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Zhao Z, Wang J, Niu J, Dong S, Shi J, Yan T, Guo W, Yang R, Tang X. The clinical effectiveness and safety of Zone III REBOA for resection of sacropelvic tumors in patients older than 70 years. World J Surg Oncol 2024; 22:120. [PMID: 38702816 PMCID: PMC11067248 DOI: 10.1186/s12957-024-03398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/28/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND REBOA is a method used to manage bleeding during surgery involving sacropelvic tumors. Nevertheless, studies on the use of REBOA among elderly people are lacking. The aim of this research was to investigate the efficacy and safety of Zone III REBOA in patients aged more than 70 years. METHODS A comparative study was conducted using case-control methods. A group of patients, referred to as Group A, who were younger than 70 years was identified and paired with a comparable group of patients, known as Group B, who were older than 70 years. Continuous monitoring of physiological parameters was conducted, and blood samples were collected at consistent intervals. RESULTS Totally, 188 participants were enrolled and received REBOA. Among the 188 patients, seventeen were aged more than 70 years. By implementing REBOA, the average amount of blood loss was only 1427 ml. Experiments were also conducted to compare Group A and Group B. No notable differences were observed in terms of demographic variables, systolic blood pressure (SBP), arterial pH, lactate levels, blood creatinine levels, potassium levels, or calcium levels at baseline. Additionally, after the deflation of the REBOA, laboratory test results, which included arterial pH, lactate, potassium concentration, calcium concentration, and blood creatinine concentration, were not significantly different (P > 0.05). CONCLUSION This study indicated that in selected patients aged more than 70 years can achieve satisfactory hemodynamic and metabolic stability with Zone III REBOA. LEVEL OF EVIDENCE Therapeutic study, Level III.
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Affiliation(s)
- Zhiqing Zhao
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Jichuan Wang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Jianfang Niu
- Department of Orthopedic Surgery, Peking University First Hospital, Beijing, China
| | - Sen Dong
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Jingtian Shi
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Taiqiang Yan
- Department of Orthopedic Surgery, Peking University First Hospital, Beijing, China.
| | - Wei Guo
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Rongli Yang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
| | - Xiaodong Tang
- Musculoskeletal Tumor Center, Peking University People's Hospital, Beijing, China
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Rodríguez-Holguín F, Salcedo A, Leib P, Caicedo Y, Serna JJ, Toro L, Carvajal S, Riascos M, Parra MW, García A, Ordoñez CA. Is REBOA the Last Card to Control a Massive Gastrointestinal Bleeding? J Surg Res 2024; 296:735-741. [PMID: 38368774 DOI: 10.1016/j.jss.2023.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 12/11/2023] [Accepted: 12/30/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential tool for the management of massive gastrointestinal bleeding (MGB). This study aims to describe the experience of the use of REBOA as adjunctive therapy in patients with MGB and to evaluate its effectiveness. METHODS Serial cases of patients with hemorrhagic shock secondary to MGB in whom REBOA was placed were collected. Patient demographics, bleeding severity, etiology, management, and clinical outcomes were recorded. RESULTS Between 2017 and 2020, five cases were analyzed. All patients had a severe gastrointestinal bleeding (Glasgow Blatchford Bleeding Score range 12-17; Clinical Rockal Score range 5-9). The etiologies of MGB were perforated gastric or duodenal ulcers, esophageal varices, and vascular lesions. Systolic blood pressure increased after REBOA placement and total occlusion time was 25-60 min. REBOA provided temporary hemorrhage control in all cases and allowed additional hemostatic maneuvers to be performed. Three patients survived more than 24 h. All patients died in index hospitalization. The main cause of death was related to hemorrhagic shock. CONCLUSIONS Endovascular aortic occlusion can work as a bridge to further resuscitation and attempts at hemostasis in patients with MGB. REBOA provides hemodynamic support and may be used simultaneously with other hemostatic maneuvers, facilitating definitive hemorrhage control.
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Affiliation(s)
- Fernando Rodríguez-Holguín
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia
| | - Alexander Salcedo
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia; División de Cirugía de Trauma y Emergencias, Universidad del Valle, Cali, Colombia
| | - Philip Leib
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - José Julián Serna
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Luis Toro
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Sandra Carvajal
- Departamento de Medicina de Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Manolo Riascos
- Departamento de Medicina de Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, Florida
| | - Alberto García
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia; División de Cirugía de Trauma y Emergencias, Universidad del Valle, Cali, Colombia
| | - Carlos A Ordoñez
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia; División de Cirugía de Trauma y Emergencias, Universidad del Valle, Cali, Colombia.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Vrancken SM, de Vroome M, van Vledder MG, Halm JA, Van Lieshout EMM, Borger van der Burg BLS, Hoencamp R, Verhofstad MHJ, van Waes OJF. Non-compressible truncal and junctional hemorrhage: A retrospective analysis quantifying potential indications for advanced bleeding control in Dutch trauma centers. Injury 2024; 55:111183. [PMID: 37981519 DOI: 10.1016/j.injury.2023.111183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/06/2023] [Accepted: 11/03/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Truncal and junctional hemorrhage is the leading cause of potentially preventable deaths in trauma patients. To reduce this mortality, the application of advanced bleeding control techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), junctional tourniquets, Foley catheters, or hemostatic agents should be optimized. This study aimed to identify trauma patients with non-compressible truncal and junctional hemorrhage (NCTJH) who might benefit from advanced bleeding control techniques during initial trauma care. We hypothesized that there is a substantial cohort of Dutch trauma patients that can possibly benefit from advanced bleeding control techniques. METHODS Adult trauma patients with an Abbreviated Injury Scale ≥3 in the torso, neck, axilla, or groin region, who were presented between January 1st, 2014 and December 31st, 2018 to two Dutch level-1 trauma centers, were identified from the Dutch Trauma Registry. Potential indications for advanced bleeding control in patients with NCTJH were assessed by an expert panel of three trauma surgeons based on injury characteristics, vital signs, response to resuscitation, and received treatment. RESULTS In total, 1719 patients were identified of whom 249 (14.5 %) suffered from NCTJH. In 153 patients (60.6 %), hemorrhagic shock could have been mitigated or prevented with advanced bleeding control techniques. This group was younger and more heavily injured: median age of 40 versus 48 years and median ISS 33 versus 22 as compared to the entire cohort. The mortality rate in these patients was 31.8 %. On average, each of the included level-1 trauma centers treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial. CONCLUSIONS More than half of included Dutch trauma patients with NCTJH may benefit from in-hospital application of advanced bleeding control techniques, such as REBOA, during initial trauma care. Widespread implementation of these techniques in the Dutch trauma system may contribute to reduction of mortality and morbidity from non-compressible truncal and junctional hemorrhage.
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Affiliation(s)
- Suzanne M Vrancken
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Trauma Research Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.
| | - Matthijs de Vroome
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jens A Halm
- Trauma Research Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands; Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Oscar J F van Waes
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Zhao Y, Gao J, Li C, Song G, Shan Y. MILD THERAPEUTIC HYPOTHERMIA REDUCES ISCHEMIA-REPERFUSION INJURY AFTER ZONE 1 REBOA IN A SWINE HEMORRHAGIC SHOCK MODEL. Shock 2023; 60:434-442. [PMID: 37493541 PMCID: PMC10510780 DOI: 10.1097/shk.0000000000002182] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 04/06/2023] [Accepted: 07/11/2023] [Indexed: 07/27/2023]
Abstract
ABSTRACT Background: Resuscitative balloon occlusion of the aorta (REBOA) is an endovascular hemostasis method used for the management of traumatic abdominal and pelvic hemorrhages. However, REBOA-associated ischemia-reperfusion injury complication limits its blocking time. We hypothesized that mild therapeutic hypothermia would relieve ischemia-reperfusion injury caused by prolonged zone 1 REBOA. Methods: Ten pigs were anesthetized, intubated, and subsequently struck with the experimental sliding-chamber ballistic gun to inflict liver damage. Animals were randomized to hypothermia (60 min of zone 1 REBOA with external cooling for 180 min, n = 5) or control (60 min of zone 1 REBOA with no external cooling, n = 5). Physiological and laboratory parameters were monitored and assessed. Distal organs were obtained for histologic analysis. Results: At 180 min, compared with the control, the hypothermia animals exhibited significantly increased pH and significantly reduced lactate, hemoglobin, and hematocrit (all P < 0.05). The change of lactate from 0 to 180 min in hypothermia animals was less than that in the control ( P = 0.02). The total bleeding in the control group was significantly less than the hypothermia ( P < 0.01). In the hypothermia group, prothrombin time at 120 and 180 min was significantly longer than that at baseline (all P < 0.05). Compared with the control, animals in the hypothermia group showed slighter pathological injury of the distal organs and significantly lower overall injury score (all P < 0.05). Conclusions: Mild therapeutic hypothermia during prolonged zone 1 REBOA offered extraordinary distal organ preservation and decreased metabolic acidosis.
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Affiliation(s)
- Yang Zhao
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Jianxin Gao
- Department of Emergency Medicine, The First Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Chengcheng Li
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Guogeng Song
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
| | - Yi Shan
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou, China
- Department of Emergency Medicine, The Sixth Medical Center of PLA General Hospital of Beijing, Beijing, China
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7
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Guan Y, Chen P, Zhou H, Hong J, Yan Y, Wang Y. Common complications and prevention strategies for resuscitative endovascular balloon occlusion of the aorta: A narrative review. Medicine (Baltimore) 2023; 102:e34748. [PMID: 37653766 PMCID: PMC10470747 DOI: 10.1097/md.0000000000034748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/15/2023] [Accepted: 07/24/2023] [Indexed: 09/02/2023] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is considered a key measure of treatment due to its use in stabilizing patients in shock through temporary inflow occlusion for noncompressible torso hemorrhage as well as its supportive role in myocardial and cerebral perfusion. Although its clinical efficacy in trauma has been widely recognized, concerns over related complications, such as vascular access and ischemia-reperfusion, are on the rise. This paper aims to investigate complications associated with REBOA and identify current and emerging prevention or mitigation strategies through a literature review based on human or animal data. Common complications associated with REBOA include ischemia/reperfusion injuries, vessel injuries, venous thromboembolism, and worsening proximal bleeding. REBOA treatment outcomes can be improved substantially with the help of precise selection of patients, better visualization tools, improvement in balloon catheters, blockage strategies, and medication intervention measures. Better understanding of REBOA-related complications and further research on the strategies to mitigate the occurrence of such complications will be of vital importance for the optimization of the clinical outcomes in patients.
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Affiliation(s)
- Yi Guan
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Pinghao Chen
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Hao Zhou
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Jiaxiang Hong
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Yanggang Yan
- College of Pediatrics, Hainan Medical University, Haikou, China
| | - Yong Wang
- Department of Emergency, Hainan Clinical Research Center for Acute and Critical Diseases, the Second Affiliated Hospital of Hainan Medical University, Haikou, China
- Department of Interventional Radiology and Vascular Surgery, the Second Affiliated Hospital of Hainan Medical University, Haikou, China
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Latif RK, Clifford SP, Baker JA, Lenhardt R, Haq MZ, Huang J, Farah I, Businger JR. Traumatic hemorrhage and chain of survival. Scand J Trauma Resusc Emerg Med 2023; 31:25. [PMID: 37226264 DOI: 10.1186/s13049-023-01088-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Trauma is the number one cause of death among Americans between the ages of 1 and 46 years, costing more than $670 billion a year. Following death related to central nervous system injury, hemorrhage accounts for the majority of remaining traumatic fatalities. Among those with severe trauma that reach the hospital alive, many may survive if the hemorrhage and traumatic injuries are diagnosed and adequately treated in a timely fashion. This article aims to review the recent advances in pathophysiology management following a traumatic hemorrhage as well as the role of diagnostic imaging in identifying the source of hemorrhage. The principles of damage control resuscitation and damage control surgery are also discussed. The chain of survival for severe hemorrhage begins with primary prevention; however, once trauma has occurred, prehospital interventions and hospital care with early injury recognition, resuscitation, definitive hemostasis, and achieving endpoints of resuscitation become paramount. An algorithm is proposed for achieving these goals in a timely fashion as the median time from onset of hemorrhagic shock and death is 2 h.
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Affiliation(s)
- Rana K Latif
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA.
- Paris Simulation Center, Office of Medical Education, University of Louisville School of Medicine, Louisville, KY, USA.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Sean P Clifford
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jeffery A Baker
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY, USA
| | - Rainer Lenhardt
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Mohammad Z Haq
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jiapeng Huang
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
- Department of Cardiovascular & Thoracic Surgery, Cardiovascular Innovation Institute, University of Louisville, Louisville, KY, USA
- The Center for Integrative Environmental Health Sciences, University of Louisville, Louisville, KY, USA
- Department of Pharmacology and Toxicology, University of Louisville School of Medicine, Louisville, KY, USA
- Division of Infectious Diseases, Department of Medicine, Center of Excellence for Research in Infectious Diseases (CERID), University of Louisville, Louisville, KY, USA
| | - Ian Farah
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
| | - Jerrad R Businger
- Department of Anesthesiology and Perioperative Medicine, University of Louisville School of Medicine, University of Louisville Hospital, 530 S. Jackson St., Louisville, KY, 40202, USA
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9
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Hilbert-Carius P, Schmalbach B, Wrigge H, Schmidt M, Abu-Zidan FM, Aschenbrenner U, Streibert F. Do we need pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) in the civilian helicopter emergency medical services (HEMS)? Intern Emerg Med 2023; 18:627-637. [PMID: 36463569 DOI: 10.1007/s11739-022-03158-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) can be a life-saving procedure for patients with non-compressible torso hemorrhage. We aimed to evaluate the potential eligibility for REBOA in trauma patients of a civilian helicopter emergency medical service (HEMS) using a stepwise approach. A retrospective analysis using the electronic database (HEMSDER) of "DRF Luftrettung" HEMS covering the period from January 2015 to June 2021 was performed. Trauma patients aged ≥ 16 years and with a National Advisory Committee for Aeronautics (NACA) score of ≥ 4 were assessed for potential REBOA eligibility using two different decision trees based on assumed severe bleeding due to injuries of the abdomen, pelvis, and/or lower extremities and different vital signs on the scene and at hospital handover. Non-parametric statistical methods were used for comparison. A total of 22.426 patients met the inclusion criteria for data analysis. Of these, 0.15-2.24% were possible candidates for pre-hospital REBOA. No significant differences between groups on scene and at hospital handover regarding demographics, assumed injuries, and pre-hospital interventions were found. In the on-scene group, 21.1% of the patients remained unstable even at hospital handover despite pre-hospital care. In the handover group, 42.8% of the patients seemed initially stable but then deteriorated during the pre-hospital course. The number of potential pre-hospital REBOA in severely injured patients with a NACA score of ≥ 4 is < 3% or can be even < 1% if more strict criteria are used. There are some patients who may benefit from pre-hospital REBOA as a life-saving procedure. Further research on earlier diagnosis of life-threatening bleeding and proper indications of REBOA in trauma patients is needed.
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bergmannstrost BG Hospital, Merseburgerstr. 165, 06179, Halle (Saale), Germany.
- DRF Luftrettung (German Air Rescue) HEMS, Christoph 84 and 85, Halle (Saale), Germany.
| | - Bjarne Schmalbach
- Wissenschaftlicher Arbeitskreis (Scientific Working Group) of DRF Luftrettung, Filderstadt, Germany
| | - Hermann Wrigge
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bergmannstrost BG Hospital, Merseburgerstr. 165, 06179, Halle (Saale), Germany
- Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Merve Schmidt
- Wissenschaftlicher Arbeitskreis (Scientific Working Group) of DRF Luftrettung, Filderstadt, Germany
| | - Fikri M Abu-Zidan
- Consultant of Statistics and Research Methodology, The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ulf Aschenbrenner
- Wissenschaftlicher Arbeitskreis (Scientific Working Group) of DRF Luftrettung, Filderstadt, Germany
- DRF Luftrettung (German Air Rescue) HEMS, Christoph Dortmund, Dortmund, Germany
| | - Fridolin Streibert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bergmannstrost BG Hospital, Merseburgerstr. 165, 06179, Halle (Saale), Germany
- DRF Luftrettung (German Air Rescue) HEMS, Christoph 84 and 85, Halle (Saale), Germany
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10
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Maiga AW, Kundi R, Morrison JJ, Spalding C, Duchesne J, Hunt J, Nguyen J, Benjamin E, Moore EE, Lawless R, Beckett A, Russo R, Dennis BM. Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection. Trauma Surg Acute Care Open 2022; 7:e000984. [PMID: 36578977 PMCID: PMC9791466 DOI: 10.1136/tsaco-2022-000984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized. Results Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control. Conclusion Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments. Level of evidence Level 5, systematic review.
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Affiliation(s)
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | | | | | - Juan Duchesne
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - John Hunt
- University Medical Center New Orleans, New Orleans, Louisiana, USA
| | - Jonathan Nguyen
- Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | | | | | - Ryan Lawless
- Denver Health Medical Center, Denver, Colorado, USA
| | | | - Rachel Russo
- University of California Davis Medical Center, Sacramento, California, USA
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11
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Aoki M, Abe T. Traumatic Cardiac Arrest: Scoping Review of Utilization of Resuscitative Endovascular Balloon Occlusion of the Aorta. Front Med (Lausanne) 2022; 9:888225. [PMID: 35783650 PMCID: PMC9243328 DOI: 10.3389/fmed.2022.888225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/26/2022] [Indexed: 12/05/2022] Open
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is increasingly used in trauma resuscitation for patients with life-threatening hemorrhage below the diaphragm and may also be used for patients with traumatic cardiac arrest (TCA). Resuscitative thoracotomy with aortic cross clamping (RT-ACC) maneuver was traditionally performed for patients with TCA due to hemorrhagic shock; however, REBOA has been substituted for RT-ACC in selected TCA cases. During cardiopulmonary resuscitation (CPR) in TCA, REBOA increases cerebral and coronary perfusion, and temporary bleeding control. Both animal and clinical studies have reported the efficacy of REBOA for TCA, and a recent observational study suggested that REBOA may contribute to the return of spontaneous circulation after TCA. Although multiple questions remain unanswered, REBOA has been applied to trauma fields as a novel technology.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
- *Correspondence: Makoto Aoki
| | - Toshikazu Abe
- Department of Emergency and Critical Care Medicine, Tsukuba Memorial Hospital, Tsukuba, Japan
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
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12
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Perlman R, Breen L, Pollock GA. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): Looking Back, Moving Forward. J Cardiothorac Vasc Anesth 2022; 36:3439-3443. [PMID: 35659831 DOI: 10.1053/j.jvca.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Ryan Perlman
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Leah Breen
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Gabriel A Pollock
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
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13
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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] [What about the content of this article? (0)] [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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14
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 03/13/2022] [Indexed: 12/29/2022]
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15
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Knapp J, Jakob DA, Haltmeier T, Lehmann B, Hautz WE. [Resuscitative endovascular balloon occlusion of the aorta in severely injured patients in the emergency trauma room: a case series]. Anaesthesist 2022; 71:599-607. [PMID: 35254464 PMCID: PMC9352627 DOI: 10.1007/s00101-022-01100-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/01/2022] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
Hemorrhage is the cause of death in 30-40% of severely injured patients due to trauma and the most frequent avoidable cause of death. In civilian emergency medical services, the majority of life-threatening hemorrhages are found in incompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a lifesaving procedure for temporary bleeding control in multiple trauma patients. Since August 2020 REBOA is implented in the treatment of seriously injured patients in the emergency department of the University Hospital of Bern. In this case series we report on our experiences in all seven patients in whom we performed this procedure during the first year.
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Affiliation(s)
- Jürgen Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz.
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Spital Schwyz, Schwyz, Schweiz.
- Klinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz.
| | - Dominik A Jakob
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Tobias Haltmeier
- Klinik für Viszerale Chirurgie und Medizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Beat Lehmann
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Wolf E Hautz
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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16
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Mazzoli CA, Chiarini V, Coniglio C, Lupi C, Tartaglione M, Gamberini L, Semeraro F, Gordini G. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Non-Traumatic Cardiac Arrest: A Narrative Review of Known and Potential Physiological Effects. J Clin Med 2022; 11:742. [PMID: 35160193 PMCID: PMC8836569 DOI: 10.3390/jcm11030742] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is widely used in acute trauma care worldwide and has recently been proposed as an adjunct to standard treatments during cardiopulmonary resuscitation in patients with non-traumatic cardiac arrest (NTCA). Several case series have been published highlighting promising results, and further trials are starting. REBOA during CPR increases cerebral and coronary perfusion pressure by increasing the afterload of the left ventricle, thus improving the chances of ROSC and decreasing hypoperfusion to the brain. In addition, it may facilitate the termination of malignant arrhythmias by stimulating baroreceptor reflex. Aortic occlusion could mitigate the detrimental neurological effects of adrenaline, not only by increasing cerebral perfusion but also reducing the blood dilution of the drug, allowing the use of lower doses. Finally, the use of a catheter could allow more precise hemodynamic monitoring during CPR and a faster transition to ECPR. In conclusion, REBOA in NTCA is a feasible technique also in the prehospital setting, and its use deserves further studies, especially in terms of survival and good neurological outcome, particularly in resource-limited settings.
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18
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Abstract
As care of the injured patient continues to evolve, new surgical technologies and new resuscitative therapies can change the algorithms that drive trauma care. In particular, the advent of resuscitative endovascular balloon occlusion of the aorta has changed the way trauma surgeons treat patients in extremis. The science of resuscitation continues to evolve, leading to controversy about the optimal administration of fluid and blood products. Laparoscopy has given additional tools to the trauma surgeon to potentially avoid exploratory laparotomy, and rib fracture fixation can be beneficial in the proper patient.
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Affiliation(s)
- Stephanie Bonne
- Department of Surgery, Division of Trauma and Surgical Critical Care, Rutgers, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA.
| | - Fariha Sheikh
- Department of Surgery, Division of Trauma and Surgical Critical Care, Rutgers, New Jersey Medical School, 150 Bergen Street, Newark, NJ 07103, USA
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19
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Sadeghi M, Hurtsén AS, Tegenfalk J, Skoog P, Jansson K, Hörer TM, Nilsson KF. End-tidal Carbon Dioxide as an Indicator of Partial REBOA and Distal Organ Metabolism in Normovolemia and Hemorrhagic Shock in Anesthetized Pigs. Shock 2021; 56:647-654. [PMID: 34014885 DOI: 10.1097/shk.0000000000001807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION It is difficult to estimate the ischemic consequences when using partial resuscitative endovascular balloon occlusion of the aorta (REBOA). The aim was to investigate if end-tidal carbon dioxide (ETCO2) is correlated to degree of aortic occlusion, measured as distal aortic blood flow, and distal organ metabolism, estimated as systemic oxygen consumption (VO2), in a porcine model of normovolemia and hemorrhagic shock. MATERIALS AND METHODS Nine anesthetized pigs (25-32 kg) were subjected to incremental steps of zone 1 aortic occlusion (reducing distal aortic blood flow by 33%, 66%, and 100%) during normovolemia and hemorrhagic grade IV shock. Hemodynamic and respiratory variables, and blood samples, were measured. Systemic VO2 was correlated to ETCO2 and measures of partial occlusion previously described. RESULTS Aortic occlusion gradually lowered distal blood flow and pressure, whereas ETCO2, VO2 and carbon dioxide production decreased at 66% and 100% aortic occlusion. Aortic blood flow correlated significantly to ETCO2 during both normovolemia and hemorrhage (R = 0.84 and 0.83, respectively) and to femoral mean pressure (R = 0.92 and 0.83, respectively). Systemic VO2 correlated strongly to ETCO2 during both normovolemia and hemorrhage (R = 0.91 and 0.79, respectively), blood flow of the superior mesenteric artery (R = 0.77 and 0.85, respectively) and abdominal aorta (R = 0.78 and 0.78, respectively), but less to femoral blood pressure (R = 0.71 and 0.54, respectively). CONCLUSION ETCO2 was correlated to distal aortic blood flow and VO2 during incremental degrees of aortic occlusion thereby potentially reflecting the degree of aortic occlusion and the ischemic consequences of partial REBOA. Further studies of ETCO2, and potential confounders, in partial REBOA are needed before clinical use.
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Affiliation(s)
- Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Anna Stene Hurtsén
- Centre for Clinical Research and Education, County Council of Värmland, Karlstad, Sweden
| | | | - Per Skoog
- Departments of Vascular Surgery and Institute of Medicine; Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden
| | - Kjell Jansson
- Department of 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
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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20
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Abstract
ABSTRACT Endovascular resuscitation is an emerging area in the resuscitation of both severe traumatic hemorrhage and nontraumatic cardiac arrest. Vascular access is the critical first procedural step that must be accomplished to initiate endovascular resuscitation. The endovascular interventions presently available and emerging are routinely or potentially performed via the femoral vessels. This may require either femoral arterial access alone or access to both the femoral artery and vein. The time-critical nature of resuscitation necessitates that medical specialists performing endovascular resuscitation be well-trained in vascular access techniques. Keen knowledge of femoral vascular anatomy and skill with vascular access techniques are required to meet the needs of critically ill patients for whom endovascular resuscitation can prove lifesaving. This review article addresses the critical importance of femoral vascular access in endovascular resuscitation, focusing on the pertinent femoral vascular anatomy and technical aspects of ultrasound-guided percutaneous vascular access and femoral vessel cutdown that may prove helpful for successful endovascular resuscitation.
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Affiliation(s)
- James E Manning
- From the Department of Emergency Medicine (J.E.M.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Division of Trauma Surgery (J.E.M.), Oregon Health & Sciences University, Portland, Oregon; Ernest E Moore Shock Trauma Center at Denver Health (E.E.M.), Denver; Department of Surgery (E.E.M.), University of Colorado, Denver, Colorado; R. Adams Cowley Shock Trauma Center (J.J.M., J.J.D.); Department of Surgery (J.J.M., J.J.D.), University of Maryland School of Medicine, Baltimore, Maryland; Naval Postgraduate School Department of Defense Analysis (R.F.L.) Monterey, California; Charles T. Dotter Department of Interventional Radiology (J.D.R.), Oregon Health & Sciences University, Portland, Oregon; and Military & Health Research Foundation (J.D.R.), Laurel, Maryland
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21
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Godø BN, Brede JR, Krüger AJ. Needs assessment of resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major haemorrhage: a cross-sectional study. Emerg Med J 2021; 39:521-526. [PMID: 34039645 PMCID: PMC9234412 DOI: 10.1136/emermed-2020-210808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 04/15/2021] [Accepted: 04/25/2021] [Indexed: 11/16/2022]
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used as an adjunct treatment in traumatic abdominopelvic haemorrhage, ruptured abdominal aortic aneurysms, postpartum haemorrhage (PPH), gastrointestinal bleeding and iatrogenic injuries during surgery. This needs assessment study aims to determine the number of patients eligible for REBOA in a typical Norwegian population. Methods This was a retrospective cross-sectional study based on data obtained from blood bank registries and the Norwegian Trauma Registry for the years 2017–2018. Patients who received ≥4 units of packed red blood cells (PRBCs) within 6 hours and met the anatomical criteria for REBOA or patients with relevant Abbreviated Injury Scale codes with concurrent hypotension or transfusion of ≥4 units of PRBCs within 6 hours were identified. A detailed two-step chart review was performed to identify potentially eligible REBOA candidates. Descriptive data were collected and compared between subgroups using non-parametric tests for statistical significance. Results Of 804 patients eligible for inclusion, 53 patients were regarded as potentially REBOA eligible (corresponding to 5.7 per 100 000 adult population/year). Of these, 19 actually received REBOA. Among the identified eligible patients, 44 (83%) had a non-traumatic aetiology. Forty-two patients (79%) were treated at a tertiary care hospital. Fourteen (78%) of the REBOA procedures were due to PPH. Conclusion The number of patients potentially eligible for REBOA after haemorrhage is low, and most cases are non-traumatic. Most patients were treated at a tertiary care hospital. The exclusion of non-traumatic patients results in a substantial underestimation of the number of potentially REBOA-eligible patients.
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Affiliation(s)
- Bård Neuenkirchen Godø
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jostein Rodseth Brede
- Department of Anesthesiology and Intensive Care Medicine, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway.,Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology Faculty of Medicine and Health Sciences, Trondheim, Sør-Trøndelag, Norway
| | - Andreas Jorstad Krüger
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Emergency Medicine and Pre-Hospital Services, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology Faculty of Medicine and Health Sciences, Trondheim, Sør-Trøndelag, Norway
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22
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Daskal Y, Hershkovitz Y, Peleg K, Dubose JJ, Kessel B, Jeroukhimov I, Givon A, Dudkiewicz M. Potential resuscitative endovascular balloon occlusion of aorta candidates: defining the potential need using the National Trauma Registry. ANZ J Surg 2021; 90:477-480. [PMID: 32339421 DOI: 10.1111/ans.15771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/30/2020] [Accepted: 02/04/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Most of the trauma patients who die in the first 24 h from arrival to the hospital do so as a result of haemorrhagic shock. Resuscitative endovascular balloon occlusion of the aorta (REBOA) facilitates expedient proximal aortic control, potentially bridging a needed gap for partial or non-responders to traditional resuscitation en route to emergent definitive haemostasis. This resuscitation tool continues to evolve and has recently achieved some consensus defined indications for its use. The aim of this study is designed to examine the potential utility of REBOA among trauma victims who die within 24 h of arrival. METHODS Data of all trauma patients who died in the first 24 h, from 2012 to 2017 were extracted from the National Trauma Registry in the Gertner Institute for Epidemiology and Health Policy Research. Patients who died in the first half an hour, and those with neck and thorax injuries were excluded. Demographics, clinical and injury data were collected. RESULTS Overall, 129 patients were included; 74% male and 26% female with the mean age of 46.4 years. A total of 76% suffered blunt trauma and 24% penetrating trauma. Mean survival time was 5.87 h. The cause of death was major abdominal organ injury in 47.2%, injury to major abdominal vessel in 23.3% and pelvic fractures in 21.7%. A total of 69 patients (53.5%) ultimately required delayed resuscitative thoracotomy in the operation room. CONCLUSION Registry data suggest that there is a subset of patients presenting to modern trauma centres who might benefit from REBOA in order to avoid death.
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Affiliation(s)
- Yaakov Daskal
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yehuda Hershkovitz
- Department of Surgery, Shamir Medical Center, Zerifin, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Joseph J Dubose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Boris Kessel
- Surgical Division, Hillel Yaffe Medical Center, Hadera, Israel
| | - Igor Jeroukhimov
- Department of Surgery, Shamir Medical Center, Zerifin, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Tel Hashomer, Israel
| | - Mickey Dudkiewicz
- Hospital Administration, Hillel Yaffe Medical Center, Hadera, Israel
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23
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Abstract
Introduction Retrospective trauma scores are often used to categorise trauma, however, they have little utility in the prehospital or hyper-acute setting and do not define major trauma to non-specialists. This study employed a Delphi process in order to gauge degrees of consensus/disagreement amongst expert panel members to define major trauma. Method A two round modified Delphi technique was used to explore subject-expert consensus and identify variables to define major trauma through systematically collating questionnaire responses. After initial descriptive analysis of variables, Kruskal-Wallis tests were used to determine statistically significant differences (p < 0.05) in response to the Delphi statements between professional groups. A hierarchical cluster analysis was undertaken to identify patterns of similarity/difference of response. A grounded theory approach to qualitative analysis of data allowed for potentially multiple iterations of the Delphi process to be influenced by identified themes. Results Of 55 expert panel members invited to participate, round 1 had 43 participants (Doctor n = 20, Paramedic n = 20, Nurse n = 5, other n = 2). No consistent patterns of opinion emerged with regards to professional group. Cluster analysis identified three patterns of similar responses and coded as trauma minimisers, the middle ground and the risk averse. Round 2 had 35 respondents with minimum change in opinion between rounds. Consensus of > 70% was achieved on many variables which included the identification of life/limb threatening injuries, deranged physiology, need for intensive care interventions and that extremes of age need special consideration. It was also acknowledged that retrospective injury severity scoring has a role to play but is not the only method of defining major trauma. Various factors had a majority of agreement/disagreement but did not meet the pre-set criteria of 70% agreement. These included the topics of burns, spinal immobilisation and whether a major trauma centre is the only place where major trauma can be managed. Conclusion Based upon the output of this Delphi study, major trauma may be defined as: “Significant injury or injuries that have potential to be life-threatening or life-changing sustained from either high energy mechanisms or low energy mechanisms in those rendered vulnerable by extremes of age”. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00870-w.
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Affiliation(s)
- Lee Thompson
- North East Ambulance Service NHS Foundation Trust, Ambulance HQ, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, England. .,Northumbria University, Coach Lane Campus, Coach Lane, Newcastle Upon Tyne, NE7 7TR, England.
| | - Michael Hill
- Northumbria University, Coach Lane Campus, Coach Lane, Newcastle Upon Tyne, NE7 7TR, England
| | - Fiona Lecky
- University of Sheffield, Western Bank, Sheffield, S10 2TN, England.,University of Manchester, Oxford Rd, Manchester, M13 9PL, England.,Salford Royal Hospitals NHS Foundation Trust, Stott Lane, Salford, M6 8HD, England.,Trauma Audit and Research Network, Summerfield House, 544 Eccles New Road, Salford, M5 5AP, England
| | - Gary Shaw
- North East Ambulance Service NHS Foundation Trust, Ambulance HQ, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle Upon Tyne, NE15 8NY, England
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24
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Affiliation(s)
- Daniel Y Ellis
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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25
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Russo RM, White JM, Baer DG. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta: A Systematic Review of the Preclinical and Clinical Literature. J Surg Res 2021; 262:101-114. [PMID: 33561721 DOI: 10.1016/j.jss.2020.12.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become a standard adjunct for the management of life-threatening truncal hemorrhage, but the technique is limited by the sequalae of ischemia distal to occlusion. Partial REBOA addresses this limitation, and the recent Food and Drug Administration approval of a device designed to enable partial REBOA will broaden its application. We conducted a systematic review of the available animal and clinical literature on the methods, impacts, and outcomes associated with partial REBOA as a technique to enable targeted proximal perfusion and limit distal ischemic injury. We hypothesize that a systematic review of the published animal and human literature on partial REBOA will provide actionable insight for the use of partial REBOA in the context of future wider clinical implementation of this technique. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines, we conducted a search of the available literature which used partial inflation of a REBOA balloon catheter. Findings from 22 large animal studies and 14 clinical studies met inclusion criteria. RESULTS Animal and clinical results support the benefits of partial REBOA including extending the resuscitative window extended safe occlusion time, improved survival, reduced proximal hypertension, and reduced resuscitation requirements. Clinical studies provide practical physiologic targets for partial REBOA including a period of total occlusion followed by gradual balloon deflation to achieve a target proximal pressure and/or target distal pressure. CONCLUSIONS Partial REBOA has several benefits which have been observed in animal and clinical studies, most notably reduced ischemic insult to tissues distal to occlusion and improved outcomes compared with total occlusion. Practical clinical protocols are available for the implementation of partial REBOA in cases of life-threatening torso hemorrhage.
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Affiliation(s)
- Rachel M Russo
- United States Air Force, 60(Th) Medical Group, Travis Air Force Base, California; University of California Davis Medical Center, Sacramento, California
| | - Joseph M White
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Cardinale M, Cungi PJ, Avaro JP, Bordes J. A REBOA Complication: EtCO 2 Is Not Just a Marker of Cardiac Output. Ann Vasc Surg 2021; 73:571-573. [PMID: 33549786 DOI: 10.1016/j.avsg.2020.12.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/17/2020] [Accepted: 12/25/2020] [Indexed: 11/15/2022]
Abstract
We describe an as yet undescribed complication, namely, the perforation of the balloon at a distance from its introduction and the use of EtCO2 to suspect the diagnosis. Following a high-kinetic motorcycle accident, a 25-year-old patient was admitted in our level 1 trauma center, and benefited from a resuscitation thoracotomy followed by a REBOA catheter in zone 3. The use of a small caliber introducer could be responsible for balloon injury. EtCO2 is not only a marker of cardiac output and its sudden increase in this situation should raise questions about the recirculation of ischemia product and therefore the effectiveness of the occlusion balloon.
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Affiliation(s)
- Michael Cardinale
- Intensive Care Unit, Military Teaching Hospital Sainte Anne, Toulon, France.
| | | | - Jean-Philippe Avaro
- Department of Anesthesia, Military Teaching Hospital Sainte Anne, Toulon, France
| | - Julien Bordes
- Thoracic Surgery Department, Military Teaching Hospital Sainte Anne, Toulon, France
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Samuels JM, Sun K, Moore EE, Coleman JR, Fox CJ, Cohen MJ, Sauaia A, MacTaggart JN. Resuscitative endovascular balloon occlusion of the aorta-Interest is widespread but need for training persists. J Trauma Acute Care Surg 2020; 89:e112-6. [PMID: 33009200 DOI: 10.1097/TA.0000000000002855] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hilbert-Carius P, McGreevy D, Abu-Zidan FM, Hörer TM. Successfully REBOA performance: does medical specialty matter? International data from the ABOTrauma Registry. World J Emerg Surg 2020; 15:62. [PMID: 33228705 PMCID: PMC7685615 DOI: 10.1186/s13017-020-00342-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure being increasingly utilized to prevent patients with non-compressible torso hemorrhage from exsanguination. The increased use of REBOA is giving rise to discussion about "Who is and who should be performing it?" METHODS Data from the international ABO (aortic balloon occlusion) Trauma Registry from between November 2014 and April 2020 were analyzed concerning the question: By who, how, and where is REBOA being performed? The registry collects retrospective and prospective data concerning use of REBOA in trauma patients. RESULTS During the study period, 259 patients had been recorded in the registry, 72.5% (n = 188) were males with a median (range) age of 46 (10-96) years. REBOA was performed in the ER in 50.5%, in the OR in 41.5%, and in the angiography suite in 8% of patients. In 54% of the patients REBOA was performed by surgeons (trauma surgeons 28%, vascular surgeons 22%, general surgeons 4%) and in 46% of the patients by non-surgeons (emergency physicians 31%, radiologists 9.5%, anesthetists 5.5%). Common femoral artery (CFA) access was achieved by use of external anatomic landmarks and palpation alone in 119 patients (51%), by cutdown in 57 patients (24%), using ultrasound in 49 patients (21%), and by fluoroscopy in 9 patients (4%). Significant differences between surgeons and non-surgeons were found regarding patient's age, injury severity, access methods, place where REBOA was performed, location patients were taken to from the emergency room, and mortality. CONCLUSION A substantial number of both surgical and non-surgical medical disciplines are successfully performing REBOA to an almost equal extent. Surgical cutdown is used less frequently as access to the CFA compared with reports in older literature and puncture by use of external anatomic landmarks and palpation alone is used with a high rate of success. Instead of discussing "Who should be performing REBOA?" future research should focus on "Which patient benefits most from REBOA?"
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Bergmannstrost Hospital Halle, Mersbuegerstraße 165, 06112, Halle (Saale), Germany.
| | - David McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Science, UAE University, Al-Ain, United Arab Emirates
| | - 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
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Yamamoto R, Suzuki M, Funabiki T, Nishida Y, Maeshima K, Sasaki J. Resuscitative endovascular balloon occlusion of the aorta and traumatic out-of-hospital cardiac arrest: A nationwide study. J Am Coll Emerg Physicians Open 2020; 1:624-632. [PMID: 33000081 PMCID: PMC7493555 DOI: 10.1002/emp2.12177] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/29/2020] [Accepted: 06/09/2020] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive method for temporary hemostasis compared with cross-clamping the aorta through resuscitative thoracotomy (RT). Although the survival benefits of REBOA remained unclear, pathophysiological benefits were identified in patients with traumatic out-of-hospital cardiac arrest (t-OHCA). We examined the clinical outcomes of t-OHCA with the hypothesis that REBOA would be associated with higher survival to discharge compared with RT. METHODS A retrospective cohort study was conducted using the Japan Trauma Data Bank (2004-2019). Adult patients with t-OHCA who had arrived without a palpable pulse and undergone aortic occlusion were included. Patients were divided into REBOA or RT groups, and propensity scores were developed using age, mechanism of injury, presence of signs of life, presence of severe head and/or chest injury, Injury Severity Score, and transportation time. Inverse probability weighting by propensity scores was performed to compare survival to discharge between the 2 groups. RESULTS Among 13,247 patients with t-OHCA, 1483 were included in this study. A total of 144 (9.7%) patients were treated with REBOA, and 5 of 144 (3.5%) in the REBOA group and 10 of 1339 (0.7%) in the RT group survived to discharge. The use of REBOA was significantly associated with increased survival to discharge (odds ratio, 4.78; 95% confidence interval, 1.61-14.19), which was confirmed by inverse probability weighting (adjusted odds ratio, 3.73; 95% confidence interval, 1.90-7.32). CONCLUSIONS REBOA for t-OHCA was associated with higher survival to discharge. These results should be validated by further research.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care MedicineKeio University School of MedicineShinjukuTokyoJapan
| | - Masaru Suzuki
- Department of Emergency MedicineTokyo Dental CollegeIchikawa General HospitalIchikawaChibaJapan
| | - Tomohiro Funabiki
- Department of Trauma and Emergency SurgerySaiseikai Yokohamashi Tobu HospitalTsurumikuYokohamaKanagawaJapan
| | - Yusho Nishida
- Department of Emergency and Critical Care MedicineKeio University School of MedicineShinjukuTokyoJapan
| | - Katsuya Maeshima
- Department of Emergency and Critical Care MedicineKeio University School of MedicineShinjukuTokyoJapan
| | - Junichi Sasaki
- Department of Emergency and Critical Care MedicineKeio University School of MedicineShinjukuTokyoJapan
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Abstract
This is a case report of a patient who sustained a stab wound to the right axilla with injuries to the right axillary artery and vein. The patient had near-exsanguination in the field and no recordable blood pressure upon admission to the trauma center. Resuscitation was performed with endotracheal intubation, a left anterolateral resuscitative thoracotomy with cross-clamping of the descending thoracic aorta, and the rapid infusion of crystalloid solutions and packed red cells. In the operating room, the third portion of the right axillary artery and the adjacent right axillary vein were found to be transected. As part of a ‘damage control’ procedure, the ends of the right axillary vein were ligated. A 14 French intra-arterial shunt was inserted into the transected ends of the right axillary artery to restore the flow to the right upper extremity. The patient’s postoperative course was complicated by a coagulopathy, adult respiratory distress syndrome (ARDS), and anuria. The coagulopathy and anuria resolved within the first 48 hours, but the patient’s ARDS was slow to resolve. On the 10th postinjury day, the patient was returned to the operating room for a definitive repair of the right axillary artery. After the intra-arterial shunt was removed, a reversed greater saphenous vein graft was inserted between the ends of the right axillary artery in a medial intermuscular (extra-anatomic) tunnel. The patient made an uneventful recovery and was discharged home on the 16th postinjury day. The following principles of advanced trauma care were part of the management of this patient: (1) occasional need for resuscitative thoracotomy with cross-clamping of the descending thoracic aorta in a patient without a thoracic injury; (2) ‘damage control’ operation with ligation of the right axillary vein and placement of a temporary intra-arterial shunt to restore the flow to the right upper extremity; and (3) vascular reconstruction with an extra-anatomic bypass in a previously contaminated field.
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Affiliation(s)
- David V Feliciano
- Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Wortmann M, Engelhart M, Elias K, Popp E, Zerwes S, Hyhlik-Dürr A. [Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]. Chirurg 2020; 91:934-942. [PMID: 32514942 PMCID: PMC7581582 DOI: 10.1007/s00104-020-01180-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hintergrund „Resuscitative endovascular balloon occlusion of the aorta“ (REBOA) stellt ein endovaskuläres Verfahren dar, bei dem ein Blockballon in die Aorta eingeführt wird, um eine distal des Ballons gelegene Blutung zu verringern und gleichzeitig die kardiale und zerebrale Oxygenierung zu verbessern. Ziel der Arbeit Vorstellung der REBOA-Technik, der möglichen Indikationen, der benötigen Materialien und der möglichen Komplikationen des Verfahrens. Material und Methoden Nichtsystematischer Übersichtsartikel über die aktuelle Literatur. Ergebnisse REBOA stellt gerade bei traumatisch bedingten Blutungen und rupturierten Aortenaneurysmen ein mögliches additives Verfahren zur hämodynamischen Stabilisierung dar. Die Komplikationsrate des Verfahrens liegt bei ungefähr 5 %, wobei Zugangskomplikationen im Vordergrund stehen, jedoch auch letale Komplikationen möglich sind. Diskussion Eine aortale Ballonblockade wird bei der Versorgung rupturierter Aortenaneurysmen standardmäßig eingesetzt. Es gibt wachsende Evidenz, dass REBOA bei der Versorgung polytraumatisierter Patienten mit einem hämorrhagischen Schock aufgrund einer abdominellen oder viszeralen Blutung eine vergleichsweise minimal-invasive Alternative zur offen chirurgischen Aortenklemmung mittels Thorakotomie darstellt. Mit der Entwicklung neuer Ballonkatheter, die ohne Führungsdraht und mit geringeren Schleusendurchmessern auskommen, wird auch ein Einsatz bei anderen Krankheitsbildern wie postoperativen abdominellen Nachblutungen, gynäkologischen Blutungen oder als additives Verfahren bei der kardiopulmonalen Reanimation diskutiert.
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Affiliation(s)
- M Wortmann
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Engelhart
- Klinik für Gefäßchirurgie und Endovasku-läre Chirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - K Elias
- Abteilung für Gefäßchirurgie, Bundeswehrkrankenhaus Westerstede/Ammerland Klinik, Westerstede, Deutschland
| | - E Popp
- Sektion Notfallmedizin, Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - S Zerwes
- Gefäßchirurgie und endovaskuläre Chirurgie, Medizinische Fakultät, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland
| | - Alexander Hyhlik-Dürr
- Gefäßchirurgie und endovaskuläre Chirurgie, Medizinische Fakultät, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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Hilbert-Carius P, McGreevy DT, Abu-Zidan FM, Hörer TM. Pre-hospital CPR and early REBOA in trauma patients - results from the ABOTrauma Registry. World J Emerg Surg 2020; 15:23. [PMID: 32228640 PMCID: PMC7104487 DOI: 10.1186/s13017-020-00301-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Severely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR. Methods Retrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate. Results Of 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25–75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8–70) minutes significantly increases blood pressure from the median (range) 56.5 (0–147) to 90 (0–200) mmHg. Conclusions Mortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Emergency and Intensive Care Medicine, Bergmannstrost BG-Klinikum Halle gGmbH, Merseburgerstr. 165, 06112, Halle, Germany.
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Science, UAE University, Al-Ain, United Arab Emirates
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Fitzgerald M, Lendrum R, Bernard S, Moloney J, Smit DV, Mathew J, Kim Y, Nickson C, Lin RMH, Yeung M, Bystrzycki A, Niggemeyer L, Hendel S, Mitra B. Feasibility study for implementation of resuscitative balloon occlusion of the aorta in peri-arrest, exsanguinating trauma at an adult level 1 Australian trauma centre. Emerg Med Australas 2019; 32:127-134. [PMID: 31867879 DOI: 10.1111/1742-6723.13443] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 10/27/2019] [Accepted: 11/10/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This prospective, observational, interventional study sought to determine if the introduction of resuscitative balloon occlusion of the aorta (REBOA) at an Australian adult major trauma centre would improve survival for major trauma patients. METHODS Patients aged 18-60 years, transported directly from scene with exsanguinating, sub-diaphragmatic haemorrhage and hypovolaemic shock (systolic BP <70 mmHg or hypovolaemic cardiac arrest) were eligible for recruitment and followed up until hospital discharge (ACTRN12618000550202). RESULTS During the 14-month study period (17 January 2015 to 12 March 2016) 3032 patients were admitted direct from scene with an overall mortality of 97 (3.71%). Of these patients 3019 had trauma centre vital signs recorded in the data set (99.57%) and 1523 were between the ages of 18-60, including 143 patients with a shock index of >1.0 (4.74%). There were 13 (0.43%) patients with a systolic BP <70 mmHg and/or cardiorespiratory arrest on arrival. The mortality in this group was six out of 13 (46.15%). Of these 13 patients, there were two (0.07% of the total cohort) where REBOA was attempted. There were no eligible patients for whom REBOA was achieved. None of the six patients who died would have benefited from REBOA deployment. CONCLUSIONS Despite considerable training and resource allocation to ensure 24-h availability, the introduction of REBOA failed to effectively demonstrate any impact on patient outcome. Despite retrospective literature supporting the introduction of REBOA, in this 14-month prospective study there was no evidence of benefit. Further studies may define indications and subgroups of patients who may benefit.
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Affiliation(s)
- Mark Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Ambulance Victoria, Melbourne, Victoria, Australia
| | - Robbie Lendrum
- Anaesthetics and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia.,Anaesthesia and Intensive Care, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.,London HEMS, Royal London Hospital, Bart's Health NHS Trust, London, UK
| | - Stephen Bernard
- Ambulance Victoria, Melbourne, Victoria, Australia.,Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John Moloney
- Ambulance Victoria, Melbourne, Victoria, Australia.,Anaesthetics and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph Mathew
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Yesul Kim
- National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia
| | - Chris Nickson
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Australian Centre for Health Innovation, Melbourne, Victoria, Australia
| | - Richard M-H Lin
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Emergency and Critical Care Medicine, Lin Shin Hospital, Taichung, Taiwan
| | - Meei Yeung
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia
| | - Adam Bystrzycki
- National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Louise Niggemeyer
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia
| | - Simon Hendel
- Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Anaesthetics and Perioperative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Monash University, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
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