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Jin X, Chu Q, Bing H, Li F, Bai J, Lou J, Sun L, Zhang C, Lin L, Li L, Wang H, Zhou Z, Zhang J, Lian H. Preperitoneal pelvic balloon tamponade-an effective intervention to control pelvic injury hemorrhage in a swine model. Front Bioeng Biotechnol 2024; 12:1340765. [PMID: 38737537 PMCID: PMC11082274 DOI: 10.3389/fbioe.2024.1340765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 04/11/2024] [Indexed: 05/14/2024] Open
Abstract
Objective: This study aimed to estimate the effects of the volume of preperitoneal balloon (PPB) on arterial and venous hemorrhage in a swine pelvic fracture model. Methods: Twenty-four swine were randomized into 0-mL, 500-mL, 800-mL, and 1000-mL intra-hematoma PPB groups. They were subjected to open-book pelvic fracture and reproducible injuries in the external iliac artery and vein. The pelvic binder and IH-PPBs with different volumes of fluid were applied to control the active hemorrhage after arterial and venous injuries. The survival time and rate during 60-min observation and digital subtraction angiography (DSA) images were the primary endpoints in this study. Secondary endpoints included survival rate within 70 min, peritoneal pressure, hemodynamics, blood loss, infusion fluid, blood pH, and lactate concentration. Results: Our results indicated that the 800-mL and 1000-mL groups had a higher survival rate (0%, 50%, 100% and 100% for 0, 500, 800, and 1000-mL groups respectively; p < 0.0001) and longer survival time (13.83 ± 2.64, 24.50 ± 6.29, 55.00 ± 6.33, and 60.00 ± 0.00 min for 0, 500, 800, and 1,000 groups respectively; p < 0.0005) than the 0-mL or 500-mL groups during the 60 min observation. Contrastingly, survival rate and time were comparable between 800-mL and 1000-mL groups during the 60-min observation. The IH-PPB volume was associated with an increase in the pressure of the balloon and the preperitoneal pressure but had no effect on the bladder pressure. Lastly, the 1000-mL group had a higher mean arterial pressure and systemic vascular resistance than the 800-mL group. Conclusion: IH-PPB volume-dependently controls vascular bleeding after pelvic fracture in the swine model. IH-PPB with a volume of 800 mL and 1000 mL efficiently managed pelvic fracture-associated arterial and venous hemorrhage and enhanced survival time and rate in the swine model without evidences of visceral injury.
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Affiliation(s)
- Xiaogao Jin
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Qinjun Chu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hailong Bing
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Fang Li
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Jingyue Bai
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junge Lou
- Department of Peripheral Vascular Intervention, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Liwei Sun
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Chenxi Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Lin Lin
- Department of Ultrasound Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Liumei Li
- Department of Anesthesiology, The Second Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong, China
| | - Haibo Wang
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Zhanfeng Zhou
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junfeng Zhang
- Department of Anesthesiology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongkai Lian
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Department of Ultrasound Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Research of Trauma Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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2
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Brenner M. The Role of Resuscitative Endovascular Balloon Occlusion of the Aorta. Surg Clin North Am 2024; 104:311-323. [PMID: 38453304 DOI: 10.1016/j.suc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized by trauma surgeons at the bedside for over a decade in both civilian and military settings. Both translational and clinical research suggest it is superior to resuscitative thoracotomy for specific patient populations. Technological advancements in recent years have significantly enhanced the safety profile of REBOA. Resuscitative balloon occlusion of the aorta has also swiftly found implementation in patients in shock from non-traumatic hemorrhage.
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Affiliation(s)
- Megan Brenner
- UCLA Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, CA 90024, USA.
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3
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Fontenelle Ribeiro Junior MA, Salman SM, Al-Qaraghuli SM, Makki F, Abu Affan RA, Mohseni SR, Brenner M. Complications associated with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review. Trauma Surg Acute Care Open 2024; 9:e001267. [PMID: 38347890 PMCID: PMC10860083 DOI: 10.1136/tsaco-2023-001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/22/2023] [Indexed: 02/15/2024] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become part of the arsenal to temporize patients in shock from severe hemorrhage. REBOA is used in trauma to prevent cardiovascular collapse by preserving heart and brain perfusion and minimizing distal hemorrhage until definitive hemorrhage control can be achieved. Significant side effects, including death, ischemia and reperfusion injuries, severe renal and lung damage, limb ischemia and amputations have all been reported. The aim of this article is to provide an update on complications related to REBOA. REBOA has emerged as a critical intervention for managing severe hemorrhagic shock, aiming to temporize patients and prevent cardiovascular collapse until definitive hemorrhage control can be achieved. However, this life-saving procedure is not without its challenges, with significant reported side effects. This review provides an updated overview of complications associated with REBOA. The most prevalent procedure-related complication is distal embolization and lower limb ischemia, with an incidence of 16% (range: 4-52.6%). Vascular and access site complications are also noteworthy, documented in studies with incidence rates varying from 1.2% to 11.1%. Conversely, bleeding-related complications exhibit lower documentation, with incidence rates ranging from 1.4% to 28.6%. Pseudoaneurysms are less likely, with rates ranging from 2% to 14%. A notable incidence of complications arises from lower limb compartment syndrome and lower limb amputation associated with the REBOA procedure. Systemic complications include acute kidney failure, consistently reported across various studies, with incidence rates ranging from 5.6% to 46%, representing one of the most frequently documented systemic complications. Infection and sepsis are also described, with rates ranging from 2% to 36%. Pulmonary-related complications, including acute respiratory distress syndrome and multisystem organ failure, occur in this population at rates ranging from 7.1% to 17.5%. This comprehensive overview underscores the diverse spectrum of complications associated with REBOA.
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Affiliation(s)
| | | | | | - Farah Makki
- Medicine, University of Sharjah, Sharjah, UAE
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4
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Kim DH, Moon J, Chang SW, Kang BH. Early experience with resuscitative endovascular balloon occlusion of the aorta for unstable pelvic fractures in the Republic of Korea: a multi-institutional study. Eur J Trauma Emerg Surg 2023; 49:2495-2503. [PMID: 37277572 DOI: 10.1007/s00068-023-02293-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/23/2023] [Indexed: 06/07/2023]
Abstract
PURPOSE Recently, trauma centers in the Republic of Korea introduced resuscitative endovascular balloon occlusion of the aorta (REBOA) for application in severe pelvic fracture cases. This study aimed to determine the efficacy of REBOA and its associated factors in enhancing survival. METHODS Data from patients with severe pelvic injuries at two regional trauma centers from 2016 to 2020 were retrospectively reviewed. Patients were dichotomized into REBOA and no-REBOA groups, and patient characteristics and clinical outcomes were compared using 1:1 propensity score matching. Additional survival-based analysis was performed in the REBOA group. RESULTS REBOA was performed in 42 of the 174 patients with pelvic fractures. As patients in the REBOA group had more severe injuries than did patients in the no-REBOA group, 1:1 propensity score matching was performed to adjust for severity. After matching, 24 patients were included in each group and mortality was not significantly different (REBOA 62.5% vs. no-REBOA 41.7%, P = 0.149). Kaplan-Meier analysis revealed no significant differences in mortality between the two matched groups (log-rank test, P = 0.408). Among the 42 patients treated with REBOA, 14 survived. Shorter REBOA duration (63 [40-93] vs. 166 [67-193] min, P = 0.015) and higher systolic blood pressure before REBOA (65 [58-76] vs. 54 [49-69] mmHg, P = 0.035) were associated with better survival. CONCLUSIONS The effectiveness of REBOA has not been definitively established; however, it was not associated with increased mortality in this study. Additional studies are required to better understand how REBOA can be effectively used for treatment.
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Affiliation(s)
- Dong Hun Kim
- Division of Trauma Surgery, Department of Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Jonghwan Moon
- Division of Trauma Surgery, Department of Surgery, Ajou School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-Si, Gyeonggi-Do, 16499, Republic of Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Dankook University College of Medicine, Cheonan, Republic of Korea
| | - Byung Hee Kang
- Division of Trauma Surgery, Department of Surgery, Ajou School of Medicine, 164 Worldcup-Ro, Yeongtong-Gu, Suwon-Si, Gyeonggi-Do, 16499, Republic of Korea.
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Walters S, Cuthbert R, Ward J, Arshad H, Culpan P, Perkins Z, Tai N, Bates P. Causes and associations with mortality in patients with pelvic ring injuries with haemorrhagic shock. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2971-2979. [PMID: 36922411 DOI: 10.1007/s00590-023-03516-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND High energy pelvic ring injuries are associated with significant morbidity and mortality and can be accompanied by haemorrhagic shock following associated vascular injury. This study evaluated the causes and predictors of mortality in haemodynamically unstable pelvic fractures. METHODS This retrospective observational study at a Major Trauma Centre reviewed 938 consecutive adult patients (≥ 18yrs) with pelvic ring injuries between December 2014 and November 2018. Patients with features of haemorrhagic shock were included, defined as: arrival Systolic BP < 90 mmHg, Base Deficit ≥ 6.0 mmol/l, or transfusion of ≥ 4 units of packed red blood cells within 24 h. RESULTS Of the 102 patients included, all sustained injuries from high energy trauma, and 47.1% underwent a haemorrhage control intervention (Resuscitative Endovascular Balloon Occlusion of the Aorta-REBOA, Interventional Radiology-IR, or Laparotomy). These were more often required following vertical shear injuries (OR 10.7, p = 0.036). Overall, 33 patients (32.4%) died; 16 due to a head injury, and only 2 directly from acute pelvic exsanguination (6.1%). Multivariable logistic regression demonstrated that increasing age, Injury Severity Score, Abbreviated Injury Scale (AIS) Head ≥ 3 and open pelvic fracture were all independent predictors of mortality, and IR was associated with reduced mortality. Lateral Compression III (LC3) injuries were associated with mortality due to multiple organ dysfunction syndrome (MODS). CONCLUSION Haemodynamically unstable patients with pelvic ring injuries have a high mortality rate, but death is usually attributed to other injuries or later complications, and not from acute exsanguination. This reflects improvements in resuscitative care, transfusion protocols, and haemorrhage control techniques.
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Affiliation(s)
- Samuel Walters
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK.
| | - Rory Cuthbert
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Jonathan Ward
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Homa Arshad
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Paul Culpan
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Zane Perkins
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Nigel Tai
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
| | - Peter Bates
- Royal London Hospital, Whitechapel Road, Whitechapel, London, E1 1BB, UK
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6
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Chu Q, Jin X, Bing H, Zhang C, Bai J, Li F, Lou J, Sun L, Lin L, Li L, Wang H, Zhou Z, Lian H. RESUSCITATIVE RECTAL BALLOON COMPRESSION COMBINED WITH PELVIC BINDER EFFICIENTLY CONTROLLED FATAL VENOUS HEMORRHAGE IN A HEMODYNAMICALLY UNSTABLE PELVIC FRACTURE CANINE MODEL. Shock 2023; 59:912-921. [PMID: 37001912 PMCID: PMC10227942 DOI: 10.1097/shk.0000000000002116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/31/2023] [Indexed: 04/03/2023]
Abstract
ABSTRACT Objective: This study evaluated the feasibility of a combination of pelvic binder and rectal balloon compression in managing fatal venous hemorrhage in a canine model of pelvic fracture. Methods: Rectums from humans (rectal cancer patients), swine, and canines were retrieved to determine their elasticity by measuring their stress and strain. Canines were selected as the animal model in this study because their rectum demonstrated more reversible strain than swine rectum. Doppler ultrasound was used to assess the effect of rectal balloon volume on the blood flow of pelvic iliac blood vessels in three canines. A rectal balloon of 250 mL was chosen to control pelvic venous bleeding as it could provide a peak effect in reducing the blood flow of bilateral internal iliac veins. Then, the open-book pelvic fracture with fatal bleeding of both internal iliac veins animal model was built. The animals were divided into four groups after the modeled surgery to undergo no treatment, pelvic binder, rectal balloon compression, or a combination of pelvic binder and rectal balloon compression. The treatment efficacy was evaluated based on their survival time, survival rate, blood loss, bleeding rate, infusion rate, blood pH, lactate concentration, the stability of hemodynamics, blood loss, and fluid infusion volume. Results: Our results showed that after the reproducible injuries in both internal iliac veins, the combination of pelvic binder and rectal balloon compression was associated with the best survival rate and survival time compared with the other treatment groups. In addition, the combination of pelvic binder and rectal balloon compression exhibited more stable hemodynamics than the pelvic binder or rectal balloon compression treatment alone. Conclusions: This study demonstrated the potential feasibility of using pelvic binder combined with rectal balloon compression to manage the fatal venous bleeding in pelvic fractures.
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Affiliation(s)
- Qinjun Chu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xiaogao Jin
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Center for Advanced Medicine, College of Medicine, Zhengzhou University, Zhengzhou, China
- Trauma Research Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hailong Bing
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Chenxi Zhang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Jingyue Bai
- Department of Peripheral Vascular Intervention, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Fang Li
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Junge Lou
- Department of Ultrasound Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, Henan
| | - Liwei Sun
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Lin Lin
- Center for Advanced Medicine, College of Medicine, Zhengzhou University, Zhengzhou, China
- Trauma Research Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Liumei Li
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Haibo Wang
- Department of Peripheral Vascular Intervention, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Zhanfeng Zhou
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Hongkai Lian
- Department of Orthopedics, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
- Trauma Research Center, Zhengzhou Central Hospital Affiliated to Zhengzhou University, Zhengzhou, China
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7
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Shaw J, Brenner M. Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results. Semin Vasc Surg 2023; 36:250-257. [PMID: 37330238 DOI: 10.1053/j.semvascsurg.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 06/19/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.
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Affiliation(s)
- Joanna Shaw
- Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, California, 90024
| | - Megan Brenner
- Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, California, 90024.
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8
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Harfouche MN, Feliciano DV, Kozar RA, DuBose JJ, Scalea TM. A Cautionary Tale: The Use of Propensity Matching to Evaluate Hemorrhage-Related Trauma Mortality in the American College of Surgeons TQIP Database. J Am Coll Surg 2023; 236:1208-1216. [PMID: 36847370 DOI: 10.1097/xcs.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Propensity-matched methods are increasingly being applied to the American College of Surgeons TQIP database to evaluate hemorrhage control interventions. We used variation in systolic blood pressure (SBP) to demonstrate flaws in this approach. STUDY DESIGN Patients were divided into groups based on initial SBP (iSBP) and SBP at 1 hour (2017 to 2019). Groups were defined as follows: iSBP 90 mmHg or less who decompensated to 60 mmHg or less (immediate decompensation [ID]), iSBP 90 mmHg or less who remained greater than 60 mmHg (stable hypotension [SH]), and iSBP greater than 90 mmHg who decompensated to 60 mmHg or less (delayed decompensation [DD]). Individuals with Head or Spine Abbreviated Injury Scale score 3 or greater were excluded. Propensity score was assigned using demographic and clinical variables. Outcomes of interest were in-hospital mortality, emergency department death, and overall length of stay. RESULTS Propensity matching yielded 4,640 patients per group in analysis #1 (SH vs DD) and 5,250 patients per group in analysis #2 (SH vs ID). The DD and ID groups had 2-fold higher in-hospital mortality than the SH group (DD 30% vs 15%, p < 0.001; ID 41% vs 18%, p < 0.001). Emergency department death rate was 3 times higher in the DD group and 5 times higher in the ID group (p < 0.001), and length of stay was 4 days shorter in the DD group and 1 day shorter in the ID group (p < 0.001). Odds of death were 2.6 times higher for the DD vs SH group and 3.2 times higher for the ID vs SH group (p < 0.001). CONCLUSIONS Differences in mortality rate by SBP variation underscore the difficulty of identifying individuals with a similar degree of hemorrhagic shock using the American College of Surgeons TQIP database despite propensity matching. Large databases lack the detailed data needed to rigorously evaluate hemorrhage control interventions.
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Affiliation(s)
- Melike N Harfouche
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - David V Feliciano
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Rosemary A Kozar
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
| | - Joseph J DuBose
- Dell Medical School, University of Texas at Austin, Austin, TX (DuBose)
| | - Thomas M Scalea
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD (Harfouche, Feliciano, Kozar, Scalea)
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9
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 92.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Chien CY, Lewis MR, Dilday J, Biswas S, Luo Y, Demetriades D. Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study. Am J Surg 2023; 225:414-419. [PMID: 36253317 DOI: 10.1016/j.amjsurg.2022.09.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.
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Affiliation(s)
- Chih-Ying Chien
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Joshua Dilday
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Subarna Biswas
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Yong Luo
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Trauma Center & Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States.
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Anand T, El-Qawaqzeh K, Nelson A, Hosseinpour H, Ditillo M, Gries L, Castanon L, Joseph B. Association Between Hemorrhage Control Interventions and Mortality in US Trauma Patients With Hemodynamically Unstable Pelvic Fractures. JAMA Surg 2023; 158:63-71. [PMID: 36449300 PMCID: PMC9713682 DOI: 10.1001/jamasurg.2022.5772] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022]
Abstract
Importance Management of hemodynamically unstable pelvic fractures remains a challenge. Hemostatic interventions are used alone or in combination. There is a paucity of data on the association between the pattern of hemorrhage control interventions and outcomes after a severe pelvic fracture. Objective To characterize clinical outcomes and study the patterns of hemorrhage control interventions in hemodynamically unstable pelvic fractures. Design, Setting, and Participants In this cohort study, a retrospective review was performed of data from the 2017 American College of Surgeons Trauma Quality Improvement Program database, a national multi-institutional database of trauma patients in the United States. Adult patients (aged ≥18 years) with pelvic fractures who received early transfusions (≥4 units of packed red blood cells in 4 hours) and underwent intervention for pelvic hemorrhage control were identified. Use and order of preperitoneal pelvic packing (PP), pelvic angioembolization (AE), and resuscitative endovascular balloon occlusion of the aorta (REBOA) in zone 3 were examined and compared against the primary outcome of mortality. The associations between intervention patterns and mortality, complications, and 24-hour transfusions were further examined by backward stepwise regression analyses. Data analyses were performed in September 2021. Main Outcomes and Measures Primary outcomes were rates of 24-hour, emergency department, and in-hospital mortality. Secondary outcomes were major in-hospital complications. Results A total of 1396 patients were identified. Mean (SD) age was 47 (19) years, 975 (70%) were male, and the mean (SD) lowest systolic blood pressure was 71 (25) mm Hg. The median (IQR) Injury Severity Score was 24 (14-34), with a 24-hour mortality of 217 patients (15.5%), ED mortality of 10 patients (0.7%), in-hospital mortality of 501 patients (36%), and complication rate of 574 patients (41%). Pelvic AE was the most used intervention (774 [55%]), followed by preperitoneal PP (659 [47%]) and REBOA zone 3 (126 [9%]). Among the cohort, 1236 patients (89%) had 1 intervention, 157 (11%) had 2 interventions, and 3 (0.2%) had 3 interventions. On regression analyses, only pelvic AE was associated with a mortality reduction (odds ratio [OR], 0.62; 95% CI, 0.47 to 0.82; P < .001). Preperitoneal PP was associated with increased odds of complications (OR, 1.39; 95% CI, 1.07 to 1.80; P = .01). Increasing number of interventions was associated with increased 24-hour transfusions (β = +5.4; 95% CI, +3.5 to +7.5; P < .001) and mortality (OR, 1.57; 95% CI, 1.05 to 2.37; P = .03), but not with complications. Conclusions and Relevance This study found that among patients with pelvic fracture who received early transfusions and at least 1 invasive pelvic hemorrhage control intervention, more than 1 in 3 died, despite the availability of advanced hemorrhage control interventions. Only pelvic AE was associated with a reduction in mortality.
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Affiliation(s)
- Tanya Anand
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Khaled El-Qawaqzeh
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Adam Nelson
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Hamidreza Hosseinpour
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Michael Ditillo
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Lynn Gries
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Lourdes Castanon
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
| | - Bellal Joseph
- College of Medicine, Division of Trauma, Critical Care, Burns, and Emergency Surgery, Department of Surgery, University of Arizona, Tucson
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12
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Wu YT, Nichols C, Chien CY, Lewis MR, Demetriades D. REBOA in trauma and the risk of venous thromboembolic complications: A matched-cohort study. Am J Surg 2022; 225:1091-1095. [DOI: 10.1016/j.amjsurg.2022.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022]
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13
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Patterson JT, Wier J, Gary JL. Preperitoneal Pelvic Packing for Hypotension Has a Greater Risk of Venous Thromboembolism Than Angioembolization: Management of Refractory Hypotension in Closed Pelvic Ring Injury. J Bone Joint Surg Am 2022; 104:1821-1829. [PMID: 35939780 DOI: 10.2106/jbjs.22.00252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patients with traumatic pelvic ring injury may present with hypotension secondary to hemorrhage. Preperitoneal pelvic packing (PPP) and angioembolization (AE) are alternative interventions for management of hypotension associated with pelvic ring injury refractory to resuscitation and circumferential compression. We hypothesized that PPP may be independently associated with increased risk of venous thromboembolism (VTE) compared with AE in patients with hypotension and pelvic ring injury. METHODS Adult patients with pelvic ring injury and hypotension managed with PPP or AE were retrospectively identified in the Trauma Quality Improvement Program (TQIP) database from 2015 to 2019. Patients were matched on a propensity score for receiving PPP based on patient, injury, and treatment factors. The primary outcome was the risk of VTE after matching on the propensity score for treatment. The secondary outcomes included inpatient clinically important deep vein thrombosis, pulmonary embolism, respiratory failure, mortality, unplanned reoperation, sepsis, surgical site infection, hospital length of stay, and intensive care unit (ICU) length of stay. RESULTS In this study, 502 patients treated with PPP and 2,439 patients treated with AE met inclusion criteria. After propensity score matching on age, smoking status, Injury Severity Score, Tile B or C pelvic ring injury, bilateral femoral fracture, serious head injury, units of plasma and platelets given within 4 hours of admission, laparotomy, and level-I trauma center facility designation, 183 patients treated with PPP and 183 patients treated with AE remained. PPP, compared with AE, was associated with a 9.8% greater absolute risk of VTE, 6.5% greater risk of clinically important deep vein thrombosis, and 4.9% greater risk of respiratory failure after propensity score matching. CONCLUSIONS PPP for the management of hypotension associated with pelvic ring injury is associated with higher rates of inpatient VTE events and sequelae compared with AE. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Joseph T Patterson
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Julian Wier
- Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Joshua L Gary
- Department of Orthopaedic Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California
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14
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Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry. Injury 2022; 53:2126-2132. [PMID: 35341594 DOI: 10.1016/j.injury.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 02/23/2022] [Accepted: 03/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Aortic occlusion (AO) to facilitate the acute resuscitation of trauma and acute care surgery patients in shock remains a controversial topic. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an increasingly deployed method of AO. We hypothesized that in patients with non-compressible hemorrhage below the aortic bifurcation, the use of REBOA instead of open AO may be associated with a survival benefit. METHODS From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, we identified 1494 patients requiring AO from 45 Level I and 4 Level II trauma centers. Presentation, intervention, and outcome variables were analyzed to compare REBOA vs open AO in patients with non-compressible hemorrhage below the aortic bifurcation. RESULTS From December 2014 to January 2019, 217 patients with Zone 3 REBOA or Open AO who required pelvic packing, pelvic fixation or pelvic angio-embolization were identified. Of these, 109 AO patients had injuries isolated to below the aortic bifurcation (REBOA, 84; open AO, 25). Patients with intra-abdominal or thoracic sources of bleeding, above deployment Zone 3 were excluded. Overall mortality was lower in the REBOA group (35.% vs 80%, p <.001). Excluding patients who arrived with CPR in progress, the REBOA group had lower mortality (33.33% vs. 68.75%, p = 0.012). Of the survivors, systemic complications were not significantly different between groups. In the REBOA group, 16 patients had complications secondary to vascular access. Intensive care lengths of stay and ventilator days were both significantly shorter in REBOA patients who survived to discharge. CONCLUSIONS This study compared outcomes for patients with hemorrhage below the aortic bifurcation treated with REBOA to those treated with open AO. Survival was significantly higher in REBOA patients compared to open AO patients, while complications in survivors were not different. Given the higher survival in REBOA patients, we conclude that REBOA should be used for patients with hemorrhagic shock secondary to pelvic trauma instead of open AO. LEVEL III EVIDENCE Therapeutic.
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15
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Place du packing pré-péritonéal pelvien dans les traumatismes graves du bassin : étude à partir de 20 cas réalisés dans un trauma center de niveau 1 français. Prog Urol 2022; 32:541-550. [DOI: 10.1016/j.purol.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/04/2022] [Accepted: 02/17/2022] [Indexed: 11/17/2022]
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16
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Laverty RB, Treffalls RN, McEntire SE, DuBose JJ, Morrison JJ, Scalea TM, Moore LJ, Podbielski JM, Inaba K, Piccinini A, Kauvar DS. Life over limb: Arterial access-related limb ischemic complications in 48-hour REBOA survivors. J Trauma Acute Care Surg 2022; 92:723-728. [PMID: 34789696 DOI: 10.1097/ta.0000000000003440] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used in some trauma settings. Arterial access-related limb ischemic complications (ARLICs) resulting from the femoral arterial access required for REBOA are largely under reported. We sought to describe the incidence of these complications and the clinical, technical, and device factors associated with their development. METHODS This was a retrospective cohort study of records of adult trauma patients from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between October 2013 and September 2020 who had REBOA and survived at least 48 hours. The primary outcome was ARLIC, defined as clinically relevant extremity ischemia or distal embolization. Relevant factors associated with ARLIC were also analyzed. RESULTS Of 418 identified patients, 36 (8.6%) sustained at least one ARLIC; 22 with extremity ischemia, 25 with distal embolism, 11 with both. Patient demographics and injury characteristics were similar between ARLIC and no ARLIC groups. Access-related limb ischemic complication was associated with larger profile devices (p = 0.009), cutdown access technique (p = 0.02), and the presence of a pelvic external fixator/binder (p = 0.01). Patients with ARLIC had higher base deficit (p = 0.03) and lactate (p = 0.006). One hundred fifty-six patients received tranexamic acid (TXA), with 22 (14%) ARLICs. The rate of TXA use among ARLIC patients was 61% (vs. 35% TXA for non-ARLIC patients, p = 0.002). Access-related limb ischemic complication did not result in additional in-hospital mortality, however, ARLIC had prolonged hospital LOS (31 vs. 24 days, p = 0.02). Five ARLIC required surgical intervention, three patch angioplasty (and two with associated bypass), and four ARLIC limbs were amputated. CONCLUSION Femoral artery REBOA access carries a risk of ARLIC, which is associated with unstable pelvis fractures, severe shock, and strongly with the administration of TXA. Use of lower-profile devices and close surveillance for these complications is warranted in these settings and caution should be exercised when using TXA in conjunction with REBOA. LEVEL OF EVIDENCE Prognostic and Epidemiologic, Level III.
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Affiliation(s)
- Robert B Laverty
- From the Department of Surgery (R.B.L.), Brooke Army Medical Center, JBSA Fort Sam Houston, Houston; Department of Surgery, University of the Incarnate Word School of Medicine (R.N.T.), San Antonio; Department of Surgery, Vascular Surgery Service (S.E.M., D.S.K.), Brooke Army Medical Center, JBSA Fort Sam Houston, Houston, Texas; Department of Surgery, University of Maryland/R Adams Cowley Shock Trauma Center (J.J.D., J.J.M., T.M.S.), Baltimore, Maryland; Department of Surgery, University of Texas Health Sciences Center-Houston (L.J.M., J.M.P.), Houston, Texas; Department of Surgery, Los Angeles County + University of Southern California Hospital (K.I., A.P.), Los Angeles, California; and Department of Surgery (D.S.K.), Uniformed Services University, Bethesda, Maryland
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17
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Granieri S, Frassini S, Cimbanassi S, Bonomi A, Paleino S, Lomaglio L, Chierici A, Bruno F, Biondi R, Di Saverio S, Khan M, Cotsoglou C. Impact of resuscitative endovascular balloon occlusion of the aorta (REBOA) in traumatic abdominal and pelvic exsanguination: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:3561-3574. [DOI: 10.1007/s00068-022-01955-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 03/13/2022] [Indexed: 12/29/2022]
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18
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Snyder JA, Schuerer DJ, Bochicchio GV, Hoofnagle MH. When REBOA grows wings: Resuscitative endovascular balloon occlusion of the aorta to facilitate aeromedical transport. Trauma Case Rep 2022; 38:100622. [PMID: 35252526 PMCID: PMC8889235 DOI: 10.1016/j.tcr.2022.100622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/28/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a helpful adjunct in the control of non-compressible truncal hemorrhage. Concerns regarding ischemia time limits its applicability in transfer. We describe the first reported case of civilian transfer via aeromedical transport to a higher level of care with a zone 3 REBOA catheter deployed. Case report We present the case of a patient in hemorrhagic shock with a complex pelvic fracture exceeding the capability of a rural level-two trauma center requiring the use of REBOA catheter to permit aeromedical transport to a level-one trauma center for definitive embolization. Conclusion Deployment of REBOA catheter to facilitate aeromedical transport to an appropriate level of care may be considered if travel times can be kept brief and there is a process and training in place to empower flight medics to consider transporting with a REBOA deployed.
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Affiliation(s)
- Jason A. Snyder
- Corresponding author at: Section of Acute and Critical Care Surgery, 660 South Euclid Avenue, Campus Box 8109, St. Louis, MO 63110, USA.
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19
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DuBose JJ, Burlew CC, Joseph B, Keville M, Harfouche M, Morrison J, Fox CJ, Mooney J, O'Toole R, Slobogean G, Marchand LS, Demetriades D, Werner NL, Benjamin E, Costantini T. Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control. J Trauma Acute Care Surg 2021; 91:e93-e103. [PMID: 34238857 DOI: 10.1097/ta.0000000000003331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined. LEVEL OF EVIDENCE Review, level IV.
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Affiliation(s)
- Joseph J DuBose
- From the R Adams Cowley Shock Trauma Center (J.J.D., M.K., M.H., J.M., C.J.F., R.O., G.S.), University of Maryland Medical System, Baltimore, Maryland; Department of Surgery (C.C.B., N.L.W.), Denver Health Medical Center, Denver, Colorado; Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (B.J.), College of Medicine, University of Arizona, Tucson, Arizona; Baylor University Medical Center (J.M.), Dallas, Texas; Department of Orthopedic Surgery (L.S.M.), University of Utah, Salt Lake City, Utah; Division of Trauma and Surgical Critical Care (D.D., E.B.), LAC+USC Medical Center, University of Southern California, Los Angeles, California; Trauma/Surgical Critical Care (T.C.), Grady Memorial Hospital/Emory University School of Medicine, Atlanta, Georgia; and Division of Trauma, Surgical Critical Care, Burns and Acute Care Surgery, Department of Surgery (T.C.), University of California San Diego School of Medicine, San Diego, California
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20
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Sherman NC, Williams KN, Hennemeyer CT, Devis P, Chehab M, Joseph B, Tang AL. Effects of nonselective internal iliac artery angioembolization on pelvic venous flow in the swine model. J Trauma Acute Care Surg 2021; 91:318-324. [PMID: 34397953 DOI: 10.1097/ta.0000000000003190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pelvic angioembolization (AE) is a mainstay in the treatment algorithm for pelvic hemorrhage from pelvic fractures. Nonselective AE refers to embolization of the bilateral internal iliac arteries (IIAs) proximally rather than embolization of their tributaries distally. The aim of this study was to quantify the effect of nonselective pelvic AE on pelvic venous flow in a swine model. We hypothesized that internal iliac vein (IIV) flow following IIA AE is reduced by half. METHODS Nine Yorkshire swine underwent nonselective right IIA gelfoam AE, followed by left. Pelvic arterial and venous diameter, velocity, and flow were recorded at baseline, after right IIA AE and after left IIA AE. Linear mixed-effect model and signed rank test were used to evaluate significant changes between the three time points. RESULTS Eight swine (77.8 ± 7.1 kg) underwent successful nonselective IIA AE based on achieving arterial resistive index of 1.0. One case was aborted because of technical difficulties. Compared with baseline, right IIV flow rate dropped by 36% ± 29% (p < 0.05) and 54% ± 29% (p < 0.01) following right and left IIA AE, respectively. Right IIA AE had no initial effect on left IIV flow (0.37% ± 99%, p = 0.95). However, after left IIA AE, left IIV flow reduced by 54% ± 27% (p < 0.01). Internal iliac artery AE had no effect on the external iliac arterial or venous flow rates and no effect on inferior vena cava flow rate. CONCLUSION The effect of unilateral and bilateral IIA AE on IIV flow appears to be additive. Despite bilateral IIA AE, pelvic venous flow is diminished but not absent. There is abundant collateral circulation between the external and internal iliac vascular systems. Arterial embolization may reduce venous flow and improve on resuscitation efforts in those with unstable pelvic fractures. LEVEL OF EVIDENCE Prognostic, level IV.
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Affiliation(s)
- Nathan C Sherman
- From the Department of Orthopaedic Surgery (N.C.S.), University of Arizona, Tucson, AZ; Department of Surgery (K.N.W.), Emory University, Atlanta, GA; Department of Medical Imaging (C.T.H.), University of Arizona, Tucson, AZ; Interventional Radiology (P.D.), Southern Arizona VA Healthcare System, Tucson, AZ; and Department of Surgery (M.C., B.J., A.L.T.), University of Arizona, Tucson, AZ
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21
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Comment on Prospective Observational Evaluation of the ER-REBOA Catheter at 6 U.S. Trauma Centers. Ann Surg 2021; 274:e867. [PMID: 33443894 DOI: 10.1097/sla.0000000000004743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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