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Brauer SK, Musy AA, Schneider S, Trottmann FN, Kaderli N, Vetter C, Surbek D, Schindewolf M, Gerber AL, Stotz M, Hautz W, Zdanowicz JA. Using Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a Rescue Strategy in Severe Postpartum Hemorrhage: A Case Report. Diagnostics (Basel) 2024; 14:1980. [PMID: 39272763 PMCID: PMC11394129 DOI: 10.3390/diagnostics14171980] [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: 06/29/2024] [Revised: 09/03/2024] [Accepted: 09/05/2024] [Indexed: 09/15/2024] Open
Abstract
Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Routine treatment of PPH includes uterotonics, tranexamic acid, curettage, uterine (balloon) tamponade, compression sutures, uterine artery ligation, and, if available, transcatheter arterial embolization (TAE). In cases of severe PPH refractory to standard medical and surgical management, hysterectomy is usually the ultima ratio, and is equally associated with a higher rate of complications. In addition, this sudden loss of fertility, especially in young women, can be devastating. Here, we report a case of a 29-year-old woman who suffered from severe PPH with a blood loss > 1500 mL and hemodynamic instability after delivery of her first baby at a smaller hospital. She was consequently successfully treated with resuscitative endovascular balloon occlusion of the aorta (REBOA) by first placing a balloon catheter into the infra-renal aorta and subsequent TAE after failure of all other available treatment options prior to hysterectomy. TAE has been suggested in PPH treatment to avoid hysterectomies and thus to preserve patients' reproductive function. If hemodynamic stabilization cannot be achieved with mass transfusion, REBOA seems to be an effective rescue strategy with which to achieve hemodynamic stabilization and gain additional time for embolization. Although REBOA is already recommended in several PPH guidelines, this approach seems relatively unknown in German-speaking countries.
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Affiliation(s)
- Sophie-Kristin Brauer
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Alexandre Athanasios Musy
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Sophie Schneider
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Fabienne Nicole Trottmann
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Nina Kaderli
- Department of Obstetrics, Spital Emmental, 3400 Burgdorf, Switzerland
| | - Christian Vetter
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Marc Schindewolf
- Department of Angiology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Anna Lea Gerber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Manuela Stotz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Jarmila A Zdanowicz
- Department of Obstetrics and Gynecology, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Ryu T, Kurokawa Y, Hirayu N, Muto M, Akiba J, Uzu H, Horinouchi T, Yoshizato T, Takasu O, Tsuda N. Resuscitative endovascular balloon occlusion of the aorta: A novel approach for treating amniotic fluid embolism with disseminated intravascular coagulopathy-A report of two cases. J Obstet Gynaecol Res 2024; 50:1722-1727. [PMID: 38923672 DOI: 10.1111/jog.16007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024]
Abstract
We present two critical cases of life-threatening postpartum hemorrhage (PPH) due to amniotic fluid embolism (AFE) complicated by disseminated intravascular coagulopathy (DIC). These cases are the first to show the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for patient survival. In Case 1, the patient, experiencing critical conditions with severe PPH and DIC despite conventional treatments, including rapid blood transfusion and fibrinogen concentrate, was air-transferred to our hospital, where REBOA was promptly employed before hysterectomy was completed. Case 2 involved an ambulance-transferred patient with massive PPH and DIC despite conventional treatments. Prehospital REBOA was performed to prevent cardiac arrest during transfer, and hysterectomy was performed in the hospital. Given the rapid deterioration associated with AFE, REBOA can serve as a bridge until complete hemostasis to maintain vital signs and control bleeding in patients unresponsive to standard therapies before hemostatic interventions or during transfer.
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Affiliation(s)
- Tensei Ryu
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Yusuke Kurokawa
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Nobuhisa Hirayu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Megumi Muto
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Jun Akiba
- Department of Diagnostic Pathology, Kurume University Hospital, Kurume, Japan
| | - Hideaki Uzu
- Department of Emergency, Omuta City Hospital, Omuta, Japan
| | - Takashi Horinouchi
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Toshiyuki Yoshizato
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Osamu Takasu
- Department of Emergency and Critical Care Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Naotake Tsuda
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
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Wannatoop T, Phuangphung P, Sornmanapong T. Resuscitative endovascular balloon occlusion of the aorta in trauma management: a comprehensive study of clinical indications and challenges. Trauma Surg Acute Care Open 2024; 9:e001264. [PMID: 38596566 PMCID: PMC11002364 DOI: 10.1136/tsaco-2023-001264] [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] [Indexed: 04/11/2024] Open
Abstract
Background The application of resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma resuscitation, including for profound shock and cardiac arrest, has gained prominence. This study aimed to determine the characteristics of patients who were transported to the trauma resuscitation area (the TTRA group) and those who died at the scene (the DAS group), aiming to identify suitable REBOA candidates and critical contraindications. Methods A descriptive research design was used. We retrospectively reviewed 1158 adult trauma patients managed at a level I trauma center in 2020 and 2021. The TTRA group comprised 215 patients who, upon arrival at the trauma resuscitation area, either presented with a systolic blood pressure under 90 mm Hg or were in traumatic cardiac arrest but still exhibited signs of life. The study included patients directly transferred from incident scenes to the forensic unit. The DAS group comprised 434 individuals who were declared deceased at the scene of major trauma. REBOA indications were considered for two purposes: anatomic bleeding control for sources below the diaphragm to the groin, and circulatory restoration in patients with profound shock or cardiac arrest. Absolute REBOA contraindications were assessed, particularly for aortic and cardiac injuries, with or without cardiac tamponade. Results Predominantly male, the cohort largely consisted of motorcycle accident victims. The median Injury Severity Score was 41 (range 1-75). Within the TTRA group, the prospective applicability of REBOA was 52.6%, with a prevalence of major hemorrhagic sources from the abdomen to the groin of 38.6% and substantial intra-abdominal bleeding of 28.8%. The DAS group exhibited a prevalence of major hemorrhagic sources from the abdomen to the groin of 50.2%, and substantial intra-abdominal bleeding of 41.2%. In terms of REBOA contraindications, the DAS group demonstrated a greater prevalence of overall contraindications of 25.8%, aortic injuries 17.3%, and concomitant conditions of 16.4%. In the TTRA group, the rates of overall contraindications, aortic injury, and comorbid conditions were 12.6%, 4.2%, and 8.8, respectively. Cardiac injuries were noted in approximately 10% of patients in both groups. Conclusions This investigation underscores the potential benefits of REBOA in the management of major trauma patients. The prevalence of bleeding sources suitable for REBOA was high in both the TTRA and DAS groups. However, a significant number of patients in both groups also had contraindications to the procedure. These outcomes highlight the critical importance of enhanced training in patient assessment to ensure the safe and effective deployment of REBOA, particularly in resource-limited environments such as ongoing trauma resuscitation and prehospital care. Level of evidence Level III.
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Affiliation(s)
- Tongporn Wannatoop
- Department of Surgery, Mahidol University, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Peerayuht Phuangphung
- Department of Forensic Medicine, Mahidol University, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Tanut Sornmanapong
- Department of Surgery, Mahidol University, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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Carlsen MIS, Brede JR, Medby C, Uleberg O. Transfusion practice in Central Norway - a regional cohort study in patients suffering from major haemorrhage. BMC Emerg Med 2024; 24:3. [PMID: 38185648 PMCID: PMC10773117 DOI: 10.1186/s12873-023-00918-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/11/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND In patients with major hemorrhage, balanced transfusions and limited crystalloid use is recommended in both civilian and military guidelines. This transfusion strategy is often applied in the non-trauma patient despite lack of supporting data. The aim of this study was to describe the current transfusion practice in patients with major hemorrhage of both traumatic and non-traumatic etiology in Central Norway, and discuss if transfusions are in accordance with appropriate massive transfusion protocols. METHODS In this retrospective observational cohort study, data from four hospitals in Central Norway was collected from 01.01.2017 to 31.12.2018. All adults (≥18 years) receiving massive transfusion (MT) and alive on admission were included. MT was defined as transfusion of ≥10 units of packed red blood cells (PRBC) within 24 hours, or ≥ 5 units of PRBC during the first 3 hours after admission to hospital. Clinical data was collected from the hospital blood bank registry (ProSang) and electronic patient charts (CareSuite PICIS). Patients undergoing cardiothoracic surgery or extracorporeal membrane oxygenation treatment were excluded. RESULTS A total of 174 patients were included in the study, of which 85.1% were non-trauma patients. Seventy-six per cent of all patients received plasma:PRBC in a ratio ≥ 1:2 (high ratio) and 59.2% of patients received platelets:PRBC in a ratio ≥ 1:2 (high ratio). 32.2% received a plasma:PRBC-ratio ≥ 1:1, and 23.6% platelet:PRBC-ratio ≥ 1:1. Median fluid infusion of crystalloids in all patients was 5750 mL. Thirty-seven per cent of all patients received tranexamic acid, 53.4% received calcium and fibrinogen concentrate was administered in 9.2%. CONCLUSIONS Most patients had a non-traumatic etiology. The majority was transfused with high ratios of plasma:PRBC and platelet:PRBC, but not in accordance with the aim of the local protocol (1:1:1). Crystalloids were administered liberally for both trauma and non-trauma patients. There was a lower use of hemostatic adjuvants than recommended in the local transfusion protocol. Awareness to local protocol should be increased.
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Affiliation(s)
- Marte Irene Skille Carlsen
- Department of Anesthesiology and Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway.
- Department of Traumatology, St. Olav's University Hospital, Trondheim, Norway.
| | - Jostein Rødseth Brede
- Department of Anesthesiology and Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway
- Department of Emergency Medicine and Pre-hospital Services, St Olav's University Hospital, Trondheim, Norway
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Christian Medby
- Department of Anesthesiology and Intensive Care Medicine, St Olav's University Hospital, Trondheim, Norway
- Department of Traumatology, St. Olav's University Hospital, Trondheim, Norway
- Norwegian Armed Forces Joint Medical Services, Sessvollmoen, Norway
| | - Oddvar Uleberg
- Department of Emergency Medicine and Pre-hospital Services, St Olav's University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
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Brede JR, Rehn M. The end of balloons? Our take on the UK-REBOA trial. Scand J Trauma Resusc Emerg Med 2023; 31:69. [PMID: 37908007 PMCID: PMC10619299 DOI: 10.1186/s13049-023-01142-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality. MAIN BODY In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study. CONCLUSION The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Prinsesse Kristinas Gate 3, 7006, Trondheim, Norway.
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Steffen R, Knapp J, Hänggi M, Iten M. [Use of the REBOA catheter for uncontrollable upper gastrointestinal bleeding with hemorrhagic shock]. DIE ANAESTHESIOLOGIE 2023; 72:332-337. [PMID: 36988637 PMCID: PMC10181967 DOI: 10.1007/s00101-023-01278-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/09/2023] [Accepted: 01/18/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Richard Steffen
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, 3010, Bern, Schweiz
| | - Jürgen Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, 3010, Bern, Schweiz.
- Schweizerische Rettungsflugwacht, Rega, Zürich, Schweiz.
| | - Matthias Hänggi
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Manuela Iten
- Universitätsklinik für Intensivmedizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Brede JR, Søvik E, Rehn M. Resuscitative endovascular balloon occlusion of the aorta: the postpartum haemorrhage perspective. Crit Care 2022; 26:57. [PMID: 35277189 PMCID: PMC8917633 DOI: 10.1186/s13054-022-03942-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
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