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Brenner M. The Role of Resuscitative Endovascular Balloon Occlusion of the Aorta. Surg Clin North Am 2024; 104:311-323. [PMID: 38453304 DOI: 10.1016/j.suc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized by trauma surgeons at the bedside for over a decade in both civilian and military settings. Both translational and clinical research suggest it is superior to resuscitative thoracotomy for specific patient populations. Technological advancements in recent years have significantly enhanced the safety profile of REBOA. Resuscitative balloon occlusion of the aorta has also swiftly found implementation in patients in shock from non-traumatic hemorrhage.
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Affiliation(s)
- Megan Brenner
- UCLA Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, CA 90024, USA.
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2
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DeClerk AC, Helmer SD, Quinn KR, Haan JM. Evaluation of Resuscitative Endovascular Balloon Occlusion of the Aorta Complications in a Community-Based Trauma Center. Am Surg 2023; 89:5505-5511. [PMID: 36803133 DOI: 10.1177/00031348231157810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of management of noncompressible torso hemorrhage in trauma patients. Increased utilization has shown increased vascular complications and mortality. This study aimed to evaluate complications of REBOA placement in a community trauma setting. METHODS A 3-year retrospective review was performed of all trauma patients that underwent REBOA placement. Data collection included demographics, injury characteristics, complications, and mortality. RESULTS Twenty-three patients were included, and the overall mortality was 65.2%. Most patients suffered blunt trauma (73.9%), and median ISS and TRISS (survival probability) were 24 and 42.2%, respectively. The median time to REBOA placement was 22 minutes, and hemorrhagic control was achieved in all patients. The most common complication was acute kidney injury at 34.8%. There was one complication associated with placement that required vascular intervention but did not lead to limb amputation. CONCLUSION Resuscitative endovascular balloon occlusion of the aorta was shown to have higher rates of acute kidney injury, similar rates of vascular injury, and lower rate of limb complications compared to published literature. Resuscitative endovascular balloon occlusion of the aorta remains a useful tool for trauma resuscitation without the fear of increased complications.
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Affiliation(s)
- Andrew C DeClerk
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Stephen D Helmer
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Karson R Quinn
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - James M Haan
- Department of Surgery, University of Kansas School of Medicine-Wichita, Wichita, KS, USA
- Department of Trauma Services, Ascension Via Christi Hospital Saint Francis, Wichita, KS, USA
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Langan D, Caputo W, Swaminathan AK. REBOA and the Challenge of Research in Critical Illness: September 2023 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2023; 82:408-410. [PMID: 37596021 DOI: 10.1016/j.annemergmed.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Affiliation(s)
- Danielle Langan
- Emergency Department, Staten Island University Hospital/Northwell, Staten Island, NY
| | - William Caputo
- Emergency Department, Staten Island University Hospital/Northwell, Staten Island, NY
| | - Anand K Swaminathan
- Emergency Department, Staten Island University Hospital/Northwell, Staten Island, NY
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Shaw J, Brenner M. Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results. Semin Vasc Surg 2023; 36:250-257. [PMID: 37330238 DOI: 10.1053/j.semvascsurg.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 06/19/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.
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Affiliation(s)
- Joanna Shaw
- Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, California, 90024
| | - Megan Brenner
- Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, California, 90024.
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Lee G, Kim DH, Ma DS, Lee SW, Heo Y, Jo H, Chang SW. Feasibility and Clinical Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients with Traumatic Shock: A Single-Center 5-Year Experience. J Chest Surg 2023; 56:108-116. [PMID: 36710580 PMCID: PMC10008360 DOI: 10.5090/jcs.22.105] [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: 09/22/2022] [Revised: 11/17/2022] [Accepted: 12/06/2022] [Indexed: 01/31/2023] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as an adjunct to resuscitation of patients with traumatic shock. However, the effectiveness of REBOA is still debated because of inconsistent indications across centers and the lack of medical records. The purpose of this study was to investigate the effectiveness and feasibility of REBOA by analyzing clinical results from a single center. Methods This study included 96 patients who underwent REBOA between August 2016 and September 2021 at a regional trauma center according to the center's treatment algorithm for traumatic shock. Medical records, including the time of the decision to conduct the REBOA procedure, time of operation, type of aortic occlusion, and clinical outcomes, were collected prospectively and analyzed retrospectively. Patients were classified by REBOA protocol (group 1, 2, or 3) and survival status (survivor or non-survivor) for analysis. Results The overall success rate of the procedure was 97.9%, and the survival rate was 32.6%. In survivors, blood pressure was higher than in non-survivors both before the REBOA procedure (p=0.002) and after aortic occlusion (p=0.03). The total aortic occlusion time was significantly shorter (p=0.001) and the proportion of partial aortic occlusion was significantly higher (p=0.014) among the survivors. The non-survivors had more acidosis (p<0.001) and higher lactate concentrations (p<0.001) than the survivors. Conclusion REBOA may be a feasible bridge therapy for resuscitation of patients with traumatic shock. Prompt and accurate decision-making to perform REBOA followed by damage control surgery could improve survival rates and clinical outcomes.
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Affiliation(s)
- Gyeongho Lee
- Department of Thoracic and Cardiovascular Surgery, Dankook University Hospital, Cheonan, Korea
| | - Dong Hun Kim
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Dae Sung Ma
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Seok Won Lee
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Yoonjung Heo
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Hancheol Jo
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
| | - Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Korea
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Werner NL, Moore EE, Hoehn M, Lawless R, Coleman JR, Freedberg M, Heelan AA, Platnick KB, Cohen MJ, Coleman JJ, Campion EM, Fox CJ, Mauffrey C, Cralley A, Pieracci FM, Burlew CC. Inflate and pack! Pelvic packing combined with REBOA deployment prevents hemorrhage related deaths in unstable pelvic fractures. Injury 2022; 53:3365-3370. [PMID: 36038388 DOI: 10.1016/j.injury.2022.07.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/07/2022] [Accepted: 07/15/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is advocated for hemorrhage control in pelvic fracture patients in shock. We evaluated REBOA in patients undergoing preperitoneal pelvic packing (PPP) for pelvic fracture-related hemorrhage. METHODS Retrospective, single-institution study of unstable pelvic fractures (hemodynamic instability despite 2 units of red blood cells (RBCs) and fracture identified on x-ray). Management included the placement of a Zone III REBOA in the emergency department (ED) for systolic blood pressure <80 mmHg. All PPP patients were included and analyzed for injury characteristics, transfusion requirements, outcomes and complications. Additionally, patients who received REBOA (REBOA+) were compared to those that did not (REBOA-). RESULTS During the study period (January 2015 - January 2019), 652 pelvic fracture patients were admitted; 78 consecutive patients underwent PPP. Median RBCs at PPP completion compared to 24 h post-packing were 11 versus 3 units (p<0.05). Median time to operation was 45 min. After PPP, 7 (9%) patients underwent angioembolization. Mortality was 14%. No mortalities were due to ongoing pelvic fracture hemorrhage or physiologic exhaustion; all were a withdrawal of life sustaining support, most commonly due to neurologic insults (TBI/fat emboli = 6, stroke/spinal cord injury = 3). REBOA+ patients (n = 31) had a significantly higher injury severity score (45 vs 38, p<0.01) and higher heart rate (130 vs 118 beats per minute, p = 0.04) than REBOA-. The systolic blood pressure, base deficit, and number of RBCs transfused in the ED, and time spent in the ED were similar between groups. REBOA+ had a higher median transfusion of RBCs at PPP completion (11 units vs 5 units, p<0.01) but similar RBC transfusion in the 24 h after PPP (2 vs 1 units, p = 0.27). Mortality, pelvic infection, and ICU length of stay was not different between these cohorts. CONCLUSION PPP with REBOA was utilized in more severely injured patients with greater physiologic derangements. Although REBOA patients required greater transfusion requirements, there were no deaths due to acute pelvic hemorrhage. This suggests the combination of REBOA with PPP provides life-saving hemorrhage control in otherwise devastating injuries.
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Affiliation(s)
- Nicole L Werner
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America.
| | - Ernest E Moore
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Melanie Hoehn
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Ryan Lawless
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Julia R Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mari Freedberg
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alicia A Heelan
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - K Barry Platnick
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Mitchell J Cohen
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Jamie J Coleman
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Eric M Campion
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Charles J Fox
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Cyril Mauffrey
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Alexis Cralley
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Fredric M Pieracci
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
| | - Clay Cothren Burlew
- Denver Health Medical Center, 777 Bannock Street, MC 0206, Denver, CO 80204 United States of America
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Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry. Injury 2022; 53:2126-2132. [PMID: 35341594 DOI: 10.1016/j.injury.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 02/23/2022] [Accepted: 03/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Aortic occlusion (AO) to facilitate the acute resuscitation of trauma and acute care surgery patients in shock remains a controversial topic. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an increasingly deployed method of AO. We hypothesized that in patients with non-compressible hemorrhage below the aortic bifurcation, the use of REBOA instead of open AO may be associated with a survival benefit. METHODS From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, we identified 1494 patients requiring AO from 45 Level I and 4 Level II trauma centers. Presentation, intervention, and outcome variables were analyzed to compare REBOA vs open AO in patients with non-compressible hemorrhage below the aortic bifurcation. RESULTS From December 2014 to January 2019, 217 patients with Zone 3 REBOA or Open AO who required pelvic packing, pelvic fixation or pelvic angio-embolization were identified. Of these, 109 AO patients had injuries isolated to below the aortic bifurcation (REBOA, 84; open AO, 25). Patients with intra-abdominal or thoracic sources of bleeding, above deployment Zone 3 were excluded. Overall mortality was lower in the REBOA group (35.% vs 80%, p <.001). Excluding patients who arrived with CPR in progress, the REBOA group had lower mortality (33.33% vs. 68.75%, p = 0.012). Of the survivors, systemic complications were not significantly different between groups. In the REBOA group, 16 patients had complications secondary to vascular access. Intensive care lengths of stay and ventilator days were both significantly shorter in REBOA patients who survived to discharge. CONCLUSIONS This study compared outcomes for patients with hemorrhage below the aortic bifurcation treated with REBOA to those treated with open AO. Survival was significantly higher in REBOA patients compared to open AO patients, while complications in survivors were not different. Given the higher survival in REBOA patients, we conclude that REBOA should be used for patients with hemorrhagic shock secondary to pelvic trauma instead of open AO. LEVEL III EVIDENCE Therapeutic.
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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: 0] [Impact Index Per Article: 0] [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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9
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Abstract
Resuscitative endovascular balloon occlusion of the aorta is a tool that can play an important role for the modern-day Trauma Surgeon. Although the concept of aortic balloon occlusion is not new, its use as a rescue device for managing life-threatening traumatic hemorrhage has increased dramatically. The ideal role for resuscitative endovascular balloon occlusion of the aorta continues to evolve. In situations of noncompressible truncal hemorrhage, its use can temporize bleeding while other means of hemorrhage control, including those discussed elsewhere in this supplement, are used. However, it is a tool with potentially significant complications and consequences. Studies examining resuscitative endovascular balloon occlusion of the aorta are ongoing as, despite its ever-increasing adoption, quality evidence to support its clinical use is lacking.
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Affiliation(s)
- Paul M. Cantle
- Peter Lougheed Centre 5th East Wing, 5940-3500 26th Ave NE, Calgary, AB, Canada T1Y 6J4. Tel.: + 1 (403) 943-5474; fax: + 1 (403) 291-2734.
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Theodorou CM, Rinderknecht TN, Girda E, Galante JM, Russo RM. Fetal and neonatal outcomes following maternal aortic balloon occlusion for hemorrhage in pregnancy: A review of the literature. J Trauma Acute Care Surg 2022; 92:e10-e17. [PMID: 34561397 PMCID: PMC8982953 DOI: 10.1097/ta.0000000000003420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Hemorrhage is a leading cause of maternal death worldwide, with increased risk in women with abnormal placentation. Aortic balloon occlusion (ABO), including resuscitative endovascular balloon occlusion, has been used for obstetrical hemorrhage for 20 years, and is associated with decreased operative blood loss, fewer transfusions, and lower rates of hysterectomy. However, the effect of aortic occlusion on fetal/neonatal outcomes is not well known. METHODS A literature review on ABO for obstetrical or traumatic hemorrhage was performed. Cases were included if fetal/neonatal outcomes were reported. Data were collected on timing of balloon inflation (predelivery or postdelivery), fetal/neonatal mortality, and Apgar scores. Secondary maternal outcomes included blood loss, need for hysterectomy, ABO-related complications, and mortality. RESULTS Twenty-one reports of ABO in 825 cases of obstetrical hemorrhage were reviewed (nine case reports/series and twelve comparative studies). 13.5% (111/825) had aortic occlusion prior to delivery of the fetus. Comparative cohorts included 448 patients who underwent iliac artery balloon occlusion (n = 219) or no vascular balloon occlusion (n = 229). The most common neonatal outcome reported was Apgar scores, with no difference in fetal/neonatal outcomes between ABO and non-ABO patients in any study. One neonatal mortality occurred in the sole reported case of ABO use in a pregnant trauma patient at 24 weeks gestation. One maternal mortality occurred because of aortic dissection. Five comparative studies reported significantly decreased blood loss in ABO patients compared to non-ABO patients, and four studies reported significantly lower rates of hysterectomy in ABO patients. ABO-related complications were reported in 1.6% of patients (13/825). CONCLUSION Obstetrical hemorrhage is a devastating complication, and ABO may potentially decrease blood loss and reduce the hysterectomy rate without compromising fetal and neonatal outcomes. Further research is needed to determine the safety of predelivery aortic occlusion as this occurred in 14% of the cases.
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Affiliation(s)
- Christina M. Theodorou
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Tanya N. Rinderknecht
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Eugenia Girda
- Rutgers Cancer Institute of New Jersey, 195 Little Albany St, New Brunswick, NJ, 08901, USA
| | - Joseph M. Galante
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
| | - Rachel M. Russo
- University of California Davis Medical Center, 2335 Stockton Blvd Room 5107, Sacramento, CA, 95817, USA
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Castellini G, Gianola S, Biffi A, Porcu G, Fabbri A, Ruggieri MP, Coniglio C, Napoletano A, Coclite D, D'Angelo D, Fauci AJ, Iacorossi L, Latina R, Salomone K, Gupta S, Iannone P, Chiara O. Resuscitative endovascular balloon occlusion of the aorta (REBOA) in patients with major trauma and uncontrolled haemorrhagic shock: a systematic review with meta-analysis. World J Emerg Surg 2021; 16:41. [PMID: 34384452 PMCID: PMC8358549 DOI: 10.1186/s13017-021-00386-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background Multiple studies regarding the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in patients with non-compressible torso injuries and uncontrolled haemorrhagic shock were recently published. To date, the clinical evidence of the efficacy of REBOA is still debated. We aimed to conduct a systematic review assessing the clinical efficacy and safety of REBOA in patients with major trauma and uncontrolled haemorrhagic shock. Methods We systematically searched MEDLINE (PubMed), EMBASE and CENTRAL up to June 2020. All randomized controlled trials and observational studies that investigated the use of REBOA compared to resuscitative thoracotomy (RT) with/without REBOA or no-REBOA were eligible. We followed the PRISMA and MOOSE guidelines. Two authors independently extracted data and appraised the risk of bias of included studies. Effect sizes were pooled in a meta-analysis using random-effects models. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Primary outcomes were mortality, volume of infused blood components, health-related quality of life, time to haemorrhage control and any adverse effects. Secondary outcomes were improvement in haemodynamic status and failure/success of REBOA technique. Results We included 11 studies (5866 participants) ranging from fair to good quality. REBOA was associated with lower mortality when compared to RT (aOR 0.38; 95% CI 0.20–0.74), whereas no difference was observed when REBOA was compared to no-REBOA (aOR 1.40; 95% CI 0.79–2.46). No significant difference in health-related quality of life between REBOA and RT (p = 0.766). The most commonly reported complications were amputation, haematoma and pseudoaneurysm. Sparse data and heterogeneity of reporting for all other outcomes prevented any estimate. Conclusions Our findings on overall mortality suggest a positive effect of REBOA among non-compressible torso injuries when compared to RT but no differences compared to no-REBOA. Variability in indications and patient characteristics prevents any conclusion deserving further investigation. REBOA should be promoted in specific training programs in an experimental setting in order to test its effectiveness and a randomized trial should be planned. Supplementary Information The online version contains supplementary material available at 10.1186/s13017-021-00386-9.
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Affiliation(s)
- Greta Castellini
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy
| | - Silvia Gianola
- IRCCS Istituto Ortopedico Galeazzi, Unit of Clinical Epidemiology, Milan, Italy.
| | - Annalisa Biffi
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Gloria Porcu
- National Centre for Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy.,Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL della Romagna, Forlì, Italy
| | | | - Carlo Coniglio
- Department of Anesthesiology, Intensive Care and Pre-Hospital Emergency Services, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Antonello Napoletano
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela Coclite
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Daniela D'Angelo
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Alice Josephine Fauci
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Laura Iacorossi
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Roberto Latina
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Katia Salomone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Shailvi Gupta
- University of Maryland, Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Primiano Iannone
- Istituto Superiore di Sanità, Centro Eccellenza Clinica, Qualità e Sicurezza delle Cure, Rome, Italy
| | - Osvaldo Chiara
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Milano, Piazza Ospedale Maggiore, Milan, Italy
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Chang SW, Ma DS, Chang YR, Kim DH. Practical tips for performing resuscitative endovascular balloon occlusion of the aorta. HONG KONG J EMERG ME 2021. [DOI: 10.1177/1024907921994422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Hemorrhage is the leading cause of death in trauma settings. Non-compressible torso hemorrhage, which is caused by abdominopelvic and thoracic injuries, is an important cause of subsequent organ dysfunction and poor outcomes in multiple trauma patients. The management of hemodynamically unstable patients with non-compressible torso hemorrhage has changed, and the concept of damage control resuscitation has been developed in the last decades. Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) as a method of temporary stabilization is the modern evolution of bleeding control, and it is in the middle of a paradigm shift as a treatment for non-compressible torso hemorrhage. Despite its effectiveness in patients with hemorrhagic shock, the application of REBOA remains limited because of lack of experience and troubleshooting guidelines. Objectives: The aim of study was to provide useful tips for the implementing a step-by-step procedure for REBOA in various hospital settings and capabilities. Methods: We introduced REBOA procedures using a REBOA-customized 7 Fr balloon catheter through the animation models or radiography from preparation to access, catheter management, and device removal after procedure completed. Results: We have described REBOA procedures as follows: identification of the common femoral artery, arterial access for placement of a guidewire, precautions during a sheath insertion, guidewire and balloon positioning in the aorta, occlusion zones and adjustment of balloon location, REBOA strategy for extending the occlusion time, balloon deflation and removal, sheath removal, and medical records. Conclusion: We believe that the practical tips mentioned in this article will help in performing the REBOA procedure systematically and developing an effective REBOA framework.
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Affiliation(s)
- Sung Wook Chang
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Dae Sung Ma
- Department of Thoracic and Cardiovascular Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Ye Rim Chang
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
| | - Dong Hun Kim
- Department of Trauma Surgery, Trauma Center, Dankook University Hospital, Cheonan, Republic of Korea
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Resuscitative endovascular balloon of the aorta is feasible in penetrating chest trauma with major hemorrhage: Proposal of a new institutional deployment algorithm. J Trauma Acute Care Surg 2020; 89:311-319. [PMID: 32345890 DOI: 10.1097/ta.0000000000002773] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an emerging option for hemorrhage control, but its use is limited in scenarios such as penetrating chest trauma. The aim of this study was to describe the use of REBOA as a resuscitative adjunct in these cases with major hemorrhage and to propose a new clinical management algorithm. METHODS This was a prospective, observational study conducted at a single Level I trauma center in Colombia. We included all patients older than 14 years with severe trauma who underwent REBOA from January 2015 to December 2019. Patients received REBOA if they were in hemorrhagic shock and were unresponsive to resuscitation. RESULTS A total of 56 patients underwent REBOA placement of which 37 had penetrating trauma and 23 had chest trauma. All patients were hemodynamically unstable upon arrival to the emergency department, with a median systolic blood pressure of 69 mm Hg (interquartile range [IQR], 57-90 mm Hg) and median Injury Severity Score was 25 (IQR, 25-41). All REBOAs were deployed and inflated in zone 1, median inflation time was 40 minutes (IQR, 26-55 minutes), and no adverse neurologic outcomes were observed. Fifteen patients had REBOA and a median sternotomy. Eleven patients had concomitant abdominal wounds. Overall mortality was 28.6%, and there was no significant difference between penetrating versus blunt trauma patients (21.6% vs. 42.1%, p = 0.11). The survival rate of thoracic injured patients was similar to the predicted survival (65.2% vs. 63.3%). CONCLUSION Resuscitative endovascular balloon occlusion of the aorta can be used safely in penetrating chest trauma, and the implementation of a REBOA management algorithm is feasible with a well-trained multidisciplinary team. LEVEL OF EVIDENCE Therapeutic, level V.
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Chang SW, Kim DH, Chang YR. Educational Simulation Videos for Performing Resuscitative Endovascular Balloon Occlusion of the Aorta. JOURNAL OF TRAUMA AND INJURY 2020. [DOI: 10.20408/jti.2020.0035] [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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Theodorou CM, Anderson JE, Brenner M, Scalea TM, Inaba K, Cannon J, Seamon M, Spalding MC, Fox CJ, Moore EE, DuBose JJ, Galante JM. Practice, Practice, Practice! Effect of Resuscitative Endovascular Balloon Occlusion of the Aorta Volume on Outcomes: Data From the AAST AORTA Registry. J Surg Res 2020; 253:18-25. [PMID: 32311580 DOI: 10.1016/j.jss.2020.03.027] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/11/2020] [Accepted: 03/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular adjunct to hemorrhage control. Success relies on institutional support and focused training in arterial access. We hypothesized that hospitals with higher REBOA volumes will be more successful than low-volume hospitals at aortic occlusion with REBOA. METHODS This is a retrospective study from the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery Registry from November 2013 to January 2018. Patients aged ≥18 y who underwent REBOA were included. Successful placement of REBOA catheters (defined as hemodynamic improvement with balloon inflation) was compared between high-volume (≥80 cases; two hospitals), mid-volume (10-20 cases; four hospitals), and low-volume (<10 cases; 14 hospitals) hospitals, adjusting for patient factors. RESULTS Of 271 patients from 20 hospitals, 210 patients (77.5%) had successful REBOA placement. Most patients were male (76.0%) and sustained blunt trauma (78.1%). cardiopulmonary resuscitation (CPR) was ongoing at the time of REBOA placement in 34.5% of patients. Inpatient mortality was 67.4%, unchanged by hospital volume. Multivariable logistic regression found increased odds of successful REBOA placement at high-volume versus low-volume hospitals (odds ratio [OR], 7.50; 95% confidence interval [CI], 2.10-27.29; P = 0.002) and mid-volume versus low-volume hospitals (OR, 7.82; 95% CI, 1.52-40.31; P = 0.014) and decreased odds among patients undergoing CPR during REBOA placement (OR, 0.10; 95% CI, 0.03-0.34; P < 0.001) when adjusting for age, sex, mechanism of injury, prehospital CPR, CPR on admission, transfer status, hospital location of REBOA placement, Glasgow Coma Scale ≤ 13, and injury severity. CONCLUSIONS Hospitals with higher REBOA volumes were more likely to achieve hemodynamic improvement with REBOA inflation. However, mortality and complication rates were unchanged. Independent of hospital volume, ongoing CPR is associated with a decreased odds of successful REBOA placement.
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Affiliation(s)
- Christina M Theodorou
- Division of Trauma, University of California Davis Medical Center, Acute Care, and General Surgery Sacramento, CA.
| | - Jamie E Anderson
- Division of Trauma, University of California Davis Medical Center, Acute Care, and General Surgery Sacramento, CA
| | - Megan Brenner
- Department of Surgery, University of California Riverside School of Medicine Riverside, CA
| | - Thomas M Scalea
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Kenji Inaba
- Division of Surgical Critical Care and Trauma, Los Angeles County + University of Southern California Hospital, Los Angeles, CA
| | - Jeremy Cannon
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care & Emergency Surgery, Philadelphia, PA
| | - Mark Seamon
- Division of Traumatology, University of Pennsylvania, Surgical Critical Care & Emergency Surgery, Philadelphia, PA
| | - M Chance Spalding
- Division of Trauma and Acute Care Surgery, Grant Medical Center, Columbus, OH
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, Denver, CO
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO
| | - Joseph J DuBose
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Joseph M Galante
- Division of Trauma, University of California Davis Medical Center, Acute Care, and General Surgery Sacramento, CA
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Theodorou CM, Salcedo ES, DuBose JJ, Galante JM. Hate to Burst Your Balloon: Successful REBOA Use Takes More Than a Course. JOURNAL OF ENDOVASCULAR RESUSCITATION AND TRAUMA MANAGEMENT 2020; 4:21-29. [PMID: 32587666 DOI: 10.26676/jevtm.v4i1.106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is emerging as a viable intervention for hemorrhagic shock. Training surgeons to place the device is only part of the process. We hypothesize that implementation challenges extend beyond surgical skills training and initial REBOA use should not be expected to mirror published success. Methods All REBOA placements from January 2016 to February 2017 at a level 1 trauma center were reviewed for opportunities for improvement. From September 2016 to February 2017, all patients meeting highest trauma activation criteria were reviewed against our REBOA algorithm to identify patients meeting criteria for REBOA placement but not undergoing the procedure. Results REBOA was introduced at our institution in September 2015, with the first placement in January 2016. Trauma surgery, emergency department, and operating room staff underwent training. Nine patients had REBOA placed with six survivors. One patient underwent an unsuccessful REBOA attempt and died. Four patients had complications from REBOA. Eight additional patients met indications but did not undergo REBOA. Conclusions Successful REBOA use requires more than teaching surgeons indications and techniques. For a successful REBOA program, system factors must be addressed. System processes must ensure equipment and procedures are standardized and familiar to all involved. Complications should be expected.
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Affiliation(s)
- Christina M Theodorou
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Edgardo S Salcedo
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
| | - Joseph J DuBose
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Joseph M Galante
- Department of Surgery, University of California Davis Medical Center, Sacramento, California, USA
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17
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Engberg M, Taudorf M, Rasmussen NK, Russell L, Lönn L, Konge L. Training and assessment of competence in resuscitative endovascular balloon occlusion of the aorta (REBOA) - a systematic review. Injury 2020; 51:147-156. [PMID: 31810637 DOI: 10.1016/j.injury.2019.11.036] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 11/23/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving but high-risk emergency procedure in patients with haemorrhagic shock. Lack of physicians with competence in the procedure is a barrier to implementation of REBOA. It is currently unclear how training and assessment of competence should be done. OBJECTIVES To report and evaluate research in training and assessment of competence in REBOA and femoral arterial access with the aim to investigate the effect of simulation-based training in the procedure and to provide suggestions for the future design of training programs and assessment tools. METHODS Following PRISMA guidelines, PubMed, Embase, and Cochrane Library databases were searched for studies on training or assessment of competence in REBOA and femoral arterial access. Bias assessment was done using the Medical Education Research Study Quality Instrument. Evidence level was assessed using GRADE. RESULTS Sixteen studies were included, six of them published as abstracts. Full-text studies included 189 trainees ranging in experience level from military medics to surgical specialists. Outcome measures were heterogenous; the most used were rater checklists, knowledge testing, and procedure time. All studies confirmed an effect of training of REBOA on procedural competence in a simulation setting but had a high degree of bias. No study developed or used an assessment tool supported by validity evidence and no study investigated mid and long-term outcomes. CONCLUSION Simulation-based training of REBOA improves skills, however, the evidence level is very low and data cannot answer important questions on effect size, skill transfer and retention, and optimal course design. To advance research and training programmes, an assessment tool supported by validity evidence with broad applicability is needed.
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Affiliation(s)
- Morten Engberg
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark.
| | - Mikkel Taudorf
- Department of Diagnostic Radiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Niklas Kahr Rasmussen
- Department of Diagnostic Radiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Lene Russell
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Denmark; Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Lars Lönn
- Department of Diagnostic Radiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation (CAMES), Rigshospitalet, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
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Bulger EM, Perina DG, Qasim Z, Beldowicz B, Brenner M, Guyette F, Rowe D, Kang CS, Gurney J, DuBose J, Joseph B, Lyon R, Kaups K, Friedman VE, Eastridge B, Stewart R. Clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA, 2019: a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians. Trauma Surg Acute Care Open 2019; 4:e000376. [PMID: 31673635 PMCID: PMC6802990 DOI: 10.1136/tsaco-2019-000376] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/29/2019] [Indexed: 11/04/2022] Open
Abstract
This is a joint statement from the American College of Surgeons Committee on Trauma, the American College of Emergency Physicians, the National Association of Emergency Medical Services Physicians and the National Association of Emergency Medical Technicians regarding the clinical use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in civilian trauma systems in the USA. This statement addresses the system of care needed to manage trauma patients requiring the use of REBOA, in light of the current evidence available in this patient population. This statement was developed by an expert panel following a comprehensive review of the literature with representation from all sponsoring organizations and the US Military. This is an update to the previous statement published in 2018. It has been formally endorsed by the four sponsoring organizations.
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Affiliation(s)
- Eileen M Bulger
- Department of Surgery, University of Washington, Seattle, Washington, USA
| | - Debra G Perina
- Department if Emergency Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Zaffer Qasim
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian Beldowicz
- Department of Surgery, Madigan Army Medical Center, Tacoma, Washington, USA
| | - Megan Brenner
- Department of Surgery, University of California Riverside, Riverside, California, USA
| | - Frances Guyette
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dennis Rowe
- Government and Industry Relations, Priority Ambulance Inc, Knoxville, Tennessee, USA
| | | | - Jennifer Gurney
- Joint Trauma System, Defense Center of Excellence, San Antonio, Texas, USA
| | - Joseph DuBose
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Bellal Joseph
- Department of Surgery, University of Arizona, Tucson, Arizona, USA
| | - Regan Lyon
- Department of Emergency Medicine, Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland, USA
| | - Krista Kaups
- Department of Surgery, University of California San Francisco, Fresno, California, USA
| | - Vidor E Friedman
- Emergency Medicine, Florida Emergency Physicians, Maitland, Florida, USA
| | - Brian Eastridge
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Ronald Stewart
- Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Nakajima K, Taniguchi H, Abe T, Yamaguchi K, Doi T, Takeuchi I, Morimura N. Does the conventional landmark help to place the tip of REBOA catheter in the optimal position? A non-controlled comparison study. World J Emerg Surg 2019; 14:35. [PMID: 31346347 PMCID: PMC6635992 DOI: 10.1186/s13017-019-0255-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/08/2019] [Indexed: 11/10/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) for patients with traumatic torso hemorrhagic shock is available to keep a minimum level of circulatory status as a bridge to definitive therapy. However, the trajectory for placement of REBOA in the aorta has not yet been clearly defined. Methods We conducted a retrospective observational cohort study in the two tertiary critical care and emergency center from December 2014 to October 2018. A total of 28 patients who underwent focused assessment with sonography for trauma (FAST) were studied via contrast computed tomography (CT), and 27 were analyzed. Results We divided patients into two groups based on our CT findings. The REBOA deflate group included 16 patients, and the inflate group included 11 patients. The median trace value (interquartile range) of the blood vessel center line from the common femoral artery to the tip of REBOA (blood vessel length) and the length of REBOA itself from the common femoral artery to the tip of REBOA (REBOA insertion length) were 56.2 cm (54.5-57.2) and 55.2 cm (54.2-55.6), respectively (p < 0.0001) for the deflated group, and 51.4 cm (42.1-56.6) and 50.3 cm (42.3-55.0) (p = 0.594), respectively, for the inflated group. Conclusions If REBOA was deflated, it was placed 1.0 cm longer than the insertion length of REBOA catheter itself, but that was not the case when inflating REBOA. The individual difference was large to the extent that the balloon inflated and the extent to which the balloon was pushed back toward the caudal depending on the degree of blood pressure. Further studies would be needed to validate the study findings.
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Affiliation(s)
- Kento Nakajima
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Hayato Taniguchi
- 2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan.,3Department of Surgery Intensive Care, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603 Japan
| | - Takeru Abe
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Keishi Yamaguchi
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Tomoki Doi
- 2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan.,4Critical Care and Emergency Center, Yokosuka Kyosai Hospital, Yonegahama Street 1-16, Yokosuka, Kanagawa 238-8558 Japan
| | - Ichiro Takeuchi
- 1Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, 4-57 Urafunecho, Minami-ku, Yokohama, Kanagawa 232-0024 Japan.,2Department of Emergency Medicine, Graduate School of Medicine, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa 236-0004 Japan
| | - Naoto Morimura
- 5Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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