Effectiveness and Usage Trends of Hemorrhage Control Interventions in Patients with Pelvic Fracture in Shock

Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma

Background

The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the management of patients with subdiaphragmatic bleeding, as well as its utility in traumatic cardiac arrest (TCA), is unknown.

Methods

A working group from the Eastern Association for the Surgery of Trauma (EAST) applied the Grading of Recommendations Assessment, Development and Evaluation methodology (GRADE) to perform a systematic review and meta-analysis, assess the level of evidence, and create recommendations pertaining to the use of REBOA in the management of trauma or non-trauma patients, as well as those in TCA (1946 to 2024).

Results

Thirty-one studies were included in the meta-analysis. In unstable trauma patients with subdiaphragmatic bleeding, there was no significant difference in mortality among patients who were treated with REBOA vs no REBOA [OR 0.86, 95% CI 0.37, 2.04]. Subgroup analysis for individuals with pelvic fractures demonstrated higher mortality for REBOA vs no REBOA [OR=2.15, CI 1.35, 3.42]. In patients with TCA, pooled analysis demonstrated decreased mortality with REBOA vs resuscitative thoracotomy (OR 0.32, 95% CI 0.15, 0.69). Compared with no REBOA, prophylactic placement of REBOA prior to cesarean section in placenta accreta syndrome (PAS) had lower intra-operative blood loss [-1.06 L, CI -1.57 to -0.56] and red blood cell transfusion [-2.44 units, CI -4.27 to -0.62]. Overall, the level of evidence was assessed by the working group as very low.

Conclusion

Considering the risks associated with its use and lack of discernible benefit, the committee conditionally recommends against the use of REBOA in trauma patients who are hemodynamically unstable due to suspected subdiaphragmatic hemorrhage. Further research is needed to identify specific subpopulations who may benefit. For individuals with TCA due to suspected subdiaphragmatic bleeding and for prophylactic placement in PAS, the committee conditionally recommends for the use of REBOA.

Level of Evidence

IV.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in the presence of associated severe traumatic brain injury: A propensity-score matched study

BACKGROUND

Experimental work suggested that resuscitative Endovascular Balloon Occlusion of the aorta (REBOA) preserves cerebral circulation in animal models of traumatic brain injury. No clinical work has evaluated the role of REBOA in the presence of associated severe traumatic brain injury (TBI). We investigated the impacts of REBOA on neurological and survival outcomes.

METHODS

Propensity-score matched study, using the American College of Surgeons Trauma Quality Improvement Program database. Patients with severe TBI patients (Abbreviated Injury Scale ≥3) receiving REBOA within 4 ​h from arrival were matched with similar patients not receiving REBOA. Neurological matching included head AIS, pupils, and midline shift. Clinical outcomes were compared between the two groups.

RESULTS

434 REBOA patients were matched with 859 patients without REBOA. Patients in the REBOA group had higher rates of in-hospital mortality (63.6 ​% vs 44.2 ​%, p ​< ​0.001), severe sepsis (4.4 ​% vs 2.2 ​%, p ​= ​0.029), acute kidney injury (10.1 ​% vs 6.6 ​%, p ​= ​0.029), and withdrawal of life support (25.4 ​% vs 19.6 ​%, p ​= ​0.020) despite of lower craniectomy/craniotomy rate (7.1 ​% vs 12.7 ​%, p ​< ​0.002).

CONCLUSION

In patients with severe TBI, REBOA use is associated with an increased risk of in-hospital mortality, AKI, and infectious complications.

Hemostatic Interventions and All-Cause Mortality in Hemodynamically Unstable Pelvic Fractures: A Systematic Review and Meta-Analysis

Objective

To conduct a systematic review and meta-analysis of the all-cause mortality associated with the most commonly used hemostatic treatments in patients with hemodynamically unstable pelvic fractures.

Methods

Up to April 30, 2023, we searched PubMed, Embase, Web of Science, and Cochrane, including the references to qualified papers. A meta-analysis was performed on studies that reported odds ratios (ORs) or the number of events needed to calculate them. The PROSPERO registration number was CRD42023421137.

Results

Of the 3452 titles identified in our original search, 29 met our criteria. Extraperitoneal packing (EPP) (OR = 0.626 and 95% CI = 0.413-0.949), external fixation (EF) (OR = 0.649 and 95% CI = 0.518-0.814), and arterial embolism (AE) (OR = 0.459 and 95% CI = 0.291-0.724) were associated with decreased mortality. Resuscitative endovascular balloon occlusion of the aorta (REBOA) (OR = 2.824 and 95% CI = 1.594-5.005) was associated with increased mortality. A random effect model meta-analysis of eight articles showed no difference in mortality between patients with AE and patients with EPP for the initial treatments for controlling blood loss (OR = 0.910 and 95% CI = 0.623-1.328).

Conclusion

This meta-analysis collectively suggested EF, AE, or EPP as life-saving procedures for patients with hemodynamically unstable pelvic fractures.

Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study

BACKGROUND

Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures.

METHODS

Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications.

RESULTS

93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism.

CONCLUSIONS

REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.

Usefulness of resuscitative endovascular balloon occlusion of the aorta compared to aortic cross-clamping in severely injured trauma patients: Analysis from the Japan Trauma Data Bank

Aim

To compare in-hospital mortality of severely injured trauma patients who underwent resuscitative endovascular balloon occlusion of the aorta (REBOA) or aortic cross-clamping (ACC).

Methods

In this multicenter, retrospective cohort study using data from a nationwide trauma registry of tertiary emergency medical centers in Japan (n = 280), trauma patients who underwent aortic occlusion at the emergency department from 2004 to 2019 were divided into two groups according to the treatment they received: patients treated with ACC and patients who underwent placement of a REBOA catheter. Multiple imputations were used to handle the missing data. In-hospital mortality of the patients who underwent REBOA or ACC was compared using a mixed-effect logistic regression analysis and a propensity score-matching analysis, in which the confounders, including baseline patient demographics and severity, were adjusted.

Results

Of 1,670 patients (1,137 with REBOA and 533 with ACC), 66% were male. The median age was 56 years, and the mortality rate was 55.2% in the REBOA group and 81.6% in the ACC group. The mixed-effect model regression analysis showed a significantly lower odds ratio for in-hospital mortality rate in the REBOA group (odds ratio 0.17; 95% confidence interval, 0.12-0.26). A similar odds ratio was observed in the propensity score matching analysis (odds ratio 0.27; 95% confidence interval, 0.18-0.40).

Conclusion

Compared with ACC, REBOA use was associated with decreased mortality in severely injured trauma patients.

Efficacy of median sacral artery embolization for treating severe pelvic fractures: a retrospective study

Objective

Transcatheter arterial embolization (TAE) of bilateral internal iliac arteries (IIAs) in patients with a hemodynamically unstable pelvic fracture is associated with a low mortality rate. The persistence of unstable hemodynamics after IIA embolization indicates the involvement of other arteries, such as the median sacral artery (MSA). This study aimed to evaluate the efficacy of MSA embolization.

Methods

In this single-center, retrospective, observational study, medical records of patients who underwent MSA angiography or embolization for pelvic fractures (n = 21) between January 2007 and August 2019 were reviewed. The percentage of patients achieving hemodynamic stabilization by MSA embolization was calculated.

Results

Fifteen patients underwent MSA embolization, and the remaining six underwent MSA angiography. The shock index value was significantly higher after MSA embolization than that before MSA embolization in hemodynamically unstable patients who underwent this procedure. The success rate of MSA selection was 100%. One patient presented with urinary retention because of bladder and rectal disorders after MSA embolization. The 30-day survival rate was 85.7%.

Conclusions

Severe pelvic fractures, such as a Dennis Zone III fracture and suicidal jumper’s fracture due to trauma from a fall, may require MSA embolization.

Serum KIM-1, NGAL, and NAG Levels and Correlation with the Diagnostic Value in Patients with Fracture Traumatic Shock

Traumatic shock is the most common cause of serious adverse outcomes in patients with severe traumatic diseases such as fractures, and some studies here have shown that the main cause of death from traumatic shock is the impairment of organ function that occurs after shock. In this study, we explored the role of serum kidney injury molecule-1 (KIM-1), neutrophil gelatin-related lipid transporter protein (NGAL), and N-acetyl-β-D-glucosidase (NAG) levels in evaluating and diagnosing the condition of patients with fracture traumatic shock based on the goal of contributing to the clinical diagnosis of the patient's condition as soon as possible and taking measures to alleviate its progress. 96 patients with fracture traumatic shock were included in the study as the observation group and 58 healthy examiners as the control group, and the observation group was divided into 69 cases in the mild-moderate group and 27 cases in the severe group according to the Acute Physiology and Chronic Health Status Scale (APACHE-II). In this study, we detected and analyzed the differences in serum KIM-1, NGAL, and NAG levels between the observation group and the control group and the observation group with different disease levels. We found that the observation group was significantly higher than the control group, and the severe patients were higher than the mild to moderate patients, and we observed that serum KIM-1, NGAL, and NAG are significantly correlated with the condition of patients with fracture traumatic shock after further analysis using the Pearson model. In addition, the diagnostic value of receiver operating characteristic curve analysis showed that the AUC of serum KIM-1 for the diagnosis of fracture traumatic shock was 0.755, the AUC of serum NGAL was 0.750, the AUC of serum NAG was 0.772, and the AUC of the combination of the three indicators was 0.915. The results of this study thus suggest the possibility of serum KIM-1, NGAL, and NAG as clinical indicators for evaluating the condition of patients with fracture traumatic shock and the possibility of a combined test of serum KIM-1, NGAL, and NAG for diagnosing the condition.

Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center

BACKGROUND

The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates.

METHODS

An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging.

RESULTS

Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial.

CONCLUSION

Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills.

LEVEL OF EVIDENCE

Therapeutic, level V.