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Parra MW, Ordoñez CA, Mejia D, Caicedo Y, Lobato JM, Castro OJ, Uribe JA, Velásquez F. Damage control approach to refractory neurogenic shock: a new proposal to a well-established algorithm. Colomb Med (Cali) 2021; 52:e4164800. [PMID: 34908624 PMCID: PMC8634278 DOI: 10.25100/cm.v52i2.4800] [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: 03/31/2021] [Revised: 05/13/2021] [Accepted: 06/25/2021] [Indexed: 12/02/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is commonly used as an adjunct to resuscitation and bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock. It has also been performed for patients with neurogenic shock to support the central aortic pressure necessary for cerebral, coronary and spinal cord perfusion. Although volume replacement and vasopressors are the cornerstones of the management of neurogenic shock, we believe that a REBOA can be used as an adjunct in carefully selected cases to prevent prolonged hypotension and the risk of further anoxic spinal cord injury. This manuscript aims to propose a new damage control algorithmic approach to refractory neurogenic shock that includes the use of a REBOA in Zone 3. There are still unanswered questions on spinal cord perfusion and functional outcomes using a REBOA in Zone 3 in trauma patients with refractory neurogenic shock. However, we believe that its use in these case scenarios can be beneficial to the overall outcome of these patients.
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Affiliation(s)
- Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellin, Colombia.,Universidad de Antioquia, Department of Surgery, Medellin, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
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Parra MW, Ordoñez CA, Pino LF, Millán M, Caicedo Y, Buchelli VR, García A, González-Hadad A, Salcedo A, Serna JJ, Quintero L, Herrera MA, Hernández F, Rodríguez-Holguín F. Damage control surgery for thoracic outlet vascular injuries: the new resuscitative median sternotomy plus REBOA. Colomb Med (Cali) 2021; 52:e4054611. [PMID: 34908619 PMCID: PMC8634276 DOI: 10.25100/cm.v52i2.4611] [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: 11/03/2020] [Revised: 04/21/2021] [Accepted: 06/07/2021] [Indexed: 12/02/2022] Open
Abstract
Thoracic vascular trauma is associated with high mortality and is the second most common cause of death in patients with trauma following head injuries. Less than 25% of patients with a thoracic vascular injury arrive alive to the hospital and more than 50% die within the first 24 hours. Thoracic trauma with the involvement of the great vessels is a surgical challenge due to the complex and restricted anatomy of these structures and its association with adjacent organ damage. This article aims to delineate the experience obtained in the surgical management of thoracic vascular injuries via the creation of a practical algorithm that includes basic principles of damage control surgery. We have been able to show that the early application of a resuscitative median sternotomy together with a zone 1 resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable patients with thoracic outlet vascular injuries improves survival by providing rapid stabilization of central aortic pressure and serving as a bridge to hemorrhage control. Damage control surgery principles should also be implemented when indicated, followed by definitive repair once the correction of the lethal diamond has been achieved. To this end, we have developed a six-step management algorithm that illustrates the surgical care of patients with thoracic outlet vascular injuries according to the American Association of the Surgery of Trauma (AAST) classification.
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Affiliation(s)
- Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
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Brede JR, Skjærseth E, Klepstad P, Nordseth T, Krüger AJ. Changes in peripheral arterial blood pressure after resuscitative endovascular balloon occlusion of the aorta ( REBOA) in non-traumatic cardiac arrest patients. BMC Emerg Med 2021; 21:157. [PMID: 34911463 PMCID: PMC8672343 DOI: 10.1186/s12873-021-00551-y] [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: 11/05/2021] [Accepted: 11/28/2021] [Indexed: 11/14/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be an adjunct treatment to cardiopulmonary resuscitation (CPR). Aortic occlusion may increase aortic pressure and increase the coronary perfusion pressure and the cerebral blood flow. Peripheral arterial blood pressure is often measured during or after CPR, however, changes in peripheral blood pressure after aortic occlusion is insufficiently described. This study aimed to assess changes in peripheral arterial blood pressure after REBOA in patients with out of hospital cardiac arrest. Methods A prospective observational study performed at the helicopter emergency medical service in Trondheim (Norway). Eligible patients received REBOA as adjunct treatment to advanced cardiac life support. Peripheral invasive arterial blood pressure and end-tidal CO2 (EtCO2) was measured before and after aortic occlusion. Differences in arterial blood pressures and EtCO2 before and after occlusion was analysed with Wilcoxon Signed Rank test. Results Five patients were included to the study. The median REBOA procedural time was 11 min and median time from dispatch to aortic occlusion was 50 min. Two patients achieved return of spontaneous circulation. EtCO2 increased significantly 60 s after occlusion, by a mean of 1.16 kPa (p = 0.043). Before occlusion the arterial pressure in the compression phase were 43.2 (range 12–112) mmHg, the mean pressure 18.6 (range 4–27) mmHg and pressure in the relaxation phase 7.8 (range − 7 – 22) mmHg. After aortic occlusion the corresponding pressures were 114.8 (range 23–241) mmHg, 44.6 (range 15–87) mmHg and 14.8 (range 0–29) mmHg. The arterial pressures were significant different in the compression phase and as mean pressure (p = 0.043 and p = 0.043, respectively) and not significant in the relaxation phase (p = 0.223). Conclusion This study is, to our knowledge, the first to assess the peripheral invasive arterial blood pressure response to aortic occlusion during CPR in the pre-hospital setting. REBOA application during CPR is associated with a significantly increase in peripheral artery pressures. This likely indicates improved central aortic blood pressure and warrants studies with simultaneous peripheral and central blood pressure measurement during aortic occlusion. Trial registration The study is registered in ClinicalTrials.gov (NCT03534011).
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway. .,Department of Anesthesiology and Intensive Care Medicine, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Eivinn Skjærseth
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Pål Klepstad
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Trond Nordseth
- Department of Anesthesiology and Intensive Care Medicine, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Andreas Jørstad Krüger
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway.,Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.,Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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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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Lee LO, Potnuru P, Stephens CT, Pivalizza EG. Current Approaches to Resuscitative Endovascular Balloon Occlusion of the Aorta Use in Trauma and Obstetrics. Adv Anesth 2021; 39:17-33. [PMID: 34715974 DOI: 10.1016/j.aan.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Linden O Lee
- Department of Anesthesiology, UTHealth McGovern Medical School, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA
| | - Paul Potnuru
- Department of Anesthesiology, UTHealth McGovern Medical School, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA
| | - Christopher T Stephens
- Department of Anesthesiology, UTHealth McGovern Medical School, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA
| | - Evan G Pivalizza
- Department of Anesthesiology, UTHealth McGovern Medical School, MSB 5.020, 6431 Fannin Street, Houston, TX 77030, USA.
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Khalid S, Khatri M, Siddiqui MS, Ahmed J. Resuscitative Endovascular Balloon Occlusion of Aorta Versus Aortic Cross-Clamping by Thoracotomy for Noncompressible Torso Hemorrhage: A Meta-Analysis. J Surg Res 2021; 270:252-260. [PMID: 34715536 DOI: 10.1016/j.jss.2021.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 06/06/2021] [Revised: 08/31/2021] [Accepted: 09/23/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND The effect of resuscitative endovascular balloon occlusion of aorta (REBOA) in lowering mortality rate compared to resuscitative thoracotomy (RT) is inconclusive. In this updated systematic review and meta-analysis, we determined the effectiveness of the two techniques in patients with noncompressible torso hemorrhage (NCTH). MATERIALS AND METHODS Online databases (PubMed, Embase, and MEDLINE) were searched until April 23, 2021, for original articles investigating the effect of REBOA on relevant outcomes (e.g., mortality in ED, mortality before discharge, in-hospital mortality, length of hospital stay and length of ICU stay) among NCTH patients in contrast to open aortic occlusion by RT. Data on baseline characteristics and endpoints were extracted. Review Manager version 5.4.1 and OpenMetaAnalyst were used for analyses. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% confidence intervals were calculated. RESULTS Eight studies were included having 3241 patients in total (REBOA: 1179 and RT: 2062). The pooled analysis demonstrated that compared to RT, mortality was significantly lower in the REBOA group in all settings: In emergency department (ED) (RR 0.63 [0.45, 0.87], P = 0.006, I2 = 81%), before discharge (RR= 0.86 [0.75, 0.98], P = 0.03, I2 = 93%), and in-hospital mortality (RR 0.80 [0.68, 0.95], P = 0.009, I2 = 85%). Similarly, the length of ICU stay was significantly lower in REBOA group (WMD = 0.50 [-0.48, 1.48], P = 0.32, I2 =97%). However, no significant differences were observed in the length of hospital stay (WMD = 0.0 [-0.26, 0.26] P = 1). CONCLUSIONS Our pooled analysis shows REBOA to be effective in reducing mortality among NCTH patients. However, due to limited studies, the positive findings should be viewed discreetly and call for further investigation.
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Affiliation(s)
- Saad Khalid
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
| | - Mahima Khatri
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | | | - Jawad Ahmed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
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57
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Abstract
Traumatic injury remains the leading cause of death in patients 45 and younger. State of the art trauma care requires rapid interventions to provide hemodynamic support en route to definitive hemostasis. This article will review three critical elements in management of the bleeding trauma patient: blood products, resuscitative endovascular balloon occlusion of the aorta (REBOA), and the trauma hybrid operating room (THOR).
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Nieto-Calvache AJ, Palacios-Jaraquemada JM, Aryananda RA, Rodriguez F, Ordoñez CA, Messa Bryon A, Calvache JPB, Lopez J, Campos CI, Mejia M, Rengifo M, Galliadi LMV, Maya J, Zambrano MA, Aguayo IP, Carabalí IG, Burgos JM. How to identify patients who require aortic vascular control in placenta accreta spectrum disorders? Am J Obstet Gynecol MFM 2021; 4:100498. [PMID: 34610485 DOI: 10.1016/j.ajogmf.2021.100498] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [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: 07/27/2021] [Revised: 09/22/2021] [Accepted: 09/24/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND The placenta accreta spectrum disorder may lead to severe complications. Helpful interventions to prevent placenta accreta spectrum bleeding include vascular control procedures in the aorta or pelvic vessels. Although these procedures are related to lower intraoperative bleeding, they are associated with complications, so the possibility of selecting patients at highest risk of bleeding while avoiding vascular procedures for all cases is attractive. OBJECTIVE We describe an intraoperative staging protocol whose objective is to identify the need to use vascular control procedures in patients with placenta accreta spectrum. We also describe the results of its application in a placenta accreta spectrum referral hospital. STUDY DESIGN This descriptive, retrospective study included patients with suspected prenatal placenta accreta spectrum treated at a referral center for placenta accreta spectrum between April 2016 and June 2020. The use of the resuscitative endovascular balloon occlusion of the aorta allowed the prevention and treatment of excessive bleeding; its application was performed according to 3 approaches: (1) presurgical use in all placenta accreta spectrum patients (Group 1), (2) according to the prenatal placenta accreta spectrum topography (Group 2), and (3) according to the "intraoperative staging" (Group 3). In addition, the frequency of use of resuscitative endovascular balloon occlusion of the aorta and the clinical results in the management of placenta accreta spectrum were described in the 3 groups. RESULTS Seventy patients underwent surgery for a prenatal suspicion of placenta accreta spectrum. Of these, 16 underwent intraoperative staging (Group 3); in 20 cases, resuscitative endovascular balloon occlusion of the aorta was used based on the prenatal imaging topographic classification (Group 2), and in the remaining 34 patients (Group 1), it was always used before the laparotomy. The frequency of use of resuscitative endovascular balloon occlusion of the aorta was progressively lower in Groups 1 (32 patients, 94.1% of cases), 2 (11 patients, 75% of cases), and 3 (4 patients, 25% of cases). Similarly, resuscitative endovascular balloon occlusion of the aorta went from being applied predominantly before the laparotomy (all cases in Group 1) to being applied after intraoperative staging (all cases in Group 3). The percentage of endovascular devices applied but not used, decreased from 23.5% in Group 1 to 0% in Group 3. Complications related to the resuscitative endovascular balloon occlusion of the aorta were seen in 4 patients (2 women in Group 1, and 1 woman each in Groups 2 and 3). CONCLUSION The "intraoperative staging" of placenta accreta spectrum allows the optimization of the use of resuscitative endovascular balloon occlusion of the aorta, which decreases the frequency of its use without increasing the volume of blood loss.
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Affiliation(s)
- Albaro José Nieto-Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos).
| | | | - Rozi Aditya Aryananda
- Dr Soetomo Academic General Hospital, Universitas Airlangga, Surabaya, Indonesia (Dr Aryananda)
| | - Fernando Rodriguez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Carlos A Ordoñez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); División de Trauma y Emergencias, Departamento de Cirugía General, Fundación Valle del Lili, Cali, Colombia (Drs Rodriguez and Ordoñez)
| | - Adriana Messa Bryon
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Juan Pablo Benavides Calvache
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Jaime Lopez
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
| | - Clara Ivette Campos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Patología y Laboratorio Clínico, Fundación Valle del Lili, Cali, Colombia (Dr Campos)
| | - Mauricio Mejia
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | - Martin Rengifo
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos); Departamento de Radiología e Imágenes Diagnósticas, Fundación Valle del Lili, Cali, Colombia (Drs Mejia and Rengifo)
| | | | - Juliana Maya
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Maria Andrea Zambrano
- Programa de Ginecología y Obstetricia, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Dr Zambrano)
| | - Isabella Prado Aguayo
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Isabella Gutierrez Carabalí
- Programa de Medicina, Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia (Drs Maya, Aguayo, and Carabalí)
| | - Juan Manuel Burgos
- Clinica de Espectro de Acretismo Placentario, Fundación Valle del Lili, Cali, Colombia (Drs Nieto-Calvache, Rodriguez, Ordoñez, Bryon, Calvache, Lopez, Campos, Mejia, Rengifo, and Burgos)
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Magee GA, Fox CJ, Moore EE. Resuscitative endovascular balloon occlusion of the aorta in pelvic ring fractures: The Denver Health protocol. Injury 2021; 52:2702-6. [PMID: 32057458 DOI: 10.1016/j.injury.2020.01.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/24/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023]
Abstract
Patients presenting with hemodynamic instability associated with pelvic fractures continue to have very high mortality and surgeons continue to seek damage control strategies that may improve survival. Strategies usually require massive transfusion, immediate pelvic stabilization and another adjunctive maneuver's such as angioembolization or preperitoneal pelvic packing to prevent hemorrhagic death. One current intervention that has regained some popularity in lieu of resuscitative thoracotomy is the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This requires some manner of femoral arterial access to insert a balloon into the aorta and increase central blood pressure (cardiac and cerebral perfusion) and control active pelvic bleeding. Based on several animal models and an increasing number of publications, many US level I trauma centers have now opted to use REBOA in carefully selected patients showing signs of near cardiac arrest from non-compressible torso hemorrhage. Description of the current advances in aortic occlusion using catheter-based technology in the setting of severe shock for non-compressible torso hemorrhage from pelvic ring fracture is the purpose of this report.
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Hurley S, Erdogan M, Lampron J, Green RS. A survey of resuscitative endovascular balloon occlusion of the aorta ( REBOA) program implementation in Canadian trauma centres. CAN J EMERG MED 2021; 23:797-801. [PMID: 34537915 DOI: 10.1007/s43678-021-00193-w] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 08/06/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine how many Level 1 and Level 2 trauma centres in Canada have implemented a resuscitative endovascular balloon occlusion of the aorta (REBOA) program, and to identify facilitators and barriers to successful implementation of REBOA programs. METHODS An electronic survey was developed and administered in November 2019 (updated in July 2021) via email to directors at all 32 Level 1 and Level 2 trauma centres across Canada, and to the medical director in PEI (no Level 1 or Level 2 capacity). Survey responses were supplemented by an online search in PubMed and the grey literature. Responses were analyzed using simple descriptive statistics including frequencies and proportions. RESULTS We received responses from directors at 22 sites (17 Level 1 trauma centres, 4 Level 2 trauma centres, PEI) for a response rate of 66.7%. There are 6 Level 1 trauma centres with REBOA programs; all were implemented between 2017 and 2019. One additional Level 1 trauma centre that did not respond was found to have a REBOA program; thus, 21.9% (7/32) of Canadian Level 1 and Level 2 trauma centres have an existing REBOA program. These programs are located in three provinces (British Columbia, Ontario, Quebec). Five other centres are planning on implementing a REBOA program in the next 2 years. The number of REBOA cases performed ranged from 0 to 30 (median 2). Factors contributing most to successful program implementation were having physician champions and patient populations with sufficient REBOA candidates, while cost and lack of expertise were the greatest barriers identified. CONCLUSION As of July 2021, 21.9% (7/32) of Canadian Level 1 and Level 2 trauma centres have a REBOA program. Physician champions and a patient population with sufficient numbers of REBOA candidates were the most important factors contributing to successful implementation of these programs.
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Affiliation(s)
- Sean Hurley
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Mete Erdogan
- Nova Scotia Health Trauma Program, Nova Scotia Health, Halifax, NS, Canada
| | | | - Robert S Green
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada.
- Nova Scotia Health Trauma Program, Nova Scotia Health, Halifax, NS, Canada.
- Department of Critical Care, Dalhousie University, Halifax, NS, Canada.
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Theodorou CM, Trappey AF, Beyer CA, Yamashiro KJ, Hirose S, Galante JM, Beres AL, Stephenson JT. Quantifying the need for pediatric REBOA: A gap analysis. J Pediatr Surg 2021; 56:1395-400. [PMID: 33046222 DOI: 10.1016/j.jpedsurg.2020.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/30/2020] [Accepted: 09/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA. METHODS Trauma patients <18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage. RESULTS There were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas. CONCLUSION Nearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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62
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Hurley S, Erdogan M, Kureshi N, Casey P, Smith M, Green RS. Comparison of clinical and anatomical criteria for resuscitative endovascular balloon occlusion of the aorta ( REBOA) among major trauma patients in Nova Scotia. CAN J EMERG MED 2021; 23:528-536. [PMID: 33751492 DOI: 10.1007/s43678-021-00100-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To perform a province-wide evaluation of adult major traumas and determine the proportion of patients who met clinical and/or anatomical criteria for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS This is a retrospective analysis of all major trauma patients (age > 16) presenting to the sole adult level 1 trauma centre in Nova Scotia over a 5-year period (2012-2017). Data were collected from the Nova Scotia Trauma Registry and medical charts. We identified potential REBOA candidates using either: (1) clinical criteria (primary survey, Focused Assessment with Sonography for Trauma, pelvic/chest X-ray); or (2) anatomical criteria (ICD-10-CA codes). Potential candidates with persistent hypotension were considered true REBOA candidates. RESULTS Overall 2885 patients were included in the analysis, of whom 248 (8.6%) patients were in shock (including 106 transfer patients) and had their charts reviewed. A total of 137 patients met clinical criteria for REBOA; 44 (1.5%) had persistent hypotension 10-20 min into resuscitation and were considered true REBOA candidates. There were 59 patients who met anatomical criteria for REBOA, of whom 15 (0.5%) patients had persistent hypotension and were true REBOA candidates. The 15 REBOA candidates based on anatomical criteria also met clinical criteria for REBOA. CONCLUSIONS In this registry-based retrospective analysis, 1.5% of adult major trauma patients Nova Scotia were REBOA candidates based on resuscitative clinical presentation, while 0.5% were candidates based on post hoc anatomical injury patterns. Our findings suggest that using clinical findings and bedside imaging modalities as criteria may overestimate the number of candidates for REBOA.
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Affiliation(s)
- Sean Hurley
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, B3H 4R2, Canada
| | - Mete Erdogan
- Trauma Nova Scotia, Nova Scotia Health Authority, Room 1-026B Centennial Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada
| | - Nelofar Kureshi
- Division of Neurosurgery, Department of Surgery, Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Patrick Casey
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Matthew Smith
- Division of Vascular Surgery, Department of Surgery, Dalhousie University, 1796 Summer Street, Halifax, NS, B3H 3A7, Canada
| | - Robert S Green
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
- Trauma Nova Scotia, Nova Scotia Health Authority, Room 1-026B Centennial Building, 1276 South Park Street, Halifax, NS, B3H 2Y9, Canada.
- Department of Critical Care, Dalhousie University, Halifax, NS, B3H 4R2, Canada.
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Teeratakulpisarn P, Angkasith P, Tanmit P, Thanapaisal C, Prasertcharoensuk S, Wongkonkitsin N. A Life Saving Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta ( REBOA) with Open Groin Technique. Open Access Emerg Med 2021; 13:183-188. [PMID: 34040460 PMCID: PMC8140941 DOI: 10.2147/oaem.s311421] [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: 03/16/2021] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
A 53-year-old male pedestrian was hit by a car and arrived at our hospital with a blunt abdominal injury and hemorrhagic shock. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) was performed in a timely fashion using the open groin technique in the emergency room. The procedure resulted in rapid improvement of hemodynamic status while the bleeding source was controlled. Recently, REBOA is a proper adjunctive procedure in major non-compressible torso hemorrhage patients. The procedure requires a portable X-ray or fluoroscopic machine in the ER to confirm the balloon’s position. This method has likely limited the use of REBOA in developing countries. The procedure with open groin technique, using anatomical landmarks and physiologic change to confirm the position of the balloon, has been developed to address these concerns. Here we report on the treatment’s success with this technique and believe that it can benefit trauma patient care.
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Affiliation(s)
- Panu Teeratakulpisarn
- Department of Surgery, Faculty of Medicine, Khonkaen University, Khon Kaen, Thailand
| | - Phati Angkasith
- Department of Surgery, Faculty of Medicine, Khonkaen University, Khon Kaen, Thailand
| | - Parichat Tanmit
- Department of Surgery, Faculty of Medicine, Khonkaen University, Khon Kaen, Thailand
| | - Chaiyut Thanapaisal
- Department of Surgery, Faculty of Medicine, Khonkaen University, Khon Kaen, Thailand
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Serna C, Serna JJ, Caicedo Y, Padilla N, Gallego LM, Salcedo A, Rodríguez-Holguín F, González-Hadad A, García A, Herrera MA, Parra MW, Ordoñez CA. Damage control surgery for splenic trauma: "preserve an organ - preserve a life". Colomb Med (Cali) 2021; 52:e4084794. [PMID: 34188324 PMCID: PMC8216056 DOI: 10.25100/cm.v52i2.4794] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The spleen is one of the most commonly injured solid organs of the abdominal cavity and an early diagnosis can reduce the associated mortality. Over the past couple of decades, management of splenic injuries has evolved to a prefered non-operative approach even in severely injured cases. However, the optimal surgical management of splenic trauma in severely injured patients remains controversial. This article aims to present an algorithm for the management of splenic trauma in severely injured patients, that includes basic principles of damage control surgery and is based on the experience obtained by the Trauma and Emergency Surgery Group (CTE) of Cali, Colombia. The choice between a conservative or a surgical approach depends on the hemodynamic status of the patient. In hemodynamically stable patients, a computed tomography angiogram should be performed to determine if non-operative management is feasible and if angioembolization is required. While hemodynamically unstable patients should be transferred immediately to the operating room for damage control surgery, which includes splenic packing and placement of a negative pressure dressing, followed by angiography with embolization of any ongoing arterial bleeding. It is our recommendation that both damage control principles and emerging endovascular technologies should be applied to achieve splenic salvage when possible. However, if surgical bleeding persists a splenectomy may be required as a definitive lifesaving maneuver.
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Affiliation(s)
- Carlos Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - José Julián Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili., Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | | | - Alexander Salcedo
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili., Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili., Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Alberto García
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.,Fundación Valle del Lili., Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery Division of Trauma and Acute Care Surgery. Cali, Colombia.,Fundación Valle del Lili., Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
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Grannemann JJ, Röper A, Rehberg S, Jansen G. [Aortoesophageal fistula-A rare differential diagnosis of upper gastrointestinal bleeding]. Anaesthesist 2021; 70:866-871. [PMID: 33929554 DOI: 10.1007/s00101-021-00963-2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/03/2021] [Accepted: 03/10/2021] [Indexed: 11/24/2022]
Abstract
Approximately 1% of all patients are admitted to an emergency room for upper gastrointestinal hemorrhage. Differential diagnostics reveal an aortoesophageal fistula (AEF) as the cause of the bleeding in very few cases. Despite increasing means of diagnostics and treatment, mortality is high in patients with AEF even under maximum medical care. These are often fulminant situations with fatal outcome for the patient. We report a case that supports this observation described from previous cases and give a closer look at this rare emergency situation. A 54-year-old patient was taken to a maximum care hospital with the clinical diagnosis of upper gastrointestinal bleeding after receiving emergency medical treatment. The source of bleeding was quickly identified as an AEF following lobectomy for bronchial cancer. Despite maximum interventional intensive treatment, the patient died a few hours after hospital admission in hemorrhagic shock due to fulminant hemorrhage from the fistula.
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Affiliation(s)
- Julia Johanna Grannemann
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum OWL, Universität Bielefeld, Campus Klinikum Bielefeld, Teutoburger Straße 50, 33604, Bielefeld, Deutschland.
| | - Achim Röper
- Klinik für Anästhesiologie, operative Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum OWL, Universität Bielefeld, Campus Klinikum Bielefeld, Teutoburger Straße 50, 33604, Bielefeld, Deutschland
| | - Sebastian Rehberg
- Klinik für Anästhesiologie, Intensiv‑, Notfall‑, Transfusionsmedizin und Schmerztherapie Evangelisches Klinikum Bethel, Universitätsklinikum OWL, Universität Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Deutschland
| | - Gerrit Jansen
- Klinik für Anästhesiologie, Intensiv‑, Notfall‑, Transfusionsmedizin und Schmerztherapie Evangelisches Klinikum Bethel, Universitätsklinikum OWL, Universität Bielefeld, Campus Bielefeld-Bethel, Burgsteig 13, 33617, Bielefeld, Deutschland
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66
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Millán M, Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Pino LF, Rodríguez-Holguín F, Salcedo A, García A, Serna JJ, Herrera MA, Quintero L, Hernández F, Serna C, González Hadad A. Hemodynamically unstable non-compressible penetrating torso trauma: a practical surgical approach. Colomb Med (Cali) 2021; 52:e4024592. [PMID: 34188320 PMCID: PMC8216055 DOI: 10.25100/cm.v52i2.4592] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Penetrating torso trauma is the second leading cause of death following head injury. Traffic accidents, falls and overall blunt trauma are the most common mechanism of injuries in developed countries; whereas, penetrating trauma which includes gunshot and stabs wounds is more prevalent in developing countries due to ongoing violence and social unrest. Penetrating chest and abdominal trauma have high mortality rates at the scene of the incident when important structures such as the heart, great vessels, or liver are involved. Current controversies surround the optimal surgical approach of these cases including the use of an endovascular device such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and the timing of additional imaging aids. This article aims to shed light on this subject based on the experience earned during the past 30 years in trauma critical care management of the severely injured patient. We have found that prioritizing the fact that the patient is hemodynamically unstable and obtaining early open or endovascular occlusion of the aorta to gain ground on avoiding the development of the lethal diamond is of utmost importance. Damage control surgery starts with choosing the right surgery of the right cavity in the right patient. For this purpose, we present a practical and simple guide on how to perform the surgical approach to penetrating torso trauma in a hemodynamically unstable patient.
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Affiliation(s)
- Mauricio Millán
- Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alberto García
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Laureano Quintero
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Fabian Hernández
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Carlos Serna
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
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Karmy-Jones R, Friend A, Collins D, Martin MJ, Long W. Is there a role for REBOA? A system assessment. Am J Surg 2021; 221:1233-1237. [PMID: 33838867 DOI: 10.1016/j.amjsurg.2021.03.041] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 01/28/2021] [Accepted: 03/16/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION To analyze our experience to quantify potential need for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS Retrospective review of patients over a three-year period who presented as a trauma with hemorrhagic shock. Patients were divided into two groups: REBOA Candidate vs. Non-candidates. Injuries, outcomes, and interventions were compared. RESULTS Of 7643 trauma activations, only 37 (0.44%) fit inclusion criteria, of which 16 met criteria for candidacy for potential REBOA placement. The groups did not differ in terms of injury severity, physiology, age, timing of intervention, nor massive transfusion. Survival was linked to TRISS (p = 0.01) and Emergency Room Thoracotomy (p = 0.002). Of Candidates, 8 (50%) had injuries that could have benefited from REBOA, while 7 (44%) had injuries that could be associated with potential harm. DISCUSSION The volume of patients who would potentially benefit from REBOA appears to be small and does not appear to support system wide adoption in the studied region. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Riyad Karmy-Jones
- Divisions of Trauma/Critical Care and Thoracic/Vascular Surgery PeaceHealth Southwest Washington Medical Center, USA; PeaceHealth St. John's Medical Center, USA; Legacy Emanuel Medical Center, USA.
| | - Allen Friend
- Divisions of Trauma/Critical Care and Thoracic/Vascular Surgery PeaceHealth Southwest Washington Medical Center, USA
| | | | - Mathew J Martin
- Legacy Emanuel Medical Center, USA; Scripps Mercy Hospital, USA
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Riazanova OV, Reva VA, Fox KA, Romanova LA, Kulemin ES, Riazanov AD, Ioscovich A. Open versus endovascular REBOA control of blood loss during cesarean delivery in the placenta accreta spectrum: A single-center retrospective case control study. Eur J Obstet Gynecol Reprod Biol 2021; 258:23-28. [PMID: 33388487 DOI: 10.1016/j.ejogrb.2020.12.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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: 08/12/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare two vascular control options for blood loss prevention and hysterectomy during cesarean delivery (CD2): endovascular balloon occlusion of the aorta (REBOA3) and open bilateral common iliac artery occlusion (CIAO4) in women with extensive placenta accreta spectrum (PAS5). STUDY DESIGN This was retrospective comparison of cases of PAS using either CIAO (October 2017 through October 2018) or REBOA (November 2018 through November 2019) to prevent pathologic hemorrhage during scheduled CD. Women with confirmed placenta increta/percreta underwent either CD then intraoperative post-delivery, pre-hysterectomy open vascular control of both CIA6 (CIAO group) or pre-operative, ultrasound-guided, fluoroscopy-free REBOA followed by standard CD and balloon inflation after fetal delivery (REBOA group). Intraoperative blood loss, transfusion volumes, surgical time, blood pressure, maternal and neonatal outcomes, hospitalization length and postoperative complications were compared. RESULTS The REBOA and CIAO groups included 12 and 16 women, respectively, with similar median age of 35 years and gestational age of 34-35 weeks. All REBOA catheters were successfully placed into aortic zone three under ultrasound guidance. The quantitated median intraoperative blood loss was significantly lower for the REBOA group, (541 [IQR 300-750] mL) compared to the CIAO group (3331 [IQR 1150-4750] mL (P = 0.001). As a result, the total volume of fluid and blood replacement therapy was significantly lower in the REBOA group (P < 0.05). Median surgical time in the REBOA group was less than half as long: 76 [IQR 64-89] minutes compared to 168 [IQR 90-222] minutes in the CIAO group (P = 0.001). None of the women with REBOA required hysterectomy, while 8/16 women in the CIAO group did (P = 0.008). Furthermore, the post-anesthesia recovery and hospital discharge times in the REBOA-group were shorter (P < 0.05). One thromboembolic complication occurred in each group. The only REBOA-associated complication was non-occlusive femoral artery thrombosis, with no surgical management required. No maternal or neonatal deaths occurred in either group. CONCLUSION Fluoroscopy-free REBOA for women with PAS is associated with improved vascular control, perioperative blood loss, the need for transfusion and hysterectomy and reduces surgical time when compared to bilateral CIAO.
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Affiliation(s)
- Oksana V Riazanova
- D.O. Ott Research Institute of Obstetrics and Gynecology, Saint-Petersburg, Russian Federation
| | - Viktor A Reva
- Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX, USA
| | - Larisa A Romanova
- Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russian Federation
| | - Evgeniy S Kulemin
- Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russian Federation
| | - Artem D Riazanov
- Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russian Federation
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Stephenson K, Kalkwarf K, Giorgakis E. Application of resuscitative endovascular balloon occlusion in post-transplant mycotic hepatic artery pseudoaneurysm rupture in the setting of Aspergillus Constellatus bacteremia. Ann Hepatobiliary Pancreat Surg 2021; 25:126-131. [PMID: 33649265 PMCID: PMC7952665 DOI: 10.14701/ahbps.2021.25.1.126] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 11/17/2022] Open
Abstract
Hepatic artery pseudoaneurysm (HAP) is a rare, highly morbid and frequently fatal complication of liver transplantation. Most are a mycotic mediated weakness of the arterial wall, with associated bacterial or fungal infection of ascitic fluid. As it is usually asymptomatic prior to rupture, the majority present in acute hemorrhagic shock and dire extremis. Resuscitative endovascular balloon occlusion (REBOA) was initially developed for the management of noncompressible hemorrhagic shock in trauma; however, remains underutilized and understudied in the non-trauma setting. We present the case of a mycotic hepatic artery pseudoaneurysm rupture due to Streptococcus constellatus and Klebsiella pneumoniae post directed donor orthoptic liver transplant, in which REBOA was employed in the setting of impending exsanguination as a bridge to definitive surgical intervention. Although this patient passed away of multiorgan system failure prior to re-transplant, this case demonstrates the importance of a heightened suspicion of this devastating complication, especially in the setting of bilioenteric reconstruction and perihepatic fluid collection, as well as the benefit of utilizing resuscitative techniques such as REBOA prior to definitive surgical or endovascular therapy to mitigate the high morbidity and mortality of this condition.
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Affiliation(s)
- Krista Stephenson
- Division of Solid Organ Transplantation, Department of Surgery, UAMS Medical Center, AR, USA
| | - Kyle Kalkwarf
- Division of Trauma and Critical Care Surgery, Department of Surgery, UAMS Medical Center, Little Rock, AR, USA
| | - Emmanouil Giorgakis
- Division of Solid Organ Transplantation, Department of Surgery, UAMS Medical Center, AR, USA
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Nieto-Calvache AJ, López-Girón MC, Burgos-Luna JM, Messa-Bryon A, Monroy A, López LJ, Rodríguez F, Caicedo Y, Brenner M, Ordoñez CA. Maternal hemodynamics during aortic occlusion with REBOA in patients with placenta accreta spectrum disorder. J Matern Fetal Neonatal Med 2021; 35:5217-5223. [PMID: 33618605 DOI: 10.1080/14767058.2021.1875446] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) in controlling pelvic bleeding has been reported with increasing frequency during surgical management of placenta accreta spectrum (PAS). The deployment of REBOA may lead to significant variations in vital signs requiring special care by anesthesiology during surgery. These modifications of blood pressure by REBOA in PAS patients have not been accurately documented. We report the changes in blood pressure that occur when the aorta is occluded and then released in patients with PAS. METHODOLOGY This prospective, observational study includes 10 patients with preoperative PAS suspicion who underwent prophylactic REBOA device insertion between April 2018 and October 2019. REBOA procedural-related data and blood pressure fluctuations under invasive monitoring before and after inflation and deflation were recorded in the operating room. RESULTS After prophylactic REBOA deployment in zone 3 of the aorta in PAS patients, we observed a transitory increase in blood pressure (median increase of 22.5 mmHg in SBP and 9.5 mmHg in DBP), which reached severe hypertension (SBP >160 mmHg) in 50% of patients. All patients presented a decrease in blood pressure after the removal of the aortic occlusion (median decrease of 23 mmHg in SBP and 10.5 mmHg in DBP), and 50% (five patients) required the administration of vasopressor drugs. CONCLUSION Immediately after aortic occlusion is applied in zone 3 in PAS patients and after the occlusion is removed, significant hemodynamic changes occur, which often lead to therapeutic interventions.
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Affiliation(s)
| | | | | | | | - Angélica Monroy
- Gynaecology and Obstetrics Residency Program, Universidad Icesi, Cali, Colombia
| | - Leydi J López
- Anesthesiology Department, Fundación Valle del Lili, Cali, Colombia
| | - Fernando Rodríguez
- Trauma and Emergency Surgery Department, Fundación Valle del Lili, Cali, Colombia
| | - Yaset Caicedo
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | - Megan Brenner
- Surgical Research Department, Riverside University Health System Medical Center, Moreno Valley, CA, USA
| | - Carlos A Ordoñez
- Trauma and Emergency Surgery Department, Fundación Valle del Lili, Cali, Colombia
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Levin SR, Farber A, Burke PA, Brahmbhatt TS, Richman AP, Twomey KE, Siracuse JJ. The majority of major amputations after resuscitative endovascular balloon occlusion of the aorta are associated with preadmission trauma. J Vasc Surg 2021; 74:467-476.e4. [PMID: 33548416 DOI: 10.1016/j.jvs.2020.12.107] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/13/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving intervention. However, recent reports of associations with limb loss and mortality have called its safety into question. We aimed to evaluate patient and hospital characteristics associated with major amputation and in-hospital mortality among patients undergoing REBOA for trauma. METHODS The National Trauma Data Bank (2015-2017) was queried for patients presenting to trauma centers and treated with REBOA. We included REBOA performed on hospital day 1 in patients who survived 6 or more hours from presentation. Univariable and multivariable analyses evaluated associations with major amputation and in-hospital mortality. RESULTS A total of 316 patients underwent REBOA and survived in the acute period after presentation. Overall, mean age was 45 ± 20 years and the majority were male (73%) and White (56%). Most patients presented to level I trauma centers (72%) after blunt injuries (79%) with an average Injury Severity Score (ISS) of 31 ± 15, indicating major trauma. In 15 patients (5%), there were 18 major amputations-7 above knee and 11 below knee. A subgroup of 11 amputations were either traumatic amputations (73%) or mangled limbs requiring amputation within 24 hours (27%). Of the remaining amputations, 71% were associated with ipsilateral vascular or orthopedic lower extremity injuries of serious to severe Abbreviated Injury Scale severity. Comparing patients with amputations with those without amputations, there were no significant differences in patient demographics, comorbidities, or hospital characteristics. During hospitalization, patients requiring amputation more frequently received open peripheral vascular interventions (40% vs 10%; P = .002), underwent similar numbers of endovascular interventions (6.7% vs 4.7%; P = .5), and more often developed compartment syndrome (13% vs 2%; P = .04). Overall, there were 110 deaths (35%). The major amputation prevalence was similar between patients who died vs those who survived (3.6% vs 5.3%; P = .5). In multivariable analysis, prehospital cardiac arrest (odds ratio [OR], 8.47; 95% confidence interval [CI], 1.47-48.66; P = .02), penetrating vs blunt trauma (OR, 5.5; 95% CI, 1.05-28.82; P = .04), decreased Glasgow Coma Scale score (OR, 1.18; 95% CI, 1.05-1.32; P = .01), older age (OR, 1.06; 95% CI, 1.03-1.10; P < .001), and increased Injury Severity Score (OR, 1.05; 95% CI, 1.0-1.1; P = .03) were associated with higher mortality. CONCLUSIONS The majority of major amputations in patients undergoing REBOA were secondary to the initial traumatic mechanism. Injury type and severity, as well as initial hemodynamic derangements, are associated with mortality after REBOA. Despite concerns about prohibitive limb complications of REBOA, baseline injuries seem to be the primary cause of limb loss, but further prospective analysis is needed.
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72
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Reva VA, Perevedentcev AV, Pochtarnik AA, Khupov MT, Kalinina AA, Samokhvalov IM, Khan MA. Ultrasound-guided versus blind vascular access followed by REBOA on board of a medical helicopter in a hemorrhagic ovine model. Injury 2021; 52:175-181. [PMID: 33004204 DOI: 10.1016/j.injury.2020.09.053] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/10/2020] [Accepted: 09/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND The aim of this study is to evaluate the feasibility of en-route resuscitative endovascular balloon occlusion of the aorta (REBOA) on board of a helicopter. METHODS Six sedated male sheep (weighing 42-54 kg) underwent a controlled hemorrhage until the systolic blood pressure (BP) dropped to <90 mmHg, and were placed into a low capacity Eurocopter AS-350 (France). During the 30-minutes normal flight, every animal underwent blind (left side) and ultrasound-guided (US) (right side) vascular access (VA) to the femoral artery followed by REBOA: the first catheter (Rescue balloon, Japan) - into Zone I, the second one (MIT, Russia) - Zone III. In case of blind VA failure, an alternate US-puncture was attempted. Six experienced flight anesthetists were enrolled into the study. Vascular access and REBOA catheter placement (confirmed by X-Ray later) success rate and timing were recorded. RESULTS Among six blind punctures one was successful, 2/6 - were into the vein, 3/6 - completely failed and switched to US-punctures (making total number of US-punctures nine). Eight out of nine US-punctures were successful. However, correct wire insertion and sheath placement was performed in 1/6 animal in the 'blind' group and only in 6/9 animals in the 'US' group. It took a median of 65 seconds (range 5-260) for US-puncture and a median of 4 minutes to get the sheath in. Among the 9 VAs, there were 2 REBOA failures (1 ruptured balloon [MIT] and 1 mistaken vena cava placement primarily recognized by a sudden drop of BP and later confirmed by X-Ray). Five out of seven balloons were placed in a desired intra-aortic position: 4/5 in Zone I and 1/2 - in Zone III. A median time for a successful REBOA procedure was 5.0 (range 2.5-10.0) minutes (1 min after sheath placement). CONCLUSION Our study demonstrates the potential feasibility of the en-route REBOA which can be performed within 5 minutes. Ultrasound-guidance is critically important to achieve en-route VA.
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Affiliation(s)
- Viktor A Reva
- Department of War Surgery, Kirov Military Medical Academy, 6 Lebedeva Street, Saint-Petersburg 194044, Russian Federation.
| | - Andrey V Perevedentcev
- Russian National Service of Sanitary Aviation, 56 Pilotov Street, Saint-Petersburg 196210, Russian Federation
| | - Alexander A Pochtarnik
- Department of War Surgery, Kirov Military Medical Academy, 6 Lebedeva Street, Saint-Petersburg 194044, Russian Federation
| | - Murat T Khupov
- Russian National Service of Sanitary Aviation, 56 Pilotov Street, Saint-Petersburg 196210, Russian Federation
| | - Angelina A Kalinina
- Russian National Service of Sanitary Aviation, 56 Pilotov Street, Saint-Petersburg 196210, Russian Federation
| | - Igor M Samokhvalov
- Department of War Surgery, Kirov Military Medical Academy, 6 Lebedeva Street, Saint-Petersburg 194044, Russian Federation
| | - Mansoor A Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Barry Building, Eastern Rd, Brighton BN2 5BE, United Kingdom
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73
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Brännström A, Dahlquist A, Gustavsson J, Arborelius UP, Günther M. Increased crystalloid fluid requirements during zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta ( REBOA) versus Abdominal Aortic and Junctional Tourniquet (AAJT) after class II hemorrhage in swine. Eur J Trauma Emerg Surg 2021. [PMID: 33515048 DOI: 10.1007/s00068-020-01592-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022]
Abstract
Purpose Pelvic and lower junctional hemorrhage result in a significant amount of trauma related deaths in military and rural civilian environments. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infra-renal (zone 3) Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are two options for resuscitation of patients with life threatening blood loss from and distal to the pelvis. Evidence suggest differences in the hemodynamic response between AAJT and zone 3 REBOA, but fluid management during resuscitation with the devices has not been fully elucidated. We compared crystalloid fluid requirements (Ringer’s acetate) between these devices to maintain a carotid mean arterial pressure (MAP) > 60 mmHg. Methods 60 kg anesthetized and mechanically ventilated male pigs were subjected to a mean 1030 (range 900–1246) mL (25% of estimated total blood volume, class II) haemorrhage. AAJT (n = 6) or zone 3 REBOA (n = 6) were then applied for 240 min. Crystalloid fluids were administered to maintain carotid MAP. The animals were monitored for 30 min after reperfusion. Results Cumulative resuscitative fluid requirements increased 7.2 times (mean difference 2079 mL; 95% CI 627–3530 mL) in zone 3 REBOA (mean 2412; range 800–4871 mL) compared to AAJT (mean 333; range 0–1000 mL) to maintain target carotid MAP. Release of the AAJT required vasopressor support with norepinephrine infusion for a mean 9.6 min (0.1 µg/kg/min), while REBOA release required no vasopressor support. Conclusion Zone 3 REBOA required 7.2 times more crystalloids to maintain the targeted MAP. The AAJT may therefore be considered in a situation of hemorrhagic shock to limit the need for crystalloid infusions, although removal of the AAJT caused more severe hemodynamic and metabolic effects which required vasopressor support.
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74
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McGreevy DT, Sadeghi M, Nilsson KF, Hörer TM. Low profile REBOA device for increasing systolic blood pressure in hemodynamic instability: single-center 4-year experience of use of ER-REBOA. Eur J Trauma Emerg Surg 2021; 48:307-313. [PMID: 33515268 PMCID: PMC8825639 DOI: 10.1007/s00068-020-01586-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 09/07/2020] [Accepted: 12/27/2020] [Indexed: 11/29/2022]
Abstract
Background Hemodynamic instability due to torso hemorrhage can be managed with the assistance of resuscitative endovascular balloon occlusion of the aorta (REBOA). This is a report of a single-center experience using the ER-REBOA™ catheter for traumatic and non-traumatic cases as an adjunct to hemorrhage control and as part of the EndoVascular resuscitation and Trauma Management (EVTM) concept. The objective of this report is to describe the clinical usage, technical success, results, complications and outcomes of the ER-REBOA™ catheter at Örebro University hospital, a middle-sized university hospital in Europe. Methods Data concerning patients receiving the ER-REBOA™ catheter for any type of hemorrhagic shock and hemodynamic instability at Örebro University hospital in Sweden were collected prospectively from October 2015 to May 2020. Results A total of 24 patients received the ER-REBOA™ catheter (with the intention to use) for traumatic and non-traumatic hemodynamic control; it was used in 22 patients. REBOA was performed or supervised by vascular surgeons using 7–8 Fr sheaths with an anatomic landmark or ultrasound guidance. Systolic blood pressure (SBP) increased significantly from 50 mmHg (0–63) to 95 mmHg (70–121) post REBOA. In this cohort, distal embolization and balloon rupture due to atherosclerosis were reported in one patient and two patients developed renal failure. There were no cases of balloon migration. Overall 30-day survival was 59%, with 45% for trauma patients and 73% for non-traumatic patients. Responders to REBOA had a significantly lower rate of mortality at both 24 h and 30 days. Conclusions Our clinical data and experience show that the ER-REBOA™ catheter can be used for control of hemodynamic instability and to significantly increase SBP in both traumatic and non-traumatic cases, with relatively few complications. Responders to REBOA have a significantly lower rate of mortality.
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Affiliation(s)
- David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden.
| | - Mitra Sadeghi
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden
| | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro University Hospital, 701 85, Örebro, Sweden.,Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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75
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Li W, Petrosoniak A, Ziesmann M. REBOA in Canada: time to shine, or time's up? CAN J EMERG MED 2021; 23:3-5. [PMID: 33683620 DOI: 10.1007/s43678-020-00057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/28/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Winny Li
- Division of Emergency Medicine, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, M5B 1W8, ON, Canada
| | - Andrew Petrosoniak
- Division of Emergency Medicine, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, M5B 1W8, ON, Canada. .,St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Markus Ziesmann
- Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
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Halvachizadeh S, Mica L, Kalbas Y, Lipiski M, Canic M, Teuben M, Cesarovic N, Rancic Z, Cinelli P, Neuhaus V, Pape HC, Pfeifer R. Zone-dependent acute circulatory changes in abdominal organs and extremities after resuscitative balloon occlusion of the aorta ( REBOA): an experimental model. Eur J Med Res 2021; 26:10. [PMID: 33478582 PMCID: PMC7818556 DOI: 10.1186/s40001-021-00485-y] [Citation(s) in RCA: 7] [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: 10/13/2020] [Accepted: 01/11/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be used in severely injured patients with uncontrollable bleeding. However, zone-dependent effects of REBOA are rarely described. We compared the short-term zone- and organ-specific microcirculatory changes in abdominal organs and the extremity during occlusion of the aorta in a standardized porcine model. Methods Male pigs were placed under general anesthesia, for median laparotomy to expose intra-abdominal organs. REBOA placement occurred in Zone 1 (from origin left subclavian artery to celiac trunk), Zone 2 (between the coeliac trunk and most caudal renal artery) and Zone 3 (distal most caudal renal artery to aortic bifurcation). Local microcirculation of the intra-abdominal organs were measured at the stomach, colon, small intestine, liver, and kidneys. Furthermore, the right medial vastus muscle was included for assessment. Microcirculation was measured using oxygen-to-see device (arbitrary units, A.U). Invasive blood pressure measurements were recorded in the carotid and femoral artery (ipsilateral). Ischemia/Reperfusion (I/R)-time was 10 min with complete occlusion. Results At baseline, microcirculation of intra-abdominal organs differed significantly (p < 0.001), the highest flow was in the kidneys (208.3 ± 32.9 A.U), followed by the colon (205.7 ± 36.2 A.U.). At occlusion in Zone 1, all truncal organs showed significant decreases (p < 0.001) in microcirculation, by 75% at the colon, and 44% at the stomach. Flow-rate changes at the extremities were non-significant (n.s). During occlusion in Zone 2, a significant decrease (p < 0.001) in microcirculation was observed at the colon (− 78%), small intestine (− 53%) and kidney (− 65%). The microcirculatory changes at the extremity were n.s. During occlusion in Zone 3, truncal and extremity microcirculatory changes were n.s. Conclusion All abdominal organs showed significant changes in microcirculation during REBOA. The intra-abdominal organs react differently to the same occlusion, whereas local microcirculation in extremities appeared to be unaffected by short-time REBOA, regardless of the zone of occlusion.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland. .,Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Ladislav Mica
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Yannik Kalbas
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Miriam Lipiski
- Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Marko Canic
- Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michel Teuben
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Nikola Cesarovic
- Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Zoran Rancic
- Department of Vascular Surgery, University Hospital Zürich, Raemistrasse 100, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Valentin Neuhaus
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Hans- Christoph Pape
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University of Zurich, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.,Division of Surgical Research, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Olsen MH, Olesen ND, Karlsson M, Holmlöv T, Søndergaard L, Boutelle M, Mathiesen T, Møller K. Randomized blinded trial of automated REBOA during CPR in a porcine model of cardiac arrest. Resuscitation 2021; 160:39-48. [PMID: 33482264 DOI: 10.1016/j.resuscitation.2021.01.010] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/23/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) reportedly elevates arterial blood pressure (ABP) during non-traumatic cardiac arrest. OBJECTIVES This randomized, blinded trial of cardiac arrest in pigs evaluated the effect of automated REBOA two minutes after balloon inflation on ABP (primary endpoint) as well as arterial blood gas values and markers of cerebral haemodynamics and metabolism. METHODS Twenty anesthetized pigs were randomized to REBOA inflation or sham-inflation (n = 10 in each group) followed by insertion of invasive monitoring and a novel, automated REBOA catheter (NEURESCUE® Catheter & NEURESCUE® Assistant). Cardiac arrest was induced by ventricular pacing. Cardiopulmonary resuscitation was initiated three min after cardiac arrest, and the automated REBOA was inflated or sham-inflated (blinded to the investigators) five min after cardiac arrest. RESULTS In the inflation compared to the sham group, mean ABP above the REBOA balloon after inflation was higher (inflation: 54 (95%CI: 43-65) mmHg; sham: 44 (33-55) mmHg; P = 0.06), and diastolic ABP was higher (inflation: 38 (29-47) mmHg; sham: 26 (20-33) mmHg; P = 0.02), and the arterial to jugular oxygen content difference was lower (P = 0.04). After return of spontaneous circulation, mean ABP (inflation: 111 (95%CI: 94-128) mmHg; sham: 94 (95%CI: 65-123) mmHg; P = 0.04), diastolic ABP (inflation: 95 (95%CI: 78-113) mmHg; sham: 78 (95%CI: 50-105) mmHg; P = 0.02), CPP (P = 0.01), and brain tissue oxygen tension (inflation: 315 (95%CI: 139-491)% of baseline; sham: 204 (95%CI: 75-333)%; P = 0.04) were higher in the inflation compared to the sham group. CONCLUSION Inflation of REBOA in a porcine model of non-traumatic cardiac arrest improves central diastolic arterial pressure as a surrogate marker of coronary artery pressure, and cerebral perfusion. INSTITUTIONAL PROTOCOL NUMBER 2017-15-0201-01371.
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Affiliation(s)
- Markus Harboe Olsen
- Department of Neurointensive Care and Neuroanaesthesiology, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark.
| | - Niels D Olesen
- Department of Anesthesiology, Centre of Cancer and Organ Diseases, Rigshospitalet, University of Copenhagen, Denmark
| | - Michael Karlsson
- Department of Neurosurgery, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark
| | - Theodore Holmlöv
- Department of Neurosurgery, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark; Stockholm Health Care Services, Region Stockholm, Stockholm, Sweden
| | - Lars Søndergaard
- Department of Cardiology, Centre of Cardiac, Vascular, Pulmonary and Infectious Diseases, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Martyn Boutelle
- Faculty of Engineering, Department of Bioengineering, Imperial College, London, United Kingdom
| | - Tiit Mathiesen
- Department of Neurosurgery, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kirsten Møller
- Department of Neurointensive Care and Neuroanaesthesiology, Neuroscience Centre, Rigshospitalet, University of Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Edwards TH, Dubick MA, Palmer L, Pusateri AE. Lessons Learned From the Battlefield and Applicability to Veterinary Medicine-Part 1: Hemorrhage Control. Front Vet Sci 2021; 7:571368. [PMID: 33521075 PMCID: PMC7841008 DOI: 10.3389/fvets.2020.571368] [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: 06/10/2020] [Accepted: 12/14/2020] [Indexed: 11/25/2022] Open
Abstract
In humans, the leading cause of potentially preventable death on the modern battlefield is undoubtedly exsanguination from massive hemorrhage. The US military and allied nations have devoted enormous effort to combat hemorrhagic shock and massive hemorrhage. This has yielded numerous advances designed to stop bleeding and save lives. The development of extremity, junctional and truncal tourniquets applied by first responders have saved countless lives both on the battlefield and in civilian settings. Additional devices such as resuscitative endovascular balloon occlusion of the aorta (REBOA) and intraperitoneal hemostatic foams show great promise to address control the most difficult forms (non-compressible) of hemorrhage. The development of next generation hemostatic dressings has reduced bleeding both in the prehospital setting as well as in the operating room. Furthermore, the research and fielding of antifibrinolytics such as tranexamic acid have shown incredible promise to ameliorate the effects of acute traumatic coagulopathy which has led to significant morbidity and mortality in service members. Advances from lessons learned on the battlefield have numerous potential parallels in veterinary medicine and these lessons are ripe for translation to veterinary medicine.
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Affiliation(s)
- Thomas H Edwards
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Michael A Dubick
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
| | - Lee Palmer
- Special Forces Group, Alabama Army National Guard, Auburn, AL, United States
| | - Anthony E Pusateri
- US Army Institute of Surgical Research, Joint Base San Antonio, San Antonio, TX, United States
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Power A, Parekh A, Scallan O, Smith S, Novick T, Parry N, Moore L. Size matters: first-in-human study of a novel 4 French REBOA device. Trauma Surg Acute Care Open 2021; 6:e000617. [PMID: 33490605 PMCID: PMC7798668 DOI: 10.1136/tsaco-2020-000617] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [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: 10/06/2020] [Revised: 12/11/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging technique used for non-compressible torso hemorrhage. However, its current use continues to be limited and there is a need for a simple, fast, and low profile REBOA device. Our objective was to evaluate the feasibility of a novel 4 French REBOA device called the COBRA-OS (Control of Bleeding, Resuscitation, Arterial Occlusion System). Methods This study is the first-in-human feasibility trial of the COBRA-OS. Due to the difficulty of trialing the device in the trauma setting, we performed a feasibility study using organ donors (due to the potential usefulness of the COBRA-OS for normothermic regional perfusion) after neurological determination of death (NDD) prior to organ retrieval. Bilateral 4 French introducer sheaths were placed in both femoral arteries and the COBRA-OS was advanced up the right side and deployed in the thoracic aorta (Zone 1). Once aortic occlusion was confirmed via the left-sided arterial line, the device was deflated, moved to the infrarenal aorta (Zone 3), and redeployed. Results A total of 7 NDD organ donors were entered into the study, 71% men, with a mean age 46.6 years (range 26 to 64). The COBRA-OS was able to occlude the aorta in Zones 1 and 3 in all patients. The mean time of placing a 4 French sheath was 47.7 seconds (n=13, range 28 to 66 seconds). The mean time from skin to Zone 1 aortic occlusion was 70.1 seconds (range 58 to 105 seconds); mean balloon volumes were 15 mL for Zone 1 (range 13 to 20 mL) and 9 mL for Zone 3 (range 6 to 15 mL); there were no complications and visual inspection of the aorta in all patients revealed no injury. Discussion The COBRA-OS is a novel 4 French REBOA device that has demonstrated fast and safe aortic occlusion in this first-in-human feasibility study. Level of evidence Level V, therapeutic.
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Affiliation(s)
- Adam Power
- Surgery, Western University, London, Canada
| | | | | | | | | | - Neil Parry
- Surgery, Western University, London, Canada
| | - Laura Moore
- Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
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80
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Thrailkill MA, Gladin KH, Thorpe CR, Roberts TR, Choi JH, Chung KK, Necsoiu CN, Rasmussen TE, Cancio LC, Batchinsky AI. Resuscitative Endovascular Balloon Occlusion of the Aorta ( REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med 2021; 29:8. [PMID: 33407759 PMCID: PMC7789715 DOI: 10.1186/s13049-020-00807-9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications. Methods To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data. Results In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times. Conclusions Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.
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Affiliation(s)
- Marianne A Thrailkill
- Glacier Technical Solutions, El Paso, TX, USA.,Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA
| | | | - Catherine R Thorpe
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Teryn R Roberts
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Jae H Choi
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Corina N Necsoiu
- Prolonged Field Care Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Andriy I Batchinsky
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA. .,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA.
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81
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Madurska MJ, McLenithan A, Scalea TM, Kundi R, White JM, Morrison JJ, DuBose JJ. A feasibility study of partial REBOA data in a high-volume trauma center. Eur J Trauma Emerg Surg 2021; 48:299-305. [PMID: 33399878 DOI: 10.1007/s00068-020-01561-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 04/25/2020] [Accepted: 11/19/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporize patients with infradiaphragmatic hemorrhage. Current guidelines advise < 30 min, to avoid ischemia/ reperfusion injury, whenever possible. The technique of partial REBOA (P-REBOA) has been developed to minimize the effects of distal ischemia. This study presents our clinical experience with P-REBOA, comparing outcomes to complete occlusion (C-REBOA). PATIENTS AND METHODS Retrospective analysis of patients' electronic data and local REBOA registry between January 2016 and May 2019. INCLUSION CRITERIA adult trauma patients who received Zone I C-REBOA or P-REBOA for infradiaphragmatic hemorrhage, who underwent attempted exploration in the operating room. Comparison of outcomes based on REBOA technique (P-REBOA vs C-REBOA) and occlusion time (> 30 min, vs ≤ 30 min) RESULTS: 46 patients were included, with 14 treated with P-REBOA. There were no demographic differences between P-REBOA and C-REBOA. Prolonged (> 30 min) REBOA (regardless of type of occlusion) was associated with increased mortality (32% vs 0%, p = 0.044) and organ failure. When comparing prolonged P-REBOA with C-REBOA, there was a trend toward lower ventilator days [19 (11) vs 6 (9); p = 0.483] and dialysis (36.4% vs 16.7%; p = 0.228) with significantly less vasopressor requirement (72.7% vs 33.3%; p = 0.026). CONCLUSION P-REBOA can be delivered in a clinical setting, but is not currently associated with improved survival in prolonged occlusion. In survivors, there is a trend toward lower organ support needs, suggesting that the technique might help to mitigate ischemic organ injury. More clinical data are needed to clarify the benefit of partial occlusion REBOA.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Ashley McLenithan
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, 19131, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Joseph M White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences and The Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA.
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
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82
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Frassini S, Gupta S, Granieri S, Cimbanassi S, Sammartano F, Scalea TM, Chiara O. Emergency Management of Pelvic Bleeding. J Clin Med 2021; 10:E129. [PMID: 33401504 DOI: 10.3390/jcm10010129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 11/16/2022] Open
Abstract
Pelvic trauma continues to have a high mortality rate despite damage control techniques for bleeding control. The aim of our study was to evaluate how Extra-peritoneal Pelvic Packing (EPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) impact the efficacy on mortality and hemodynamic impact. We retrospectively evaluated patients who sustained blunt trauma, pelvic fracture and hemodynamic instability from 2002 to 2018. We excluded a concomitant severe brain injury, resuscitative thoracotomy, penetrating trauma and age below 14 years old. The study population was divided in EPP and REBOA Zone III group. Propensity score matching was used to adjust baseline differences and then a one-to-one matched analysis was performed. We selected 83 patients, 10 for group: survival rate was higher in EPP group, but not significantly in each outcome we analyzed (24 h, 7 day, overall). EPP had a significant increase in main arterial pressure after procedure (+20.13 mmHg, p < 0.001), but this was not as great as the improvement seen in the REBOA group (+45.10 mmHg, p < 0.001). EPP and REBOA are effective and improve hemodynamic status: both are reasonable first steps in a multidisciplinary management. Zone I REBOA may be useful in patients ‘in extremis condition’ with multiple sites of torso hemorrhage, particularly those in extremis.
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83
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Ordoñez CA, Parra MW, Serna JJ, Rodríguez-Holguin F, García A, Salcedo A, Caicedo Y, Padilla N, Pino LF, Hadad AG, Herrera MA, Millán M, Quintero-Barrera L, Hernández-Medina F, Ferrada R, Brenner M, Rasmussen T, Scalea T, Ivatury R, Holcomb JB. Damage control resuscitation: REBOA as the new fourth pillar. Colomb Med (Cali) 2020; 51:e4014353. [PMID: 33795897 PMCID: PMC7968430 DOI: 10.25100/cm.v51i4.4353] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Damage Control Resuscitation (DCR) seeks to combat metabolic decompensation of the severely injured trauma patient by battling on three major fronts: Permissive Hypotension, Hemostatic Resuscitation, and Damage Control Surgery (DCS). The aim of this article is to perform a review of the history of DCR/DCS and to propose a new paradigm that has emerged from the recent advancements in endovascular technology: The Resuscitative Balloon Occlusion of the Aorta (REBOA). Thanks to the advances in technology, a bridge has been created between Pre-hospital Management and the Control of Bleeding described in Stage I of DCS which is the inclusion and placement of a REBOA. We have been able to show that REBOA is not only a tool that aids in the control of hemorrhage, it is also a vital tool in the hemodynamic resuscitation of a severely injured blunt and/or penetrating trauma patient. That is why we propose a new paradigm “The Fourth Pillar”: Permissive Hypotension, Hemostatic Resuscitation, Damage Control Surgery and REBOA.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - José Julián Serna
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Fernando Rodríguez-Holguin
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili. Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Division of Transplant Surgery, Department of Surgery, Cali, Colombia
| | - Laureano Quintero-Barrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Fabian Hernández-Medina
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina. Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Megan Brenner
- University of California, Department of Surgery Riverside University Health Systems . Riverside , CA , USA
| | - Todd Rasmussen
- Uniformed Services University, F. Edward Hebert School of Medicine, Department of Surgery, Bethesda, Maryland. USA
| | - Thomas Scalea
- University of Maryland, Department of Surgery, School of Medicine, Baltimore, MD USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
| | - John B Holcomb
- University of Alabama Center for Injury Science, Department of Surgery, Birmingham. AL, USA
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84
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Ordoñez CA, Parra MW, Millán M, Caicedo Y, Guzmán-Rodríguez M, Padilla N, Salamea-Molina JC, García A, González-Hadad A, Pino LF, Herrera MA, Rodríguez-Holguín F, Serna JJ, Salcedo A, Aristizábal G, Orlas C, Ferrada R, Scalea T, Ivatury R. Damage Control in Penetrating Liver Trauma: Fear of the Unknown. Colomb Med (Cali) 2020; 51:e4134365. [PMID: 33795903 PMCID: PMC7968427 DOI: 10.25100/cm.v51i4.4422.4365] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The liver is the most commonly affected solid organ in cases of abdominal trauma. Management of penetrating liver trauma is a challenge for surgeons but with the introduction of the concept of damage control surgery accompanied by significant technological advancements in radiologic imaging and endovascular techniques, the focus on treatment has changed significantly. The use of immediately accessible computed tomography as an integral tool for trauma evaluations for the precise staging of liver trauma has significantly increased the incidence of conservative non-operative management in hemodynamically stable trauma victims with liver injuries. However, complex liver injuries accompanied by hemodynamic instability are still associated with high mortality rates due to ongoing hemorrhage. The aim of this article is to perform an extensive review of the literature and to propose a management algorithm for hemodynamically unstable patients with penetrating liver injury, via an expert consensus. It is important to establish a multidisciplinary approach towards the management of patients with penetrating liver trauma and hemodynamic instability. The appropriate triage of these patients, the early activation of an institutional massive transfusion protocol, and the early control of hemorrhage are essential landmarks in lowering the overall mortality of these severely injured patients. To fear is to fear the unknown, and with the management algorithm proposed in this manuscript, we aim to shed light on the unknown regarding the management of the patient with a severely injured liver.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery, Cuenca, Ecuador.,Universidad del Azuay, Escuela de Medicina, Cuenca, Ecuador
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Adolfo González-Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Gonzalo Aristizábal
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Claudia Orlas
- Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, USA.,Harvard Medical School & Harvard T.H., Chan School of Public Health, Boston, USA
| | - Ricardo Ferrada
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Thomas Scalea
- University of Maryland, School of Medicine, Department of Surgery, Baltimore, MD USA
| | - Rao Ivatury
- Professor Emeritus Virginia Commonwealth University, Richmond, VA, USA
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85
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Mejia D, Parra MW, Ordoñez CA, Padilla N, Caicedo Y, Pereira Warr S, Jurado-Muñoz PA, Torres M, Martínez A, Serna JJ, Rodríguez-Holguín F, Salcedo A, García A, Millán M, Pino LF, González Hadad A, Herrera MA, Moore EE. Hemodynamically unstable pelvic fracture: A damage control surgical algorithm that fits your reality. Colomb Med (Cali) 2020; 51:e4214510. [PMID: 33795905 PMCID: PMC7968423 DOI: 10.25100/cm.v51i4.4510] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pelvic fractures occur in up to 25% of all severely injured trauma patients and its mortality is markedly high despite advances in resuscitation and modernization of surgical techniques due to its inherent blood loss and associated extra-pelvic injuries. Pelvic ring volume increases significantly from fractures and/or ligament disruptions which precludes its inherent ability to self-tamponade resulting in accumulation of hemorrhage in the retroperitoneal space which inevitably leads to hemodynamic instability and the lethal diamond. Pelvic hemorrhage is mainly venous (80%) from the pre-sacral/pre-peritoneal plexus and the remaining 20% is of arterial origin (branches of the internal iliac artery). This reality can be altered via a sequential management approach that is tailored to the specific reality of the treating facility which involves a collaborative effort between orthopedic, trauma and intensive care surgeons. We propose two different management algorithms that specifically address the availability of qualified staff and existing infrastructure: one for the fully equipped trauma center and another for the very common limited resource center.
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Affiliation(s)
- David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellin, Colombia.,Universidad de Antioquia, Department of Surgery, Medellin, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL, USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Salin Pereira Warr
- Hospital Pablo Tobón Uribe, Grupo de Soporte Nutricional y Pared Abdominal, Medellin, Colombia
| | | | - Mauricio Torres
- Fundación Valle del Lili, Department of Orthopedic Surgery, Cali, Colombia
| | - Alfredo Martínez
- Fundación Valle del Lili, Department of Orthopedic Surgery, Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Mauricio Millán
- Universidad Icesi, Cali, Colombia.,Fundación Valle del Lili, Department of Surgery, Division of Transplant Surgery, Cali, Colombia
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Adolfo González Hadad
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia.,Centro Médico Imbanaco, Cali, Colombia
| | - Mario Alain Herrera
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Ernest E Moore
- University of Colorado, Denver Health Medical Center, Department of Surgery, Denver, CO USA
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86
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Ordoñez CA, Parra MW, Caicedo Y, Padilla N, Rodríguez-Holguín F, Serna JJ, Salcedo A, García A, Orlas C, Pino LF, Del Valle AM, Mejia D, Salamea-Molina JC, Brenner M, Hörer T. REBOA as a New Damage Control Component in Hemodynamically Unstable Noncompressible Torso Hemorrhage Patients. Colomb Med (Cali) 2020; 51:e4064506. [PMID: 33795901 PMCID: PMC7968426 DOI: 10.25100/cm.v51i4.4422.4506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Noncompressible torso hemorrhage is one of the leading causes of preventable death worldwide. An efficient and appropriate evaluation of the trauma patient with ongoing hemorrhage is essential to avoid the development of the lethal diamond (hypothermia, coagulopathy, hypocalcemia, and acidosis). Currently, the initial management strategies include permissive hypotension, hemostatic resuscitation, and damage control surgery. However, recent advances in technology have opened the doors to a wide variety of endovascular techniques that achieve these goals with minimal morbidity and limited access. An example of such advances has been the introduction of the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), which has received great interest among trauma surgeons around the world due to its potential and versatility in areas such as trauma, gynecology & obstetrics and gastroenterology. This article aims to describe the experience earned in the use of REBOA in noncompressible torso hemorrhage patients. Our results show that REBOA can be used as a new component in the damage control resuscitation of the severely injured trauma patient. To this end, we propose two new deployment algorithms for hemodynamically unstable noncompressible torso hemorrhage patients: one for blunt and another for penetrating trauma. We acknowledge that REBOA has its limitations, which include a steep learning curve, its inherent cost and availability. Although to reach the best outcomes with this new technology, it must be used in the right way, by the right surgeon with the right training and to the right patient.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alexander Salcedo
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | - Alberto García
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Claudia Orlas
- Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital, Boston, USA.,Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, USA
| | - Luis Fernando Pino
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia.,Hospital Universitario del Valle, Division of Trauma and Acute Care Surgery, Department of Surgery. Cali, Colombia
| | | | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellin, Colombia.,Universidad de Antioquia, Department of Surgery, Medellin, Colombia
| | - Juan Carlos Salamea-Molina
- Hospital Vicente Corral Moscoso, Division of Trauma and Acute Care Surgery. Cuenca, Ecuador.,Universidad del Azuay, Escuela de Medicina. Cuenca, Ecuador
| | - Megan Brenner
- University of California, Department of Surgery Riverside University Health Systems. Riverside, CA, USA
| | - Tal Hörer
- 15 Örebro University Hospital, Faculty of Medicine, Department of Cardiothoracic and Vascular Surgery, Örebro, Sweden
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Eksteen A, O'Dochartaigh D, Odenbach J, Douma MJ, O'Neill K, Anantha R, Bradley NL, Gauri A, Widder S. A gap analysis of the potential use of resuscitative endovascular balloon occlusion of the aorta ( REBOA) in trauma at two major Canadian trauma centers. CAN J EMERG MED 2020; 23:36-44. [PMID: 33683614 DOI: 10.1007/s43678-020-00007-5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 07/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Uncontrolled hemorrhage poses significant morbidity and mortality among injured patients. Resuscitative endovascular balloon occlusion of the aorta (REBOA) utilizes a rapidly-administered minimally invasive transfemoral balloon catheter that is inflated for aortic occlusion, allowing for time to arrange definitive surgical or angiographic intervention. As indications for its use continue to evolve, this study sought to evaluate whether there is a potential need for REBOA implementation in two high-volume trauma centers in Edmonton. METHODS Patient data within our provincial trauma registry was reviewed between 2015 and 2017 to identify major trauma patients (Injury Severity Score ≥ 12). Patients eligible for REBOA included patients with blunt or penetrating trauma to the torso or pelvis, AND death prior to discharge; and patients taken to the operating room or interventional radiology suite within 4 h of arrival. Charts were reviewed to determine if patients met current conventional criteria for REBOA. RESULTS Out of 3415 trauma patients during our study period, 237 patients met the registry screen as potentially eligible for REBOA. After primary researcher review, 67 patients underwent full chart review and then 2 trauma surgeons determined that 38 (1.1% of the study population) met criteria for deploying REBOA. CONCLUSION A small but significant number of trauma patients at the two trauma centers were identified as potential candidates for REBOA use. Implementation of a REBOA program should be done in alignment with existing clinical practice guidelines and professional society recommendations.
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Affiliation(s)
- Alistair Eksteen
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada.
| | - Domhnall O'Dochartaigh
- Alberta Health Services, Emergency, Edmonton, AB, Canada.,Shock Trauma Air Rescue Society (STARS), Edmonton, AB, Canada
| | - Jeff Odenbach
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada
| | - Matthew J Douma
- Alberta Health Services, Emergency, Edmonton, AB, Canada.,Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland
| | - Kristin O'Neill
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada.,Alberta Health Services, Emergency, Edmonton, AB, Canada.,Shock Trauma Air Rescue Society (STARS), Edmonton, AB, Canada.,Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,School of Nursing, Midwifery, and Health Systems, University College Dublin, Dublin, Ireland.,Department of Surgery, University of Alberta, Edmonton, AB, USA.,Department of Critical Care Medicine, University of British Columbia, Vancouver, Canada
| | - Ram Anantha
- Department of Surgery, University of Alberta, Edmonton, AB, USA
| | - Nori L Bradley
- Department of Surgery, University of Alberta, Edmonton, AB, USA.,Department of Critical Care Medicine, University of British Columbia, Vancouver, Canada
| | - Aliyah Gauri
- Department of Emergency Medicine, Faculty of Medicine and Dentistry 2J2.00 WC Mackenzie Health Sciences Centre, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada
| | - Sandy Widder
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.,Department of Surgery, University of Alberta, Edmonton, AB, USA
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88
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Smith AD, Hudson J, Moore LJ, Scalea TM, Brenner ML. Resuscitative endovascular balloon occlusion of the aorta ( REBOA) for temporization of hemorrhage in adolescent trauma patients. J Pediatr Surg 2020; 55:2732-2735. [PMID: 32912618 DOI: 10.1016/j.jpedsurg.2020.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 07/06/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative technique for traumatic hemorrhage control in the adult population. The purpose of this study is to describe the details of REBOA placement in adolescent trauma patients. METHODS Patients 18 years of age or less who received REBOA for aortic occlusion (AO) from August 2013 to February 2017 at 2 urban tertiary care centers were included. RESULTS 7 adolescent trauma patients received REBOA by trauma surgeons for both blunt (n = 4) and penetrating mechanisms (n = 3); mean age was 17 + 1.5 years, mean admission lactate 13.0 + 4.85 mmol/L, and mean Hgb 10.7 + 2.7 g/dL. 3 patients received REBOA through a 12Fr sheath and 4 through a 7Fr sheath. AO occurred mostly at the distal thoracic aorta (Zone I) (85.7%) and also in the distal abdominal aorta (Zone III) (14.3%). 57% of patients were in arrest with ongoing CPR at the time of REBOA. In-hospital mortality was 57%; all of these patients were in arrest at the time of REBOA, had return of spontaneous circulation (ROSC), and survived to the operating room. No complications from REBOA were identified. CONCLUSION REBOA appears to be feasible for use in adolescents despite their smaller caliber vessels, even with use of a 12Fr sheath. REBOA results in improved physiology and can bridge adolescent trauma patients presenting in extremis to the operating room. TYPE OF STUDY Treatment/therapeutic study LEVEL OF EVIDENCE: Level IV.
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Affiliation(s)
- Alexis D Smith
- Children's Healthcare of Atlanta, Department of Pediatric Surgery, 5461 Meridian Mark Rd Suite 570, Atlanta, GA 30342.
| | - Jessica Hudson
- University of Texas Health Sciences Center at Houston, Department of Surgery, 6550 Fannin Street #583, Houston, TX 77030
| | - Laura J Moore
- University of Texas Health Sciences Center at Houston, Department of Surgery, 6550 Fannin Street #583, Houston, TX 77030
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, Department of Surgery, 22 South Greene Street, Baltimore, MD 21201
| | - Megan L Brenner
- University of California Riverside, Department of Surgery, 26520 Cactus Avenue Moreno Valley, CA 92555
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89
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Theodorou CM, Brenner M, Morrison JJ, Scalea TM, Moore LJ, Cannon J, Seamon M, DuBose JJ, Galante JM. Nationwide use of REBOA in adolescent trauma patients: An analysis of the AAST AORTA registry. Injury 2020; 51:2512-2516. [PMID: 32798039 PMCID: PMC7609470 DOI: 10.1016/j.injury.2020.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Trauma is the leading cause of death for children and adolescents. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method of hemorrhage control used primarily in adults. We aimed to characterize REBOA use in pediatric patients. METHODS The American Association for the Surgery of Trauma (AAST) Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry was queried for patients <18 years old undergoing REBOA placement (2013-2020). The primary outcome was mortality. Secondary outcomes included injury severity score (ISS), additional interventions, and complications. RESULTS Eleven patients with a median age of 17 years old had REBOA placed, with a survival rate of 30%. Inflation of the REBOA balloon resulted in a significant increase in systolic blood pressure (SBP) (median SBP pre-REBOA 53 mmHg vs. post-REBOA 110 mmHg, p=0.0007). Patients were severely injured with a median ISS of 29 (interquartile range 16-42). There were no access-site complications. All three surviving patients had a discharge Glasgow Coma Scale of 15. CONCLUSION REBOA is used in patients <18 years old, but all reported patients in this registry were adolescents. No REBOA-related complications were reported. Identifying pediatric patients who may benefit from REBOA and modifying currently existing technology for this group of patients is an area of ongoing research.
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Affiliation(s)
- Christina M. Theodorou
- University of California Davis Medical Center, Department of Surgery. Sacramento, CA, USA,Corresponding author. , (C.M. Theodorou)
| | - Megan Brenner
- University of California Riverside, Department of Surgery. Riverside, CA, USA
| | | | - Thomas M. Scalea
- University of Maryland, Department of Surgery. Baltimore, MD, USA
| | - Laura J. Moore
- University of Texas Health Sciences Center Houston, Department of Surgery. Houston, TX, USA
| | - Jeremy Cannon
- University of Pennsylvania, Department of Surgery. Philadelphia, PA, USA
| | - Mark Seamon
- University of Pennsylvania, Department of Surgery. Philadelphia, PA, USA
| | - Joseph J. DuBose
- University of Maryland, Department of Surgery. Baltimore, MD, USA
| | - Joseph M. Galante
- University of California Davis Medical Center, Department of Surgery. Sacramento, CA, USA
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90
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Hatchimonji JS, Sikoutris J, Smith BP, Vella MA, Dumas RP, Qasim ZA, Gallagher JJ, Reilly PM, Raza SS, Cannon JW. The REBOA Dissipation Curve: Training Starts to Wane at 6 Months in the Absence of Clinical REBOA Cases. J Surg Educ 2020; 77:1598-1604. [PMID: 32741695 DOI: 10.1016/j.jsurg.2020.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/27/2020] [Accepted: 05/03/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a low-frequency, high-acuity intervention. We hypothesized that REBOA-specific knowledge and comfort deteriorate significantly within 6 months of a formal training course if REBOA is not performed in the interim. METHODS A comprehensive REBOA course was developed including didactics and hands-on practical simulation training. Baseline knowledge and comfort were assessed with a precourse objective test and a subjective self-assessment. REBOA knowledge and comfort were then re-assessed immediately postcourse and again at 6 months and 1 year. Performance trends were measured using paired Student's t and Wilcoxon signed-rank tests. RESULTS Thirteen participants were evaluated including trauma faculty (n = 10) and fellows (n = 3). Test scores improved significantly from precourse (72% ± 10% correct) to postcourse (88% ± 8%, p < 0.001). At 6 months, scores remained no different from postcourse (p = 0.126); at 1 year, scores decreased back to baseline (p = 0.024 from postcourse; 0.285 from precourse). Subjective comfort with femoral arterial line placement and REBOA improved with training (p = 0.044 and 0.003, respectively). Femoral arterial line comfort remained unchanged from postcourse at 6 months (p = 0.898) and 1 year (p = 0.158). However, subjective comfort with REBOA decreased relative to postcourse levels at 6 months (p = 0.009), driven primarily by participants with no clinical REBOA cases in the interim. CONCLUSIONS A formal REBOA curriculum improves knowledge and comfort with critical aspects of this procedure. This knowledge persists at 6 months, though subjective comfort deteriorated among those without REBOA placement in the interim. REBOA refresher training should be considered at 6-month intervals in the absence of clinical REBOA cases. LEVEL OF EVIDENCE/STUDY TYPE Level III, prognostic.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Jennifer Sikoutris
- Undergraduate Nursing Department, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania
| | - Brian P Smith
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Vella
- Division of Acute Care Surgery and Trauma, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Ryan P Dumas
- Division of General and Acute Care Surgery, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Zaffer A Qasim
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - John J Gallagher
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Shariq S Raza
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Uniformed Services university of the Health Sciences, Bethesda, Maryland
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91
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Manzano-Nunez R, McGreevy D, Orlas CP, García AF, Hörer TM, DuBose J, Ordoñez CA. Outcomes and management approaches of resuscitative endovascular balloon occlusion of the aorta based on the income of countries. World J Emerg Surg 2020; 15:57. [PMID: 33046096 PMCID: PMC7549081 DOI: 10.1186/s13017-020-00337-w] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/27/2020] [Indexed: 11/28/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) could provide a survival benefit to severely injured patients as it may improve their initial ability to survive the hemorrhagic shock. Although the evidence supporting the use of REBOA is not conclusive, its use has expanded worldwide. We aim to compare the management approaches and clinical outcomes of trauma patients treated with REBOA according to the countries’ income based on the World Bank Country and Lending Groups. Methods We used data from the AORTA (USA) and the ABOTrauma (multinational) registries. Patients were stratified into two groups: (1) high-income countries (HICs) and (2) low-to-middle income countries (LMICs). Propensity score matching extracted 1:1 matched pairs of subjects who were from an LMIC or a HIC based on age, gender, the presence of pupillary response on admission, impeding hypotension (SBP ≤ 80), trauma mechanism, ISS, the necessity of CPR on arrival, the location of REBOA insertion (emergency room or operating room) and the amount of PRBCs transfused in the first 24 h. Logistic regression (LR) was used to examine the association of LMICs and mortality. Results A total of 817 trauma patients from 14 countries were included. Blind percutaneous approach and surgical cutdown were the preferred means of femoral cannulation in HICs and LIMCs, respectively. Patients from LMICs had a significantly higher occurrence of MODS and respiratory failure. LR showed no differences in mortality for LMICs when compared to HICs; neither in the non-matched cohort (OR = 0.63; 95% CI: 0.36‑1.09; p = 0.1) nor in the matched cohort (OR = 1.45; 95% CI: 0.63‑3,33; p = 0.3). Conclusion There is considerable variation in the management practices of REBOA and the outcomes associated with this intervention between HICs and LMICs. Although we found significant differences in multiorgan and respiratory failure rates, there were no differences in the risk-adjusted odds of mortality between the groups analyzed. Trauma surgeons practicing REBOA around the world should joint efforts to standardize the practice of this endovascular technology worldwide.
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Affiliation(s)
- Ramiro Manzano-Nunez
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia. .,Universidad del Rosario, Escuela de Medicina y Ciencias de la Salud, Bogotá, Colombia. .,Méderi Hospital Universitario Mayor, Carrera 24 No 63C - 69 Barrio Siete de Agosto, Bogotá, DC, Colombia. .,R. Adams Cowley Shock Trauma, Baltimore, MD, USA.
| | - David McGreevy
- Méderi Hospital Universitario Mayor, Carrera 24 No 63C - 69 Barrio Siete de Agosto, Bogotá, DC, Colombia
| | - Claudia P Orlas
- Clinical Research Center, Fundacion Valle del Lili, Cali, Colombia
| | | | - Tal M Hörer
- Méderi Hospital Universitario Mayor, Carrera 24 No 63C - 69 Barrio Siete de Agosto, Bogotá, DC, Colombia
| | - Joseph DuBose
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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92
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Abstract
It is extremely difficult to provide non-compressible torso hemorrhage control particularly in trauma setting. A vast majority of cases present inability of successful exsanguination arrest, leading to cardiovascular collapse, myocardial and cerebral hypoperfusion and death eventually. The only possible treatment for these patients is prompt bleeding control, either open or endovascular. Aortic occlusion seems to be the most rapid and convenient way to restrain blood loss and possibly increase survival. However, it is not proven yet. Traditional aortic occlusion for trauma consisted of supradiaphragmatic thoracic aorta cross-clamping through resuscitative thoracotomy (RT). This complicated and devastating procedure triggered the necessity to work on a simpler, less invasive resuscitation bridge which can be implemented in emergency departments or even in prehospital setting. Resuscitative balloon occlusion of the aorta (REBOA) provides a novel method of hemorrhagic shock stabilization in bleeding below the diaphragm. The mechanism lies in improving myocardial and cerebral perfusion and ceasing major bleeding itself. This method together with invasive endovascular and surgical procedures creates a new approach of choice for trauma patients. It is called Endovascular Hybrid Trauma and Resuscitation Management (EVTM) and introduces this concept to modern clinical practice. Through a detailed review, this article aims to introduce REBOA procedure to a broader recipient and present REBOA details, benefits and limitations.
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Affiliation(s)
- Piotr Marciniuk
- Klinika Kardiochirurgii i Chirurgii Naczyniowej Gdańskiego Uniwersytetu Medycznego
| | - Rafał Pawlaczyk
- Klinika Kardiochirurgii i Chirurgii Naczyniowej Gdańskiego Uniwersytetu Medycznego
| | - Jan Rogowski
- Klinika Kardiochirurgii i Chirurgii Naczyniowej Gdańskiego Uniwersytetu Medycznego
| | - Jacek Wojciechowski
- Klinika Kardiochirurgii i Chirurgii Naczyniowej Gdańskiego Uniwersytetu Medycznego
| | - Łukasz Znaniecki
- Klinika Kardiochirurgii i Chirurgii Naczyniowej Gdańskiego Uniwersytetu Medycznego
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93
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Campagna GA, Cunningham ME, Hernandez JA, Chau A, Vogel AM, Naik-Mathuria BJ. The utility and promise of Resuscitative Endovascular Balloon Occlusion of the Aorta ( REBOA) in the pediatric population: An evidence-based review. J Pediatr Surg 2020; 55:2128-2133. [PMID: 32061369 DOI: 10.1016/j.jpedsurg.2020.01.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 10/07/2019] [Revised: 12/17/2019] [Accepted: 01/24/2020] [Indexed: 11/18/2022]
Abstract
Hemorrhage is the main cause of preventable death in both military and civilian trauma, and many of these patients die from non-compressible torso injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method used for hemodynamic control of the hemorrhaging patient and has been compared to resuscitative thoracotomy (RT) with cross clamping of the aorta. REBOA has received a great deal of attention in recent years for its applicability and promise in adult trauma and non-trauma settings, but its utility in children is mostly unknown. The purpose of this review article is to summarize and consolidate what is currently known about the use of REBOA in children. Some of the challenges in implementing REBOA in children include small vascular anatomy and lack of outcomes data. Although the evidence is limited, there are established instances in the literature of children and adolescents who have undergone endovascular occlusion of the aorta for hemorrhage control with positive outcomes and survival rates equivalent to their adult counterparts. There is a need for further formal evaluation of REBOA in pediatric patients with prospective studies to look at the safety, feasibility and efficacy of the technique. STUDY TYPE: Narrative Literature Review LEVEL OF EVIDENCE: IV.
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Affiliation(s)
- Giovanni A Campagna
- Baylor College of Medicine, School of Medicine, 1 Baylor Plaza, Houston, TX, 77030, USA
| | - Megan E Cunningham
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA
| | - Jose A Hernandez
- Texas Children's Hospital, Department of Radiology, Division of Pediatric Interventional Radiology, 6701 Fannin St, Houston, TX, 77030, USA
| | - Alex Chau
- Texas Children's Hospital, Department of Radiology, Division of Pediatric Interventional Radiology, 6701 Fannin St, Houston, TX, 77030, USA
| | - Adam M Vogel
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA
| | - Bindi J Naik-Mathuria
- Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, 6701 Fannin St, Houston, TX, 77030, USA.
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94
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Bailey AJM, Lee A, Li HOY, Glen P. Intraoperative balloon occlusion of the aorta for blood management in sacral and pelvic tumor resection: A systematic review and meta-analysis. Surg Oncol 2020; 35:156-161. [PMID: 32877885 DOI: 10.1016/j.suronc.2020.08.016] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Neoplasms of the sacrum and pelvis are challenging to manage due to their complex vascularity and size and are at high risk of bleeding during resection. Intra-aortic balloon occlusion (IABO) has been used in trauma to control massive blood loss, but its efficacy and safety in oncologic sacral and pelvic surgery are unknown. The primary objective of this systematic review and meta-analysis was to assess the effectiveness of IABO in providing hemorrhage control during resection of sacral and pelvic tumors. METHODS This PROSPERO pre-registered study meta-analyzed all studies reporting on the use of IABO in the setting of pelvic and sacral tumour resection, in accordance with the PRISMA guidelines. The primary outcome of the meta-analysis was intraoperative blood loss, with secondary outcomes consisting of transfusion volume, post-operative blood loss, operative time, complication rate, and mortality. RESULTS Across studies, IABO was associated with a large, significant reduction in intraoperative blood loss (SMD -0.81, 95% CI -1.01 to -0.60, P < 0.0001) and transfused red blood cell volume (SMD 0.92, 95% CI -1.30 to -0.53, P < 0.0001). Two studies reported that complication rates were comparable between patients receiving IABO and patient receiving conventional surgery (Odds ratio = 1.29, 95% CI: 0.59 to 2.83, P = 0.52). All studies descriptively reported improved visualization of the operative field with IABO. CONCLUSIONS Our findings demonstrated that IABO is an effective technique to decrease blood loss and transfusion requirements during sacral and pelvic tumor surgery. Future clinical trials should be conducted to establish the safety of this method and explore potential contraindications.
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Affiliation(s)
| | - Alex Lee
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | | | - Peter Glen
- Faculty of Medicine, University of Ottawa, Ottawa, Canada; Division of General Surgery, University of Ottawa, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada.
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95
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Whittington JR, Pagan ME, Nevil BD, Kalkwarf KJ, Sharawi NE, Hughes DS, Sandlin AT. Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta ( REBOA) in the management of placenta accreta spectrum. J Matern Fetal Neonatal Med 2020; 35:3049-3052. [PMID: 32781879 DOI: 10.1080/14767058.2020.1802717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare prophylactic and emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement in the management of placenta accreta spectrum (PAS). STUDY DESIGN Retrospective chart review of all patients with PAS (January 2018 to January 2020) at a single tertiary center who underwent prophylactic or emergent REBOA for cesarean hysterectomy for PAS. RESULTS A total of 16 pregnant patients with PAS underwent percutaneous REBOA placement by acute care surgeons in collaboration with a multi-disciplinary PAS team. The REBOA catheter was placed prophylactically in 11 cases and emergently in 5 cases. No complications occurred in the prophylactic placement group. In the emergent placement group, 3 of 4 surviving patients had vascular access site complications requiring intervention. CONCLUSION A multidisciplinary approach for the management of PAS utilizing REBOA is feasible in the setting of both planned and emergent cesarean hysterectomy and can aid in the control of acute hemorrhage. The risk for vascular access site complications related to REBOA catheter placement is higher in the emergent setting compared to prophylactic placement.
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Affiliation(s)
- Julie R Whittington
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan E Pagan
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bryan D Nevil
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nadir El Sharawi
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam T Sandlin
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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96
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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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97
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Mikdad S, van Erp IAM, Moheb ME, Fawley J, Saillant N, King DR, Kaafarani HMA, Velmahos G, Mendoza AE. Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: A nationwide analysis. Injury 2020; 51:1834-1839. [PMID: 32564964 DOI: 10.1016/j.injury.2020.06.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/09/2020] [Accepted: 06/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Early hemorrhage control after severe blunt pelvic trauma is life-saving. The aim of this study is to compare the efficacy and outcomes of pre-peritoneal packing (PPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with a subsequent hemorrhage control procedure to control life-threatening pelvic hemorrhage in trauma patients. METHODS A 3-year (2015-2017) retrospective analysis of the Trauma Quality Improvement Program (TQIP) was performed. All blunt trauma patients (aged ≥15 years) who underwent PPP or Zone 3 REBOA placement were included while deaths on arrival and transfers were excluded. Patients were matched on clinical characteristics using propensity score matching (PSM). Univariate analysis was performed to compare mortality, time to procedure, time in ED, transfusion requirements, complications rates, and ICU and hospital length of stay (LOS) amongst patient groups. RESULTS Of 420 trauma patients, 307 underwent PPP and 113 REBOA. Patients had similar hemodynamics and ISS upon presentation, but PPP patients had a higher GCS (P = 0.037) and more blunt kidney injuries (P = 0.015). After PSM, 206 trauma patients were included in the analysis. There were no significant differences in blood transfusion, LOS, or major complications. Time to REBOA was shorter than time to PPP (52 vs 77.5 min; P<0.001) with longer time in ED (65 vs 51 min; p = 0.023). The 24-hour (32.4 vs 17.7%; P = 0.23) and in-hospital mortality (52.0 vs 37.3%; P = 0.048) were higher after REBOA. CONCLUSION PPP is associated with improved survival compared to REBOA placement. Delay in definitive hemorrhage control may provide a potential explanation, but causation remains unresolved. This data suggests that early PPP may offer a benefit over REBOA in the setting of hemorrhage after blunt pelvic trauma. Further, large, multi-institutional studies are warranted to support these findings. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Sarah Mikdad
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Inge A M van Erp
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Jason Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - George Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
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98
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Hatchimonji JS, Chipman AM, McGreevy DT, Hörer TM, Burruss S, Han S, Spalding MC, Fox CJ, Moore EE, Diaz JJ, Cannon JW. Resuscitative Endovascular Balloon Occlusion of Aaorta Use in Nontrauma Emergency General Surgery: A Multi-institutional Experience. J Surg Res 2020; 256:149-155. [PMID: 32707397 DOI: 10.1016/j.jss.2020.06.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 01/17/2020] [Revised: 04/27/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND The aim of this study was to determine the current utilization patterns of resuscitative endovascular balloon occlusion of aorta (REBOA) for hemorrhage control in nontrauma patients. METHODS Data on REBOA use in nontrauma emergency general surgery patients from six centers, 2014-2019, was pooled for analysis. We performed descriptive analyses using Fisher's exact, Student's t, chi-squared, or Mann-Whitney U tests as appropriate. RESULTS Thirty-seven patients with acute hemorrhage from nontrauma sources were identified. REBOA placement was primarily performed by trauma attendings (20/37, 54%) and vascular attendings (13/37, 35%). In seven patients (19%), balloons were positioned prophylactically but never inflated. In 24 (65%) of 37 patients, REBOA was placed in the operating room. 28/37 balloons (76%) were advanced to zone 1, 8/37 (22%) were advanced to zone 3, and there was one REBOA use in the inferior vena cava. Most common indications were gastrointestinal and peripartum bleeding. In the 30 cases of balloon inflation, 24 of 30 (80%) resulted in improved hemodynamics. Eleven of 30 patients (37%) died before discharge. One patient developed a distal embolism, but there were no reports of limb loss. Twelve patients (40% of all REBOA inflations and 63% of survivors) were discharged to home. CONCLUSIONS REBOA has been used in a range of acutely hemorrhaging emergency general surgery patients with low rates of access-related complications. Mortality is high in this patient population and further research is needed; however, appropriate patient selection and early use may improve survival in these life-threatening cases.
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Affiliation(s)
- Justin S Hatchimonji
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Amanda M Chipman
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland Medical Center, Baltimore, Maryland
| | - David T McGreevy
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of life science, Örebro University, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Faculty of life science, Örebro University, Sweden
| | - Sigrid Burruss
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - Stephanie Han
- Department of Surgery, Loma Linda University Medical Center, Loma Linda, California
| | - M Chance Spalding
- Department of Surgery, OhioHealth Grant Medical Center, Columbus, Ohio
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, Colorado
| | - Jose J Diaz
- R Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland Medical Center, Baltimore, Maryland
| | - Jeremy W Cannon
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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99
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Singer KE, Morris MC, Blakeman C, Stevens-Topie SM, Veile R, Fortuna G, DuBose JJ, Stuever MF, Makley AT, Goodman MD. Can Resuscitative Endovascular Balloon Occlusion of the Aorta Fly? Assessing Aortic Balloon Performance for Aeromedical Evacuation. J Surg Res 2020; 254:390-397. [PMID: 32540506 DOI: 10.1016/j.jss.2020.05.021] [Citation(s) in RCA: 4] [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: 02/27/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Noncompressible torso hemorrhage remains a leading cause of death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) placement may occur before transport; however, its efficacy has not been demonstrated at altitude. We hypothesized that changes in altitude would not result in blood pressure changes proximal to a deployed REBOA. METHODS A simulation model for 7Fr guidewireless REBOA was used at altitudes up to 22,000 feet. Female pigs then underwent hemorrhagic shock to a mean arterial pressure (MAP) of 40 mm Hg. After hemorrhage, a REBOA catheter was deployed in the REBOA group and positioned but not inflated in the no-REBOA group. Animals underwent simulated aeromedical evacuation at 8000 ft or were left at ground level. After altitude exposure, the balloon was deflated, and the animals were observed. RESULTS Taking the REBOA catheter to 22,000 ft in the simulation model resulted in a lower systolic blood pressure but a preserved MAP. In the porcine model, REBOA increased both systolic blood pressure and MAP compared with no-REBOA (P < 0.05) and was unaffected by altitude. No differences in postflight blood pressure, acidosis, or systemic inflammatory response were observed between ground and altitude REBOA groups. CONCLUSIONS REBOA maintained MAP up to 22,000 feet in an inanimate model. In the porcine model, REBOA deployment improved MAP, and the balloon remained effective at altitude.
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Affiliation(s)
| | | | | | | | - Rosalie Veile
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Gerald Fortuna
- Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Joseph J DuBose
- Department of Vascular Surgery, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Mary F Stuever
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
| | - Amy T Makley
- Department of Surgery, University of Cincinnati, Cincinnati, Ohio
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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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