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Maiga AW, Kundi R, Morrison JJ, Spalding C, Duchesne J, Hunt J, Nguyen J, Benjamin E, Moore EE, Lawless R, Beckett A, Russo R, Dennis BM. Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection. Trauma Surg Acute Care Open 2022; 7:e000984. [PMID: 36578977 PMCID: PMC9791466 DOI: 10.1136/tsaco-2022-000984] [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: 06/28/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Background Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized. Results Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control. Conclusion Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments. Level of evidence Level 5, systematic review.
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Affiliation(s)
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | | | | | - Juan Duchesne
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - John Hunt
- University Medical Center New Orleans, New Orleans, Louisiana, USA
| | - Jonathan Nguyen
- Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
| | | | | | - Ryan Lawless
- Denver Health Medical Center, Denver, Colorado, USA
| | | | - Rachel Russo
- University of California Davis Medical Center, Sacramento, California, USA
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Cralley AL, Moore EE, Scalea TM, Inaba K, Bulger EM, Meyer DE, Fox CJ, Sauaia A. Predicting success of resuscitative endovascular occlusion of the aorta: Timing supersedes variable techniques in predicting patient survival. J Trauma Acute Care Surg 2021; 91:473-479. [PMID: 34086662 DOI: 10.1097/ta.0000000000003307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular occlusion of the aorta (REBOA) is used for temporary aortic occlusion of trauma patients in the management of noncompressible hemorrhage. Previous studies have focused on how to properly perform REBOA in the trauma environment to improve survival rates, but high-grade evidence defining the ideal patient population does not yet exist. This post hoc analysis of the Emergent Truncal Hemorrhage Control Study seeks to identify the most important clinical factors for physicians to consider when selecting for REBOA candidates and their potential survival following REBOA. METHODS Post hoc analysis of a large, multicenter, prospective observational study conducted at six level 1 trauma centers, 2017 to 2018, was performed. An onsite data collector documented all time points for REBOA patients since admission. Candidate predictors were demographics; injury severity; physiology preprocedure, during procedure, and postprocedure; cardiopulmonary resuscitation; and REBOA-specific variables (time to procedure, procedure-related time intervals, access site, technique, sheath size, catheter length, balloon volume, deployment zone). Predictive models for survival at three different time points along the trauma triage and REBOA process timeline ("Admission," "REBOA Initiation," and "Postaortic Occlusion") were devised by logistic regression. RESULTS Eighty-eight patients had REBOA placement. The Admission model selected age, Glasgow Coma Scale, and admission systolic blood pressure as significant predictors of survival (area under the receiver operating characteristic curve [AUROC], 0.86; 95% CI, 0.77-0.94). The REBOA Initiation and Postaortic Occlusion models selected age, Glasgow Coma Scale, and the systolic blood pressure measured just before balloon inflation as predictors for survival (AUROC, 0.87 [95% CI, 0.78-0.97] and AUROC, 0.90 [95% CI, 0.81-0.99], respectively). No REBOA procedural variables were identified as predictors of patient survival. CONCLUSION Only patient-specific criteria of age, neurologic status, and severity of shock predicted survival. The hemodynamic stability of the patient at the time REBOA is initiated is more important than how REBOA is initiated. These findings suggest that earlier preparation for REBOA placement may be a key to improved survival. LEVEL OF EVIDENCE Therapeutic, level IV.
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Affiliation(s)
- Alexis L Cralley
- From the Department of Surgery (A.L.C., E.E.M.), Denver Health Medical Center, Denver, Colorado; Department of Surgery (T.M.S., C.J.F.), University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery (K.I.), University of Southern California, Los Angeles, California; Department of Surgery (E.M.B.), University of Washington School of Medicine, Seattle, Washington; Department of Surgery at UT Health (D.E.M.), Texas Health Science Center's McGovern Medical School, Houston, Texas; Colorado School of Public Health (A.S.), Aurora, Colorado
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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: 2] [Impact Index Per Article: 0.7] [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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Ellis DY. REBOA: Where are we now? Emerg Med Australas 2021; 32:4-6. [PMID: 32023004 DOI: 10.1111/1742-6723.13432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel Y Ellis
- Trauma Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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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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Russo RM, White JM, Baer DG. Partial Resuscitative Endovascular Balloon Occlusion of the Aorta: A Systematic Review of the Preclinical and Clinical Literature. J Surg Res 2021; 262:101-114. [PMID: 33561721 DOI: 10.1016/j.jss.2020.12.054] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 12/04/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become a standard adjunct for the management of life-threatening truncal hemorrhage, but the technique is limited by the sequalae of ischemia distal to occlusion. Partial REBOA addresses this limitation, and the recent Food and Drug Administration approval of a device designed to enable partial REBOA will broaden its application. We conducted a systematic review of the available animal and clinical literature on the methods, impacts, and outcomes associated with partial REBOA as a technique to enable targeted proximal perfusion and limit distal ischemic injury. We hypothesize that a systematic review of the published animal and human literature on partial REBOA will provide actionable insight for the use of partial REBOA in the context of future wider clinical implementation of this technique. METHODS Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols guidelines, we conducted a search of the available literature which used partial inflation of a REBOA balloon catheter. Findings from 22 large animal studies and 14 clinical studies met inclusion criteria. RESULTS Animal and clinical results support the benefits of partial REBOA including extending the resuscitative window extended safe occlusion time, improved survival, reduced proximal hypertension, and reduced resuscitation requirements. Clinical studies provide practical physiologic targets for partial REBOA including a period of total occlusion followed by gradual balloon deflation to achieve a target proximal pressure and/or target distal pressure. CONCLUSIONS Partial REBOA has several benefits which have been observed in animal and clinical studies, most notably reduced ischemic insult to tissues distal to occlusion and improved outcomes compared with total occlusion. Practical clinical protocols are available for the implementation of partial REBOA in cases of life-threatening torso hemorrhage.
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Affiliation(s)
- Rachel M Russo
- United States Air Force, 60(Th) Medical Group, Travis Air Force Base, California; University of California Davis Medical Center, Sacramento, California
| | - Joseph M White
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Marsh AM, Betzold R, Rueda M, Morrow M, Lottenberg L, Borrego R, Ghneim M, DuBose JJ, Morrison JJ, Azar FK. Clinical Use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the Management of Hemorrhage Control: Where Are We Now? CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00285-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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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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