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Marsden M, Lendrum R, Davenport R. Revisiting the promise, practice and progress of resuscitative endovascular balloon occlusion of the aorta. Curr Opin Crit Care 2023; 29:689-695. [PMID: 37861182 DOI: 10.1097/mcc.0000000000001106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) to temporarily control bleeding and improve central perfusion in critically injured trauma patients remains a controversial topic. In the last decade, select trauma services around the world have gained experience with REBOA. We discuss the recent observational data together with the initial results of the first randomized control trial and provide a view on the next steps for REBOA in trauma resuscitation. RECENT FINDINGS While the observational data continue to be conflicting, the first randomized control trial signals that in the UK, in-hospital REBOA is associated with harm. Likely a result of delays to haemorrhage control, views are again split on whether to abandon complex interventions in bleeding trauma patients and to only prioritize transfer to the operating room or to push REBOA earlier into the post injury phase, recognizing that some patients will not survive without intervention. SUMMARY Better understanding of cardiac shock physiology provides a new lens in which to evaluate REBOA through. Patient selection remains a huge challenge. Invasive blood pressure monitoring, combined with machine learning aided decision support may assist clinicians and their patients in the future. The use of REBOA should not delay definitive haemorrhage control in those patients without impending cardiac arrest.
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Affiliation(s)
- Max Marsden
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- Academic Department of Military Surgery and Trauma, Research and Clinical Innovation, Birmingham
| | - Robert Lendrum
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
- London's Air Ambulance
- Department of Perioperative Medicine, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, UK
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Ko HJ, Koo HF, Al-Saadi N, Froghi S. A comparison of mortality and indicators of treatment success of resuscitative endovascular balloon occlusion of aorta (REBOA): a systematic review and meta-analysis. Indian J Thorac Cardiovasc Surg 2023; 39:27-36. [PMID: 36590045 PMCID: PMC9794671 DOI: 10.1007/s12055-022-01413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022] Open
Abstract
Background Emergency resuscitative thoracotomy (RT) is a recognised method of controlling non-compressible torso haemorrhage (NCTH) often in adjunct to emergency surgery. Recently, there is much debate regarding resuscitative endovascular balloon occlusion of aorta (REBOA) on its role in civilian trauma cases in controlling NCTH. This study aims to provide an updated review on in-hospital mortality rates in patients who underwent REBOA versus RT and standard care without REBOA (non-REBOA) and to identify the potential indicators of REBOA survival. Methods Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to perform the study. All adult trauma cases were included, while pre-hospital, military and non-English studies were excluded. A literature search was done on studies from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. A significance level of p < 0.05 was used. Results Twenty-five studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01, 0.12-0.26). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62, 0.46-3.53). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (- 40.57 min, p < 0.01) and injury severity score (- 8.50, p < 0.01). Conclusions REBOA has a potential for wider application in civilian settings, with our study demonstrating lower in-hospital mortality compared to RT. Prospective multi-centre studies are needed for further evaluation of the indications and feasibility of REBOA.Level of Evidence + Study Type: Level IV. Systematic review with meta-analysis. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-022-01413-3.
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Affiliation(s)
- Ho Juen Ko
- University College London, London, UK
- Department of HPB & Liver Transplantation, Division of Surgery & Interventional Sciences, Royal Free Hospital, Pond Street, Hampstead, NW2 2QG London UK
| | | | - Nina Al-Saadi
- Vascular Surgery Glenfield Hospital UHL NHS Trust, Leicester, UK
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Irahara T, Oishi D, Tsuda M, Kajita Y, Mori H, Terashima T, Tanabe S, Hattori M, Kuge Y, Takeyama N. Combined, converted, and prophylactic use of resuscitative endovascular balloon occlusion of the aorta for severe torso trauma: a retrospective study. Acute Med Surg 2022; 9:e792. [PMID: 36203855 PMCID: PMC9525620 DOI: 10.1002/ams2.792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used as an intra‐aortic balloon occlusion in Japan; however, protocols for its effective use in different conditions have not been established. This study aimed to summarize the strategies of REBOA use in severe torso trauma. Methods Twenty‐nine cases of REBOA for torso trauma treated at our hospital over 5 years were divided into hemodynamically unstable (HU) (n = 12), cardiac arrest (CA) (n = 13), and hemodynamically stable (HS) (n = 4) groups. We retrospectively examined patient characteristics, trauma mechanism, injury site, severity score, intervention type, and survival rates at 24 h in each group. Results In the HU group, 9 and 3 patients survived and died within 24 h, respectively; time to intervention (56.6 versus 130.7 min, P = 0.346) tended to be shorter and total occlusion time (40.2 versus 337.7 min, P = 0.009) was significantly shorter in survivors than in nonsurvivors. In the CA group, 10 patients were converted from resuscitative thoracotomy with aortic cross‐clamp (RTACC); one patient survived. All four patients in the HS group survived, having received prophylactic REBOA. Conclusion The efficacy of REBOA for severe torso trauma depends on the patient's condition. If the patients are hemodynamically unstable, time to intervention and total occlusion time could correlate with survival. The combined use of REBOA with definitive hemostasis could improve outcomes. Conversion from RTACC in the cardiac arrest patients and prophylactic use in the hemodynamically stable patients can be one of the potentially effective options, although further studies are needed.
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Affiliation(s)
- Takayuki Irahara
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Dai Oishi
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Masanobu Tsuda
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Yuka Kajita
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Hisatake Mori
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Tsuguaki Terashima
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Subaru Tanabe
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Miyuki Hattori
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Yuuji Kuge
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
| | - Naoshi Takeyama
- Advanced Critical Care CenterAichi Medical University HospitalNagakuteJapan
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Inaba K, Alam HB, Brasel KJ, Brenner M, Brown CVR, Ciesla DJ, de Moya MA, DuBose JJ, Moore EE, Moore LJ, Sava JA, Vercruysse GA, Martin MJ. A Western Trauma Association critical decisions algorithm: Resuscitative endovascular balloon occlusion of the aorta. J Trauma Acute Care Surg 2022; 92:748-753. [PMID: 34686636 DOI: 10.1097/ta.0000000000003438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Kenji Inaba
- From the Division of Trauma and Surgical Critical Care (K.I., M.J.M.), Department of Surgery, University of Southern California, Los Angeles, California; Department of Surgery (H.B.A.), Northwestern University, Chicago, Illinois; Department of Surgery (K.J.B.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (M.B.), University of California Riverside, Riverside, California; Department of Surgery (C.V.R.B., J.J.D.), University of Texas at Austin, Austin, Texas; Department of Surgery (D.J.C.), University of South Florida, Tampa, Florida; Department of Surgery (M.A.d.M.), Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Surgery (E.E.M.), Ernest E Moore Shock Trauma Center at Denver Health, Denver, Colorado; Department of Surgery (L.J.M.), University of Texas, McGovern Medical School, Houston, Houston, Texas; Department of Surgery (J.A.S.), MedStar Washington Hospital, Washington, DC; and Department of Surgery (G.A.V.), University of Michigan, Ann Arbor, Michigan
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Hadley JB, Coleman JR, Moore EE, Lawless R, Burlew CC, Platnick B, Pieracci FM, Hoehn MR, Coleman JJ, Campion EM, Cohen MJ, Cralley A, Eitel AP, Bartley M, Vigneshwar N, Sauaia A, Fox CJ. Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center. J Trauma Acute Care Surg 2021; 91:295-301. [PMID: 33783417 PMCID: PMC8375411 DOI: 10.1097/ta.0000000000003198] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills. LEVEL OF EVIDENCE Therapeutic, level V.
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Affiliation(s)
- Jamie B Hadley
- From Department of Surgery, University of Colorado School of Medicine (J.B.H., J.R.C., A.P.E., M.B., N.V., C.J.F.); and Department of Surgery, Denver Health Medical Center (E.E.M., R.L., C.C.B., B.P., F.M.P., M.R.H., J.J.C., E.M.C., M.J.C., A.S., A.C.), Denver, Colorado
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Matsumoto S, Funabiki T, Hayashida K, Yamazaki M, Ebihara T, Moriya T. Effectiveness and Usage Trends of Hemorrhage Control Interventions in Patients with Pelvic Fracture in Shock. World J Surg 2021; 44:2229-2236. [PMID: 32112165 DOI: 10.1007/s00268-020-05441-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hemorrhage control for pelvic fractures remains challenging. There are several kinds of hemostatic interventions, including angiography/angioembolization (AG/AE), external fixation (EF), and resuscitative endovascular balloon occlusion of the aorta (REBOA). However, no large studies have been conducted for the comparative review of each intervention. In this study, we examined the usage trend of therapeutic interventions in Japan for patients with pelvic fractures in shock and the influence of these interventions on mortality. METHODS Data of adult patients with pelvic fracture who were in shock were obtained from the Japanese Trauma Data Bank (2004-2014). The primary endpoint was the influence of each intervention (AG/AE, EF, and REBOA) on in-hospital mortality. We also investigated the frequency of each intervention. RESULTS A total of 3149 patients met all our inclusion criteria. Specifically, 1131 (35.9%), 496 (15.8%), and 256 (8.1%) patients underwent AG, EF, and REBOA interventions, respectively. Therapeutic AE was performed in 690 patients who underwent AG (61.0%). The overall mortality rate was 31.4%. Multiple regression analysis identified that AG/AE (OR 0.64, 95% CI 0.52-0.80) and EF (OR 0.75, 95% CI 0.58-0.98) were significantly associated with survival, whereas REBOA (OR 4.17, 95% CI 3.00-5.82) was significantly associated with worse outcomes. CONCLUSIONS In Japan, patients with pelvic fracture who were in shock had high mortality rates. AG/AE and EF were associated with decreased mortality. AG may benefit from the early detection of arterial bleeding, leading to decreased mortality of patients with pelvic fracture in shock.
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Affiliation(s)
- Shokei Matsumoto
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa, 230-0012, Japan. .,Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, 330-8503, Japan.
| | - Tomohiro Funabiki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa, 230-0012, Japan
| | - Kei Hayashida
- Department of Emergency Medicine, Feinstein Institutes for Medical Research, Northwell Health System, 350 Community Dr, Manhasset, NY, 11030, USA
| | - Motoyasu Yamazaki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, 3-6-1 Shimosueyoshi, Tsurumi-ku, Yokohama-shi, Kanagawa, 230-0012, Japan
| | - Takayuki Ebihara
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, 330-8503, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, 330-8503, Japan
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Kim S, Chung JS, Jang SW, Jung PY. Pitfalls, Complications, and Necessity of Education about REBOA: A Single Regional Trauma Center Study. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Matsumoto S, Funabiki T, Kazamaki T, Orita T, Sekine K, Yamazaki M, Moriya T. Placement accuracy of resuscitative endovascular occlusion balloon into the target zone with external measurement. Trauma Surg Acute Care Open 2020; 5:e000443. [PMID: 32426527 PMCID: PMC7228664 DOI: 10.1136/tsaco-2020-000443] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/12/2020] [Accepted: 03/25/2020] [Indexed: 12/11/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) should be safely placed at zone 1 or 3, depending on the location of the hemorrhage. Ideally, REBOA placement should be confirmed via fluoroscopy, but it is not commonly available for trauma bays. This study aimed to evaluate the accuracy of REBOA placement using the external measurement method in a Japanese trauma center. Methods A retrospective review identified all trauma patients who underwent REBOA and were admitted to our trauma center from 2008 to 2018. Patient characteristics, REBOA placement accuracy, and complications according to target zones 1 and 3 were reviewed. Results During the study period, 38 patients met our inclusion criteria. The in-hospital mortality rate was 57.9%. REBOA was mainly used for bleeding from the abdominal (44.7%) and pelvic (36.8%) regions. Of these, 30 patients (78.9%) underwent REBOA for target zone 1, and 8 patients (21.1%) underwent REBOA for target zone 3. The proportion of abdominal bleeding source in the target zone 1 group was greater than that in the target zone 3 group (56.7% vs. 0%). Overall, the proportion of REBOA placement was 76.3% in zone 1, 21.1% in zone 2, and 2.6% in zone 3. The total REBOA placement accuracy was 71.1%. At each target zone, the REBOA placement accuracy for target zone 3 was significantly lower than that for target zone 1 (12.5% vs. 86.7%, p<0.001). No significant associations between non-target zone placement and patient characteristics, complications, or mortality were found. Conclusions The REBOA placement accuracy for target zone 3 was low, and zone 2 placement accounted for 21.1% of the total, but no complications and mortalities related to non-target zone placement occurred. Further external validation study is warranted. Level of evidence Level IV.
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Affiliation(s)
- Shokei Matsumoto
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan.,Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Tomohiro Funabiki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Taku Kazamaki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Tomohiko Orita
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Kazuhiko Sekine
- Department of Emergency Medicine, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Motoyasu Yamazaki
- Department of Trauma and Emergency Surgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Takashi Moriya
- Department of Emergency and Critical Care Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
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Chung JS, Kim OH, Kim S, Jang JY, An GJ, Jung PY. Resuscitative Endovascular Balloon occlusion of the aorta in Impending Traumatic arrest: Is It Effective? JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
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