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Shum-Tim L, Bichara-Allard S, Hopkins B, AlShahwan N, Hanley S, Manzano-Nunez R, Garcia AF, Deckelbaum D, Grushka J, Razek T, Fata P, Khwaja K, McKendy K, Jastaniah A, Wong EG. Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2024; 96:499-509. [PMID: 37478348 DOI: 10.1097/ta.0000000000004109] [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: 07/23/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients. METHODS We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year. RESULTS Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%). CONCLUSION This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications. LEVEL OF EVIDENCE Systematic Review and Meta-Analysis; Level III.
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Affiliation(s)
- Lukas Shum-Tim
- From the Division of Trauma Surgery (L.S.-T., S.B.-A., B.H., N.A.S., D.D., J.G., T.R., P.F., K.K., K.M.K., A.J., E.G.W.), McGill University, Montreal; Division of Vascular Surgery (S.H.), McGill University, Gatineau, QC, Canada; Department of Surgery, (NAS) King Saud University; Clinical Research Unit, Hospital del Mar Medical Research Institute (IMIM), (R.M.-N.), Barcelona, Spain; and Department of Surgery (A.F.G.), Fundación Valle del Lili, Cali, Colombia
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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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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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Maiga AW, Zuckerwise LC, Crispens MA, Sorabella LL, Prescott LS, Brown AJ, Gunter OL, Dennis BM. Early Femoral Access by Acute Care Surgeons: A Multidisciplinary Approach to Prevent Maternal Exsanguination in Placenta Accreta Spectrum. Am Surg 2023; 89:4973-4976. [PMID: 36524878 DOI: 10.1177/00031348221146956] [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: 12/06/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) use has expanded to the obstetric condition of placenta accreta spectrum (PAS). Early reports of REBOA for PAS describe prophylactic catheter deployment. We developed a multidisciplinary approach to PAS, with early femoral artery access and selective REBOA deployment. We compared morbidity, mortality, and blood loss before and after implementation of our multidisciplinary protocol for PAS. Prior to, femoral access was obtained only emergently, and maternal death occurred in 2/3 cases (66%). Following protocol implementation, there was one maternal death (6%). There were no access-related complications. We have not yet needed to deploy the REBOA during PAS cases. In contrast to urgent hemorrhage control or prophylactic REBOA deployment, routine early femoral arterial access and selective REBOA deployment as part of a multidisciplinary team approach is a novel strategy for managing PAS. Our experience suggests most PAS cases do not require prophylactic REBOA deployment.
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Affiliation(s)
- Amelia W Maiga
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marta A Crispens
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L Sorabella
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren S Prescott
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alaina J Brown
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver L Gunter
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
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Marsden MER, Buckley AM, Park C, Tai N, Rees P. Balloons on the battlefield: REBOA implementation in the UK Defence Medical Services. BMJ Mil Health 2023; 169:448-451. [PMID: 34408063 DOI: 10.1136/bmjmilitary-2021-001925] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/19/2021] [Indexed: 11/04/2022]
Abstract
Established in 2018, the Defence Endovascular Resuscitation (DefER) group recognised that resuscitative endovascular balloon occlusion of the aorta (REBOA) offered an option to improve survival in battle casualties dying from haemorrhage, particularly in remote and austere surgical settings. Following a successful jHub opportunity assessment, DefER purchased training and operational kit at pace. By 1 April 2019, the first forward surgical group undertook a bespoke endovascular training and assessment package. Results of the pilot were presented back to a jHub 4* Innovation Board, which initially awarded £500 000 to fund the project to full implementation. Med Op Cap provided a solution to establish REBOA as a core capability on to the 370 modules. REBOA catheters and arterial access kit are now available to deployed Role 2 facilities across defence as an adjunct to damage control resuscitation in specific circumstances. REBOA has, from a standing start, gained pan-Defence Medical Services (DMS) endorsement and has been integrated into deployed damage control resuscitation. To establish a new resuscitation capability across all Role 2 platforms within 15 months of inception represents implementation at pace. This agility was unlocked by empowering clinicians to develop the platform in conjunction with commercial procurement. This article describes how this innovative pathway facilitated the rapid introduction of a lifesaving haemorrhage control technique to equip DMS clinicians.
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Affiliation(s)
- Max E R Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - A M Buckley
- jHubMed, UKStratCom, London, UK
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - C Park
- Critical Care, King's College Hospital, London, UK
- London's Air Ambulance, Barts Health NHS Trust, London, UK
| | - N Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - P Rees
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Barts Heart Centre, Barts Health NHS Trust, London, UK
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Marsden MER, Park C, Barratt J, Tai N, Rees P. Defence Medical Services' REBOA training course. BMJ Mil Health 2023; 169:452-455. [PMID: 34607909 DOI: 10.1136/bmjmilitary-2021-001926] [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: 06/24/2021] [Accepted: 08/25/2021] [Indexed: 11/04/2022]
Abstract
Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) enables temporary haemorrhage control and physiological stabilisation. This article describes the bespoke Defence Medical Services (DMS) training package for effectively using REBOA. The article covers how the course was designed, how the key learning objectives are taught, participant feedback and the authors' perceptions of future training challenges and opportunities. Since the inaugural training course in April 2019, the authors have delivered six courses, training over 100 clinicians. For the first time in the UK DMS, we designed and delivered a robust specialist endovascular training programme, with demonstrable, significant increases in confidence and competence. As a result of this course, the first DMS REBOA-equipped forward surgical teams deployed in June 2019. Looking to the future, there is a requirement to develop an assessment of skill retention and the potential need for revalidation.
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Affiliation(s)
- Max E R Marsden
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- Centre for Trauma Science, Blizard Institute, Queen Mary University of London Barts and The London School of Medicine and Dentistry, London, UK
| | - C Park
- Critical Care, King's College Hospital NHS Trust, London, London, UK
- London's Air Ambulance, Barts Health NHS Trust, London, UK
| | - J Barratt
- Emergency Medicine, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
| | - N Tai
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK
- UK STRATCOM, jHubMed, London, UK
| | - P Rees
- Academic Department of Military Medicine, Royal Centre for Defence Medicine, Birmingham, UK
- Barts Heart Centre, Barts Health NHS Trust, London, UK
- University of St Andrews School of Medicine, St Andrews, UK
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Qian W, Zhong H, Ghiasi S. Short: Prediction of fetal blood oxygen content in response to partial occlusion of maternal aorta. SMART HEALTH (AMSTERDAM, NETHERLANDS) 2023; 28:100391. [PMID: 38260035 PMCID: PMC10803053 DOI: 10.1016/j.smhl.2023.100391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Acute hemorrhage in pregnancy may lead to maternal and/or fetal morbidity or mortality. In emergency medicine, blockage of the aorta via an inflatable endovascular balloon, technically referred to Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), is used to manage hemorrhage. However, the application of REBOA in pregnancy needs to strike a balance between two competing objectives of limiting maternal blood loss and ensuring fetal wellness, for which one would need to predict the impact of regulated blood pressure on fetal wellness. To address this problem, we propose an efficient machine learning-based method to predict the temporal impact of the distal Mean Arterial Blood Pressure (dMAP) controlled by the REBOA on the oxygen content in the fetal blood. Evaluation of the algorithm on data collected from in-vivo experiments from pregnant ewe animal models exhibits mean absolute error of 0.61, 1.09, 1.42, 1.70 mmHg, and coefficient of determination of 0.95, 0.86, 0.76, 0.64 for prediction of partial pressure of oxygen in fetal arterial blood, a key predictor of fetal wellness, in 2.5, 5, 7.5, 10-minute prediction horizons, respectively.
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Affiliation(s)
- Weitai Qian
- Dept. of Electrical and Computer Engineering, University of California Davis, Davis, CA, 95618, USA
| | - Hongtao Zhong
- Dept. of Electrical and Computer Engineering, University of California Davis, Davis, CA, 95618, USA
| | - Soheil Ghiasi
- Dept. of Electrical and Computer Engineering, University of California Davis, Davis, CA, 95618, USA
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Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in Non-Traumatic Cardiac Arrest: A Narrative Review of Known and Potential Physiological Effects. J Clin Med 2022; 11:jcm11030742. [PMID: 35160193 PMCID: PMC8836569 DOI: 10.3390/jcm11030742] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 01/24/2022] [Accepted: 01/27/2022] [Indexed: 11/17/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is widely used in acute trauma care worldwide and has recently been proposed as an adjunct to standard treatments during cardiopulmonary resuscitation in patients with non-traumatic cardiac arrest (NTCA). Several case series have been published highlighting promising results, and further trials are starting. REBOA during CPR increases cerebral and coronary perfusion pressure by increasing the afterload of the left ventricle, thus improving the chances of ROSC and decreasing hypoperfusion to the brain. In addition, it may facilitate the termination of malignant arrhythmias by stimulating baroreceptor reflex. Aortic occlusion could mitigate the detrimental neurological effects of adrenaline, not only by increasing cerebral perfusion but also reducing the blood dilution of the drug, allowing the use of lower doses. Finally, the use of a catheter could allow more precise hemodynamic monitoring during CPR and a faster transition to ECPR. In conclusion, REBOA in NTCA is a feasible technique also in the prehospital setting, and its use deserves further studies, especially in terms of survival and good neurological outcome, particularly in resource-limited settings.
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Quantifying the need for pediatric REBOA: A gap analysis. J Pediatr Surg 2021; 56:1395-1400. [PMID: 33046222 PMCID: PMC7982345 DOI: 10.1016/j.jpedsurg.2020.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/30/2020] [Accepted: 09/13/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Trauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA. METHODS Trauma patients <18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage. RESULTS There were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas. CONCLUSION Nearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies. TYPE OF STUDY Retrospective comparative study. LEVEL OF EVIDENCE Level III.
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Hilbert-Carius P, McGreevy D, Abu-Zidan FM, Hörer TM. Successfully REBOA performance: does medical specialty matter? International data from the ABOTrauma Registry. World J Emerg Surg 2020; 15:62. [PMID: 33228705 PMCID: PMC7685615 DOI: 10.1186/s13017-020-00342-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive procedure being increasingly utilized to prevent patients with non-compressible torso hemorrhage from exsanguination. The increased use of REBOA is giving rise to discussion about "Who is and who should be performing it?" METHODS Data from the international ABO (aortic balloon occlusion) Trauma Registry from between November 2014 and April 2020 were analyzed concerning the question: By who, how, and where is REBOA being performed? The registry collects retrospective and prospective data concerning use of REBOA in trauma patients. RESULTS During the study period, 259 patients had been recorded in the registry, 72.5% (n = 188) were males with a median (range) age of 46 (10-96) years. REBOA was performed in the ER in 50.5%, in the OR in 41.5%, and in the angiography suite in 8% of patients. In 54% of the patients REBOA was performed by surgeons (trauma surgeons 28%, vascular surgeons 22%, general surgeons 4%) and in 46% of the patients by non-surgeons (emergency physicians 31%, radiologists 9.5%, anesthetists 5.5%). Common femoral artery (CFA) access was achieved by use of external anatomic landmarks and palpation alone in 119 patients (51%), by cutdown in 57 patients (24%), using ultrasound in 49 patients (21%), and by fluoroscopy in 9 patients (4%). Significant differences between surgeons and non-surgeons were found regarding patient's age, injury severity, access methods, place where REBOA was performed, location patients were taken to from the emergency room, and mortality. CONCLUSION A substantial number of both surgical and non-surgical medical disciplines are successfully performing REBOA to an almost equal extent. Surgical cutdown is used less frequently as access to the CFA compared with reports in older literature and puncture by use of external anatomic landmarks and palpation alone is used with a high rate of success. Instead of discussing "Who should be performing REBOA?" future research should focus on "Which patient benefits most from REBOA?"
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Bergmannstrost Hospital Halle, Mersbuegerstraße 165, 06112, Halle (Saale), Germany.
| | - David McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Science, UAE University, Al-Ain, United Arab Emirates
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.,Department of General Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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Mikdad S, van Erp IAM, Moheb ME, Fawley J, Saillant N, King DR, Kaafarani HMA, Velmahos G, Mendoza AE. Pre-peritoneal pelvic packing for early hemorrhage control reduces mortality compared to resuscitative endovascular balloon occlusion of the aorta in severe blunt pelvic trauma patients: A nationwide analysis. Injury 2020; 51:1834-1839. [PMID: 32564964 DOI: 10.1016/j.injury.2020.06.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/09/2020] [Accepted: 06/03/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Early hemorrhage control after severe blunt pelvic trauma is life-saving. The aim of this study is to compare the efficacy and outcomes of pre-peritoneal packing (PPP) and Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) with a subsequent hemorrhage control procedure to control life-threatening pelvic hemorrhage in trauma patients. METHODS A 3-year (2015-2017) retrospective analysis of the Trauma Quality Improvement Program (TQIP) was performed. All blunt trauma patients (aged ≥15 years) who underwent PPP or Zone 3 REBOA placement were included while deaths on arrival and transfers were excluded. Patients were matched on clinical characteristics using propensity score matching (PSM). Univariate analysis was performed to compare mortality, time to procedure, time in ED, transfusion requirements, complications rates, and ICU and hospital length of stay (LOS) amongst patient groups. RESULTS Of 420 trauma patients, 307 underwent PPP and 113 REBOA. Patients had similar hemodynamics and ISS upon presentation, but PPP patients had a higher GCS (P = 0.037) and more blunt kidney injuries (P = 0.015). After PSM, 206 trauma patients were included in the analysis. There were no significant differences in blood transfusion, LOS, or major complications. Time to REBOA was shorter than time to PPP (52 vs 77.5 min; P<0.001) with longer time in ED (65 vs 51 min; p = 0.023). The 24-hour (32.4 vs 17.7%; P = 0.23) and in-hospital mortality (52.0 vs 37.3%; P = 0.048) were higher after REBOA. CONCLUSION PPP is associated with improved survival compared to REBOA placement. Delay in definitive hemorrhage control may provide a potential explanation, but causation remains unresolved. This data suggests that early PPP may offer a benefit over REBOA in the setting of hemorrhage after blunt pelvic trauma. Further, large, multi-institutional studies are warranted to support these findings. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Sarah Mikdad
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Inge A M van Erp
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Mohamad El Moheb
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Jason Fawley
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - David R King
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - George Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
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Balogh ZJ, Way TL, Bendinelli C, Warren KJ. Current concepts on haemorrhage control in severe trauma. ANZ J Surg 2020; 90:406-408. [DOI: 10.1111/ans.15873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 03/11/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Zsolt J. Balogh
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
| | - Teagan L. Way
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
| | - Cino Bendinelli
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
| | - Kirrily‐Rae J. Warren
- Department of TraumatologyJohn Hunter Hospital and the University of Newcastle Newcastle New South Wales Australia
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