2021; 91:663-671. [PMID: 34225347 DOI: 10.1097/ta.0000000000003338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Valid and reliable assessment of skills is essential for improved and evidence-based training concepts. In a recent study, we presented a novel tool to assess procedural skills in resuscitative endovascular balloon occlusion of the aorta (REBOA), REBOA-RATE, based on international expert consensus. Although expert consensus is a strong foundation, the performance of REBOA-RATE has not been explored. The study aimed to examine the reliability and validity of REBOA-RATE. METHODS This was an experimental simulation-based study. We enrolled doctors with three levels of expertise to perform two REBOA procedures in a simulated scenario of out-of-hospital cardiac arrest. Procedures were video-recorded, and videos were blinded and randomized. Three clinical experts independently rated all procedures using REBOA-RATE. Data were analyzed using Messick's framework for validity evidence, including generalizability analysis of reliability and determination of a pass/fail standard. RESULTS Forty-two doctors were enrolled: 16 novices, 13 anesthesiologists, and 13 endovascular experts. They all performed two procedures, yielding 84 procedures and 252 ratings. The REBOA-RATE assessment tool showed high internal consistency (Cronbach's α = 0.95) and excellent interrater reliability (intraclass correlation coefficient, 0.97). Assessment using one rater and three procedures could ensure overall reliability suitable for high-stakes testing (G-coefficient >0.80). Mean scores (SD) for the three groups in the second procedure were as follows: novices, 32% (24%); anesthesiologists, 55% (29%); endovascular experts, 93% (4%) (p < 0.001). The pass/fail standard was set at 81%, which all experts but no novices passed. CONCLUSION Data strongly support the reliability and validity of REBOA-RATE, which successfully discriminated between all experience levels. The REBOA-RATE assessment tool requires minimal instruction, and one rater is sufficient for reliable assessment. Together, these are strong arguments for the use of REBOA-RATE to assess REBOA skills, allowing for competency-based training and certification concepts. LEVEL OF EVIDENCE Diagnostic test, no or poor gold standard, level V.
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Affiliation(s)
- Morten Engberg
- From the Copenhagen Academy for Medical Education and Simulation (CAMES), Centre for Human Resources and Education (M.E., L.K., M.B.S., M.F., L.R.), Capital Region of Denmark, København; Department of Clinical Medicine, Faculty of Health and Medical Sciences (M.E., L.L., L.K., M.T.), University of Copenhagen; Department of Radiology (L.L., M.T.), Copenhagen University Hospital Rigshospitalet, Copenhagen; The Mobile Emergency Care Unit, Department of Anaesthesiology and Intensive Care (S.M.), The Prehospital Research Unit (S.M.), Region of Southern Denmark, Odense University Hospital; Department of Regional Health Research (S.M.), University of Southern Denmark, Odense, Denmark; Department of Cardiothoracic and Vascular Surgery and Department of Surgery, Faculty of Life Science (T.H.), Örebro University Hospital, Örebro; Department of Clinical Sciences, Faculty of Medicine (H.L.), Lund University, Lund; Section of Interventional Radiology, Department of Surgery (H.L.), Helsingborg Hospital, Helsingborg, Sweden; Department of Radiology and Nuclear Medicine (E.S.), St. Olavs University Hospital, Trondheim, Norway; Department of Otorhinolaryngology, Head & Neck Surgery and Audiology (M.F.), and Department of Intensive Care (L.R.), Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Plodr M, Safr M, Novak I. Thoracic aortic rupture due to airbag deployment. World J Emerg Med 2021; 12:327-329. [PMID: 34512833 DOI: 10.5847/wjem.j.1920-8642.2021.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 05/26/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Michal Plodr
- Department of Emergency Medicine and Military General Medicine, Faculty of Military Health Sciences, University of Defence, Hradec Kralove 50001, Czech Republic.,Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove 50002, Czech Republic
| | - Miroslav Safr
- Department of Forensic Medicine, University Hospital Hradec Kralove, Hradec Kralove 50005, Czech Republic
| | - Ivo Novak
- Emergency Medical Services of the Hradec Kralove Region, Hradec Kralove 50002, Czech Republic
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Castellini G, Gianola S, Biffi A, Porcu G, Fabbri A, Ruggieri MP, Coniglio C, Napoletano A, Coclite D, D'Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Gupta S, Iannone P, Chiara O. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg 2021; 16:41. [PMID: 34384452 PMCID: PMC8358549 DOI: 10.1186/s13017-021-00386-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Multiple studies regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with non-compressible torso injuries and uncontrolled haemorrhagic shock were recently published. To date, the clinical evidence of the efficacy of REBOA is still debated. We aimed to conduct a systematic review assessing the clinical efficacy and safety of REBOA in patients with major trauma and uncontrolled haemorrhagic shock. Methods We systematically searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2020. All randomized controlled trials and observational studies that investigated the use of REBOA compared to resuscitative thoracotomy (RT) with/without REBOA or no-REBOA were eligible. We followed the PRISMA and MOOSE guidelines. Two authors independently extracted data and appraised the risk of bias of included studies. Effect sizes were pooled in a meta-analysis using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Primary outcomes were mortality, volume of infused blood components, health-related quality of life, time to haemorrhage control and any adverse effects. Secondary outcomes were improvement in haemodynamic status and failure/success of REBOA technique. Results We included 11 studies (5866 participants) ranging from fair to good quality. REBOA was associated with lower mortality when compared to RT (aOR 0.38; 95% CI 0.20–0.74), whereas no difference was observed when REBOA was compared to no-REBOA (aOR 1.40; 95% CI 0.79–2.46). No significant difference in health-related quality of life between REBOA and RT (p = 0.766). The most commonly reported complications were amputation, haematoma and pseudoaneurysm. Sparse data and heterogeneity of reporting for all other outcomes prevented any estimate. Conclusions Our findings on overall mortality suggest a positive effect of REBOA among non-compressible torso injuries when compared to RT but no differences compared to no-REBOA. Variability in indications and patient characteristics prevents any conclusion deserving further investigation. REBOA should be promoted in specific training programs in an experimental setting in order to test its effectiveness and a randomized trial should be planned. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00386-9.
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Affiliation(s)
- Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy.
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL della Romagna, Forlì, Italy
| | | | - Carlo Coniglio
- Department of Anesthesiology, Intensive Care and Pre-Hospital Emergency Services, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Antonello Napoletano
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela Coclite
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela D'Angelo
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Alice Josephine Fauci
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Laura Iacorossi
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Roberto Latina
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Katia Salomone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Shailvi Gupta
- University of Maryland, Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Primiano Iannone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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Engberg M, Hörer T, Rasmussen TE, Taudorf M, Nayahangan LJ, Rasmussen NK, Russell L, Konge L, Lönn L. Developing a tool to assess competence in resuscitative endovascular balloon occlusion of the aorta: An international Delphi consensus study. J Trauma Acute Care Surg 2021; 91:310-317. [PMID: 34259442 DOI: 10.1097/ta.0000000000003191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emergency procedure that is potentially lifesaving in major noncompressible torso hemorrhage. It may also improve outcome in nontraumatic cardiac arrest. However, the procedure can be technically challenging and requires the immediate presence of a qualified operator. Thus, evidence-based training and assessment of operator skills are essential for successful implementation and patient safety. A prerequisite for this is a valid and reliable assessment tool specific for the procedure. The aim of this study was to develop a tool for assessing procedural competence in REBOA based on best-available knowledge from international experts in the field. METHODS We invited international REBOA experts from multiple specialties to participate in an anonymous three-round iterative Delphi study to reach consensus on the design and content of an assessment tool. In round 1, participants suggested items to be included. In rounds 2 and 3, the relevance of each suggested item was evaluated by all participants to reach consensus. Interround data processing was done systematically by a steering group. RESULTS Forty panelists representing both clinical and educational expertise in REBOA from 16 countries (in Europe, Asia, and North and South America) and seven different specialties participated in the study. After 3 Delphi rounds and 532 initial item suggestions, the panelists reached consensus on a 10-item assessment tool with behaviorally anchored rating scales. It includes assessment of teamwork, procedure time, selection and preparation of equipment, puncture technique, guidewire handling, sheath handling, placement of REBOA catheter, occlusion, and evaluation. CONCLUSION We present the REBOA-RATE assessment tool developed systematically by international experts in the field to optimize content validity. Following further studies of its validity and reliability, this tool represents an important next step in evidence-based training programs in REBOA, for example, using mastery learning. LEVEL OF EVIDENCE Therapeutic, level V.
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Affiliation(s)
- Morten Engberg
- From the Centre for Human Resources and Education, Capital Region of Denmark (M.E., L.J.N., L.R., L.K.), Copenhagen Academy for Medical Education and Simulation, Copenhagen, Denmark; Department of Clinical Medicine (M.E., N.K.R., L.K., L.L.), Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Cardiothoracic and Vascular Surgery (T.H.), and Department of Surgery (T.H.), Faculty of Life Science, Örebro University Hospital, Örebro, Sweden; Walter Reed National Military Medical Center (T.E.R.); National Institutes of Health Clinical Center (T.E.R.), Bethesda, Maryland; Department of Radiology (M.T., N.K.R., L.L.), and Department of Intensive Care (L.R.), Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Kinslow K, Shepherd A, Sutherland M, McKenney M, Elkbuli A. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Use in Animal Trauma Models. J Surg Res 2021; 268:125-135. [PMID: 34304008 DOI: 10.1016/j.jss.2021.06.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 05/14/2021] [Accepted: 06/21/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was developed to prevent traumatic exsanguination. We aim to identify the outcomes in animal models with 1) partial versus complete REBOA occlusion and 2) zone 1 versus 2 placements. METHODS The PRISMA guidelines were followed. We conducted a search of PubMed, EMBASE and Google Scholar for REBOA studies in animal trauma models using the following search terms: "REBOA trauma", "REBOA outcomes" "REBOA complications". SYRCLE's RoB Tool was utilized for the risk of bias and study quality assessment. RESULTS Our search yielded 14 RCTs for inclusion. Eleven studies directly investigated partial REBOA versus total aortic occlusion. Overall, partial REBOA techniques were associated with similar attainment of proximal MAP but with significantly less ischemic burden. Significant mortality benefit with partial occlusion was observed in three studies. Survival time post-occlusion also was improved with zone 3 placement versus zone 1 (100% versus 33%; P < 0.01). CONCLUSIONS There appears to be a fine balance between desired proximal arterial pressure and time of occlusion for overall survival and subsequent risk of distal ischemia. Many "partial occlusion" techniques may be superior in attaining such balance over prolonged REBOA inflation where no distal flow is allowed. Tailored zone 3 placement may offer significant mortality and morbidity advantages compared to sustained total occlusion and indiscriminate zone 1 placement strategies. As clear conclusions regarding REBOA are unlikely to be established in animal models, larger randomized investigations utilizing human subjects are needed to describe optimal REBOA technique and applicability in greater detail.
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Affiliation(s)
- Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida
| | - Aaron Shepherd
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Kendall Regional Medical Center, Miami, Florida; Department of Surgery, University of South Florida, Tampa, Florida.
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Hurley S, Erdogan M, Kureshi N, Casey P, Smith M, Green RS. Comparison of clinical and anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA) among major trauma patients in Nova Scotia. CAN J EMERG MED 2021; 23:528-536. [PMID: 33751492 DOI: 10.1007/s43678-021-00100-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS This is a retrospective analysis of all major trauma patients (age > 16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012-2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates. RESULTS Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10-20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA. CONCLUSIONS In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.
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Affiliation(s)
- Sean Hurley
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Mete Erdogan
- Trauma Nova Scotia, Nova Scotia Health Authority, Room 1-026B Centennial Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada
| | - Nelofar Kureshi
- Division of Neurosurgery, Department of Surgery, Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Patrick Casey
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Matthew Smith
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Robert S Green
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
- Trauma Nova Scotia, Nova Scotia Health Authority, Room 1-026B Centennial Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.
- Department of Critical Care, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
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50
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[Interventional management of peripheral vascular injuries : From the exclusion indication to the procedure of first choice]. Unfallchirurg 2021; 124:635-641. [PMID: 34189587 DOI: 10.1007/s00113-021-01029-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] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Approximately one third of all traumatic peripheral artery injuries affect the upper extremities, while two thirds involve the arteries of the lower extremities. Historically, these injuries were treated by open surgical repair. Nowadays, interventional treatment, such as embolization or stent grafting are increasingly used to treat peripheral artery injuries. OBJECTIVE Determination of the current state of interventional treatment options for injuries of peripheral arteries. MATERIAL AND METHODS Selective literature review on the current state of interventional management of peripheral artery injuries. RESULTS Although scarce, the available data confirm the efficacy of interventional techniques for managing peripheral artery injuries; however, despite improvements in treatment techniques and interventional devices, not all patients are equally well suited for endovascular or open surgical treatment. Consequently, a multidisciplinary decision on the best treatment has to be made on a case by case basis. CONCLUSION According to the promising clinical data, interventional treatment should be considered more often. Diagnostic algorithms need to be adapted accordingly.
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