1
|
Salvagno M, Grinza M, Coppalini G, de Cassai A, Soloperto R, Degrassi A, Carlin A, Annoni F, Calabrese F, Taccone FS. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) as a strategy for postpartum haemorrhage management: A narrative review. Int J Obstet Anesth 2024; 60:104260. [PMID: 39306573 DOI: 10.1016/j.ijoa.2024.104260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 08/23/2024] [Accepted: 08/25/2024] [Indexed: 10/21/2024]
Abstract
Postpartum hemorrhage (PPH) remains one of the leading causes of maternal mortality worldwide, with a significant impact on global health. Optimal management of PPH involves distinct steps executed simultaneously by a multidisciplinary approach, with anesthesiologists playing a key role in hemodynamic control and patient resuscitation. In this context, an aortic blood flow interruption through an internal balloon should be considered a rescue option among the various opportunities, to treat or prevent abdominal hemorrhages. Given this perspective, there is increasing interest in the role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), originally used in trauma and military medicine, which has emerged as a novel strategy for managing PPH. Indeed, this technique has shown promise in managing severe cases of PPH, especially where traditional measures are insufficient. It also offers potential as a prophylactic measure in pregnancies with high risk for PPH, such as in the case of placenta accrete spectrum. This review aims to examine the efficacy, safety, and potential applications of REBOA in PPH management and prevention. At the same time, challenges such as the need for skilled operators, potential complications, costs, and the consideration of fetal safety were also discussed. REBOA presents as a promising tool against PPH, with efficacy in reducing blood loss, preserving fertility, and potentially decreasing maternal mortality and improving outcomes. However, its implementation requires careful consideration, training, and further research to establish clear guidelines for its use in obstetric care.
Collapse
Affiliation(s)
- Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium.
| | - Marta Grinza
- Department of Obstetrics and Gynecology, CHU Brugmann UVC, Brussels, Belgium
| | - Giacomo Coppalini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium; Department of Anesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alessandro de Cassai
- Department of Anesthesiology and Intensive Care, Azienda Ospedale Università di Padova, Padue, Italy
| | - Rossana Soloperto
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Alessia Degrassi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Andrew Carlin
- Department of Obstetrics and Gynecology, CHU Brugmann UVC, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| | - Fabrizia Calabrese
- Department of Anesthesiology and Intensive Care, Azienda Ospedale Università di Padova, Padue, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Brussels, Belgium
| |
Collapse
|
2
|
Rodríguez-Holguín F, Salcedo A, Leib P, Caicedo Y, Serna JJ, Toro L, Carvajal S, Riascos M, Parra MW, García A, Ordoñez CA. Is REBOA the Last Card to Control a Massive Gastrointestinal Bleeding? J Surg Res 2024; 296:735-741. [PMID: 38368774 DOI: 10.1016/j.jss.2023.12.040] [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: 03/28/2023] [Revised: 12/11/2023] [Accepted: 12/30/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential tool for the management of massive gastrointestinal bleeding (MGB). This study aims to describe the experience of the use of REBOA as adjunctive therapy in patients with MGB and to evaluate its effectiveness. METHODS Serial cases of patients with hemorrhagic shock secondary to MGB in whom REBOA was placed were collected. Patient demographics, bleeding severity, etiology, management, and clinical outcomes were recorded. RESULTS Between 2017 and 2020, five cases were analyzed. All patients had a severe gastrointestinal bleeding (Glasgow Blatchford Bleeding Score range 12-17; Clinical Rockal Score range 5-9). The etiologies of MGB were perforated gastric or duodenal ulcers, esophageal varices, and vascular lesions. Systolic blood pressure increased after REBOA placement and total occlusion time was 25-60 min. REBOA provided temporary hemorrhage control in all cases and allowed additional hemostatic maneuvers to be performed. Three patients survived more than 24 h. All patients died in index hospitalization. The main cause of death was related to hemorrhagic shock. CONCLUSIONS Endovascular aortic occlusion can work as a bridge to further resuscitation and attempts at hemostasis in patients with MGB. REBOA provides hemodynamic support and may be used simultaneously with other hemostatic maneuvers, facilitating definitive hemorrhage control.
Collapse
Affiliation(s)
- Fernando Rodríguez-Holguín
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia
| | - Alexander Salcedo
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia; División de Cirugía de Trauma y Emergencias, Universidad del Valle, Cali, Colombia
| | - Philip Leib
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - José Julián Serna
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Luis Toro
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Sandra Carvajal
- Departamento de Medicina de Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Manolo Riascos
- Departamento de Medicina de Emergencias, Fundación Valle del Lili, Cali, Colombia
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, Florida
| | - Alberto García
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia; División de Cirugía de Trauma y Emergencias, Universidad del Valle, Cali, Colombia
| | - Carlos A Ordoñez
- División de Cirugía de Trauma y Emergencias, Fundación Valle del Lili, Cali, Colombia; Department of Trauma and Acute Care Surgery, Universidad Icesi, Cali, Colombia; División de Cirugía de Trauma y Emergencias, Universidad del Valle, Cali, Colombia.
| |
Collapse
|
3
|
Fontenelle Ribeiro Junior MA, Salman SM, Al-Qaraghuli SM, Makki F, Abu Affan RA, Mohseni SR, Brenner M. Complications associated with the use of resuscitative endovascular balloon occlusion of the aorta (REBOA): an updated review. Trauma Surg Acute Care Open 2024; 9:e001267. [PMID: 38347890 PMCID: PMC10860083 DOI: 10.1136/tsaco-2023-001267] [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: 10/02/2023] [Accepted: 12/22/2023] [Indexed: 02/15/2024] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become part of the arsenal to temporize patients in shock from severe hemorrhage. REBOA is used in trauma to prevent cardiovascular collapse by preserving heart and brain perfusion and minimizing distal hemorrhage until definitive hemorrhage control can be achieved. Significant side effects, including death, ischemia and reperfusion injuries, severe renal and lung damage, limb ischemia and amputations have all been reported. The aim of this article is to provide an update on complications related to REBOA. REBOA has emerged as a critical intervention for managing severe hemorrhagic shock, aiming to temporize patients and prevent cardiovascular collapse until definitive hemorrhage control can be achieved. However, this life-saving procedure is not without its challenges, with significant reported side effects. This review provides an updated overview of complications associated with REBOA. The most prevalent procedure-related complication is distal embolization and lower limb ischemia, with an incidence of 16% (range: 4-52.6%). Vascular and access site complications are also noteworthy, documented in studies with incidence rates varying from 1.2% to 11.1%. Conversely, bleeding-related complications exhibit lower documentation, with incidence rates ranging from 1.4% to 28.6%. Pseudoaneurysms are less likely, with rates ranging from 2% to 14%. A notable incidence of complications arises from lower limb compartment syndrome and lower limb amputation associated with the REBOA procedure. Systemic complications include acute kidney failure, consistently reported across various studies, with incidence rates ranging from 5.6% to 46%, representing one of the most frequently documented systemic complications. Infection and sepsis are also described, with rates ranging from 2% to 36%. Pulmonary-related complications, including acute respiratory distress syndrome and multisystem organ failure, occur in this population at rates ranging from 7.1% to 17.5%. This comprehensive overview underscores the diverse spectrum of complications associated with REBOA.
Collapse
Affiliation(s)
| | | | | | - Farah Makki
- Medicine, University of Sharjah, Sharjah, UAE
| | | | | | | |
Collapse
|
4
|
Suzuki T, Sugiura T, Okazaki J, Kimura H. Postpartum hemorrhage with associated placenta previa in a kidney transplant recipient: A case report. Int J Surg Case Rep 2024; 114:109109. [PMID: 38086133 PMCID: PMC10726234 DOI: 10.1016/j.ijscr.2023.109109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/22/2023] [Accepted: 12/02/2023] [Indexed: 12/21/2023] Open
Abstract
INTRODUCTION The efficacy and safety of uterine artery embolization (UAE) and prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA) against postpartum hemorrhage (PPH) in pregnant women after kidney transplantation have not been reported. Here, we describe a case of PPH associated with placenta previa in pregnancy following kidney transplantation, which was managed with UAE and prophylactic REBOA. CASE PRESENTATION A 35-year-old, gravida 2, para 1 woman with total placenta previa presented with vaginal bleeding (460 mL) at 33 weeks and 3 days of gestation. Previously, she underwent a living-donor kidney transplantation for IgA nephropathy, and the renal artery of the transplanted kidney was anastomosed with the right internal iliac artery. An emergency cesarean section with prophylactic REBOA was performed under general anesthesia. A balloon catheter was introduced via the left femoral artery and positioned above the aortic bifurcation (Aortic zone 3). Upon confirming fetal delivery, the balloon was immediately inflated, and the total aortic occlusion time was 20 min. However, following aortic balloon deflation, atonic bleeding continued despite Bakri balloon usage and uterotonic drug administration. Subsequently, UAE was performed for the refractory PPH, the left uterine artery was embolized using a gelatin sponge, and hemostasis was successfully achieved. The patient recovered uneventfully and was discharged on postoperative day 7. DISCUSSION AND CONCLUSION In pregnancies following kidney transplantation, prophylactic REBOA controls bleeding; however, it decreases blood flow to the transplanted kidney. Furthermore, uterine nutrient vasculature alterations are observed, necessitating a thorough understanding of the uterine artery supply pathways during UAE.
Collapse
Affiliation(s)
- Toshinao Suzuki
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan.
| | - Takahiro Sugiura
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan.
| | - Junko Okazaki
- Department of Anesthesiology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
| | - Hiroaki Kimura
- Department of Obstetrics and Gynecology, Kimitsu Chuo Hospital, 1010 Sakurai, Kisarazu, Chiba 292-8535, Japan
| |
Collapse
|
5
|
Haering D, Meador H, Lynch E, Lauria M, Garchar E, Braude D. Management of Postpartum Hemorrhage in Critical Care Transport. Air Med J 2023; 42:488-495. [PMID: 37996188 DOI: 10.1016/j.amj.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 11/25/2023]
Abstract
Postpartum hemorrhage is a relatively common and highly morbid complication of the postpartum period that often requires management by specialized providers at tertiary care facilities. Critical care transport teams may be tasked with transporting postpartum patients who are already experiencing postpartum hemorrhage, but they should also be aware that other peripartum patients may be at risk for developing postpartum hemorrhage while in the process of transport. As such, it is imperative that transport providers understand the signs, symptoms, causes, and complications of postpartum hemorrhage as well as the options for intervention and treatment. This article reviews the current clinical evidence regarding resuscitation and medical management strategies that transport teams should be familiar with as well as more advanced and invasive management techniques they may encounter and be expected to monitor during transport, such as balloon tamponade and aortic balloon occlusion.
Collapse
Affiliation(s)
- Donald Haering
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM.
| | - Hallie Meador
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Lynch
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Michael Lauria
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| | - Elizabeth Garchar
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Darren Braude
- Lifeguard Air Emergency Services, University of New Mexico Hospital, Albuquerque, NM; Department of Emergency Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM
| |
Collapse
|
6
|
Kluck SL, Russo RM, Appel NB, Frankfurt AI, Weltge C, Shimer T, Feagins B, Frotan A, Rinehart B, Cohen RA. Aortic balloon occlusion in distal zone 3 reduces blood loss from obstetric hemorrhage in placenta accreta spectrum. J Trauma Acute Care Surg 2023; 94:710-717. [PMID: 36812423 PMCID: PMC10155693 DOI: 10.1097/ta.0000000000003917] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Peripartum hemorrhage is a significant cause of maternal death. We developed a standardized, multidisciplinary cesarean hysterectomy protocol for placenta accreta spectrum (PAS) using prophylactic resuscitative endovascular balloon occlusion of the aorta (REBOA). We initially placed the balloon in proximal zone 3, below the renal arteries. An internal review revealed more bleeding than expected, and we subsequently changed our protocol to occlude the origin of the inferior mesenteric artery (distal zone 3), to decrease blood flow through collateral circulation. We hypothesized that distal zone 3 occlusion would reduce blood loss and transfusion volume and may permit a longer duration of occlusion compared with proximal zone 3 occlusion without increasing ischemic complications. METHODS We conducted a single-center retrospective cohort study of patients with suspected PAS who underwent REBOA-assisted cesarean hysterectomy from December 2018 to March 2022. Medical records of all patients with PAS were reviewed. Data were extracted from hospital admission through 3 months postpartum. RESULTS Forty-four patients met the inclusion criteria. Nine never had the balloon inflated. Eighteen patients had placement in proximal zone 3, whereas twenty-six patients had placement in distal zone 3. Background and clinical characteristics were similar in both groups. Placental pathology was obtained in every case. After adjusting for relevant risk factors, multivariate analysis revealed that distal occlusion was associated with a 45.9% (95% confidence interval, 23.8-61.6%) decrease in estimated blood loss, 41.5% (13.7-60.4%) decrease in red blood cell transfusion volume, and 44.9% (13.5-64.9%) reduction in total transfusion volume. There were no vascular access or resuscitative endovascular balloon occlusion of the aorta-related complications in either group. CONCLUSION This study highlights the safety of prophylactic REBOA in planned cesarean hysterectomy for PAS and provides a rationale for distal zone 3 positioning to reduce blood loss. Resuscitative endovascular balloon occlusion of the aorta should be considered at other institutions with placenta accreta programs, especially in patients with extensive collateral flow. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
Collapse
|
7
|
Resuscitative endovascular balloon occlusion of the aorta for life-threatening postpartum hemorrhage: A nationwide observational study in Japan. J Trauma Acute Care Surg 2022; 93:418-423. [PMID: 35444149 DOI: 10.1097/ta.0000000000003650] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used for postpartum hemorrhage (PPH) which is one of the leading causes of maternal mortality worldwide; however, its utility in the obstetrics setting remains unclear. Thus, this study aimed to describe the characteristics, demographics and mortality of patients with PPH who underwent REBOA. METHODS We used the Japanese Diagnosis Procedure Combination inpatient database to identify patients with PPH who underwent REBOA from April 2012 to March 2020. We examined the patients' characteristics, interventions administered and in-hospital mortality. RESULTS We identified 143 patients with PPH who underwent REBOA. The most common cause of PPH was atonic postpartum hemorrhage (52.4%), followed by disseminated intravascular coagulation (29.4%) and amniotic fluid embolism documented (11.2%). Among patients who delivered at hospitals in which REBOA was performed (n = 55), 38.2% of patients experienced preterm births and 70.9% delivered via cesarean section. The proportion of patients who underwent transcatheter arterial embolization and hysterectomy was 53.8% and 16.1%, respectively. In-hospital mortality was 7.0%. CONCLUSION The results of the present study could be helpful in clinical decision-making and providing patients and families with additional treatment options for PPH. LEVEL OF EVIDENCE Therapeutic, level IV.
Collapse
|
8
|
A Team Approach to Peripartum Hemorrhage Control Incorporating Resuscitative Endovascular Balloon Occlusion of the Aorta. J Trauma Acute Care Surg 2022; 93:e89-e94. [PMID: 35319543 DOI: 10.1097/ta.0000000000003612] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
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: 6] [Impact Index Per Article: 3.0] [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.
Collapse
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
| |
Collapse
|
10
|
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.
Collapse
|
11
|
Nieto-Calvache AJ, Vergara-Galliadi LM, Rodríguez F, Ordoñez CA, García AF, López MC, Manzano R, Velásquez J, Carbonell JP, Bryon AM, Echavarría MP, Escobar MF, Carvajal J, Benavides-Calvache JP, Burgos JM. A multidisciplinary approach and implementation of a specialized hemorrhage control team improves outcomes for placenta accreta spectrum. J Trauma Acute Care Surg 2021; 90:807-816. [PMID: 33496549 DOI: 10.1097/ta.0000000000003090] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The main complication of placenta accreta spectrum (PAS) is massive bleeding. Endoarterial occlusion techniques have been incorporated into the management of this pathology. Our aim was to examine the endovascular practice patterns among PAS patients treated during a 9-year period in a low-middle income country in which an interdisciplinary group's technical skills were improved with the creation of a PAS team. METHODOLOGY A retrospective cohort study including all PAS patients treated from December 2011 to November 2020 was performed. We compared the clinical results obtained according to the type of endovascular device used (group 1, internal iliac artery occlusion balloons; group 2, resuscitative endovascular balloons of the aorta; group 3, no arterial balloons due to low risk of bleeding) and according to the year in which they were attended (reflects the PAS team level of experience). A fourth group of comparisons included the woman diagnosed during a cesarean delivery and treated in a nonprotocolized way. RESULTS A total of 113 patients were included. The amount of blood loss decreased annually, with a median of 2,500 mL in 2014 (when endovascular occlusion balloons were used in all patients) and 1,394 mL in 2020 (when only 38.5% of the patients required arterial balloons). Group 3 patients (n = 16) had the lowest bleeding volume (1,245 mL) and operative time (173 minutes) of the entire population studied. Group 2 patients (n = 46) had a bleeding volume (mean, 1,700 mL) and transfusions frequency (34.8%) slightly lower than group 1 patients (n = 30) (mean of 2,000 mL and 50%, respectively). They also had lower hysterectomy frequency (63% vs. 76.7% in group 1) and surgical time (205 minutes vs. 275 in group 1) despite a similar frequency of confirmed PAS and S2 compromise. CONCLUSION Endovascular techniques used for bleeding control in PAS patients are less necessary as interdisciplinary groups improve their surgical and teamwork skills. LEVEL OF EVIDENCE Therapeutic care management, level III.
Collapse
Affiliation(s)
- Albaro José Nieto-Calvache
- From the Placenta Accreta Spectrum Clinic (A.J.N.-C., F.R., C.A.O., A.F.G., J.V., J.P.C., A.M.B., M.P.E., M.F.E., J.C., J.P.B.-C., J.M.B.), Clinical Research Center (L.M.V.-G., M.C.L., R.M.); Division of Trauma and Acute Care Surgery, Department of Surgery (F.R., C.A.O., A.F.G.); and Interventional Radiology Department (J.V., J.P.C.), Fundación Valle del Lili, Cali, Colombia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Sandlin AT, Magann EF, Whittington JR, Schneider AM, Ramseyer AM, Hughes DS, Ounpraseuth ST. Management of pregnancies complicated by placenta accreta spectrum utilizing a multidisciplinary care team in a rural state. J Matern Fetal Neonatal Med 2021; 35:5964-5969. [PMID: 33769169 DOI: 10.1080/14767058.2021.1903425] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
PURPOSE To compare maternal and neonatal outcomes following the development of a multidisciplinary care team for the management of pregnancies complicated by placenta accreta spectrum (PAS) in a rural state. METHODS This is a retrospective cohort study evaluating pregnancies managed before PAS team care management formation (2010-2015) and after (2016-2020) in a university medical center. Maternal and neonatal outcomes were analyzed. Patients were grouped by delivery date to either before or after dedicated PAS team formation. Maternal and neonatal outcomes were analyzed. Frequencies and percentages were reported for categorical measures while means and standard deviations were computed for continuous measures. Wilcoxon rank-sum test was used for continuous variables while Chi-square or Fisher's exact was used for categorical measures. FINDINGS There were 82 patients with PAS managed at our institution (29 in Pre-PAS team group and 53 in Post-PAS team group). The number of units of packed red blood cells (PRBCS) transfused intraoperatively was significantly higher in the Pre-PAS care team group (6.52 vs. 3.26, p = .0057). The total number of units PRBCS transfused (9.93 vs. 3.51, p = .0014) and total number of cryoprecipitate transfused (0.77 vs. 0.08, p = .0225) during the entire hospital stay were increased in the Pre-PAS team group. Median neonatal 1 min and 5 min APGAR scores were lower in the Pre-PAS care team group (2 vs 6 at 1 min, p = .0035; 6 vs. 7at 5 min, p = .0301). CONCLUSIONS Management of PAS by a dedicated, multidisciplinary team results in less blood transfusion requirements and improved maternal and neonatal outcomes.
Collapse
Affiliation(s)
- Adam T Sandlin
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Everett F Magann
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Julie R Whittington
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Allison M Schneider
- The College of Medicine, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Abigail M Ramseyer
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Department of Obstetrics and Gynecology, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| | - Songthip T Ounpraseuth
- Department of Biostatistics, University of Arkansas for the Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
13
|
Manzano-Nuñez R, Chica-Yanten J, Naranjo MP, Caicedo-Holguin I, Ordoñez JM, McGreevy D, Puyana JC, Hörer TM, Moore EE, García AF. Use of REBOA in the universe of magical realism: a real-world review. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2021. [DOI: 10.5554/22562087.e973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
While reading the novella “Chronicle of a Death Foretold” by the Colombian Nobel Laureate Gabriel García-Marquez, we were surprised to realize that the injuries sustained by the main character could have been successfully treated had he received modern trauma care in which REBOA may have been considered. This is a discussion of Mr. Nasar's murder to explore whether he could have been saved by deploying REBOA as a surgical adjunct to bleeding control and resuscitation. In reading García-Marquez's novel we noted the events that unfolded at the time of Santiago Nasar's murder. To contextualize the claim that Mr. Nasar could have survived, had his injuries been treated with REBOA, we explored and illustrated what could have done differently and why. On the day of his death, Mr. Nasar sustained multiple penetrating stab wounds. Although he received multiple stab wounds to his torso, the book describes seven potentially fatal injuries, resulting in hollow viscus, solid viscus, and major vascular injuries. We provided a practical description of the clinical and surgical management algorithm we would have followed in Mr. Nasar's case. This algorithm included the REBOA deployment for hemorrhage control and resuscitation. The use of REBOA as part of the surgical procedures performed could have saved Mr. Nasar's life. Based on our current knowledge about REBOA in trauma surgery, we claim that its use, coupled with appropriate surgical care for hemorrhage control, could have saved Santiago Nasar's life, and thus prevent a death foretold.
Collapse
|
14
|
Riazanova OV, Reva VA, Fox KA, Romanova LA, Kulemin ES, Riazanov AD, Ioscovich A. Open versus endovascular REBOA control of blood loss during cesarean delivery in the placenta accreta spectrum: A single-center retrospective case control study. Eur J Obstet Gynecol Reprod Biol 2021; 258:23-28. [PMID: 33388487 DOI: 10.1016/j.ejogrb.2020.12.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/05/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare two vascular control options for blood loss prevention and hysterectomy during cesarean delivery (CD2): endovascular balloon occlusion of the aorta (REBOA3) and open bilateral common iliac artery occlusion (CIAO4) in women with extensive placenta accreta spectrum (PAS5). STUDY DESIGN This was retrospective comparison of cases of PAS using either CIAO (October 2017 through October 2018) or REBOA (November 2018 through November 2019) to prevent pathologic hemorrhage during scheduled CD. Women with confirmed placenta increta/percreta underwent either CD then intraoperative post-delivery, pre-hysterectomy open vascular control of both CIA6 (CIAO group) or pre-operative, ultrasound-guided, fluoroscopy-free REBOA followed by standard CD and balloon inflation after fetal delivery (REBOA group). Intraoperative blood loss, transfusion volumes, surgical time, blood pressure, maternal and neonatal outcomes, hospitalization length and postoperative complications were compared. RESULTS The REBOA and CIAO groups included 12 and 16 women, respectively, with similar median age of 35 years and gestational age of 34-35 weeks. All REBOA catheters were successfully placed into aortic zone three under ultrasound guidance. The quantitated median intraoperative blood loss was significantly lower for the REBOA group, (541 [IQR 300-750] mL) compared to the CIAO group (3331 [IQR 1150-4750] mL (P = 0.001). As a result, the total volume of fluid and blood replacement therapy was significantly lower in the REBOA group (P < 0.05). Median surgical time in the REBOA group was less than half as long: 76 [IQR 64-89] minutes compared to 168 [IQR 90-222] minutes in the CIAO group (P = 0.001). None of the women with REBOA required hysterectomy, while 8/16 women in the CIAO group did (P = 0.008). Furthermore, the post-anesthesia recovery and hospital discharge times in the REBOA-group were shorter (P < 0.05). One thromboembolic complication occurred in each group. The only REBOA-associated complication was non-occlusive femoral artery thrombosis, with no surgical management required. No maternal or neonatal deaths occurred in either group. CONCLUSION Fluoroscopy-free REBOA for women with PAS is associated with improved vascular control, perioperative blood loss, the need for transfusion and hysterectomy and reduces surgical time when compared to bilateral CIAO.
Collapse
Affiliation(s)
- Oksana V Riazanova
- D.O. Ott Research Institute of Obstetrics and Gynecology, Saint-Petersburg, Russian Federation
| | - Viktor A Reva
- Kirov Military Medical Academy, Saint-Petersburg, Russian Federation.
| | - Karin A Fox
- Baylor College of Medicine, Houston, TX, USA
| | - Larisa A Romanova
- Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russian Federation
| | - Evgeniy S Kulemin
- Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russian Federation
| | - Artem D Riazanov
- Saint Petersburg State Pediatric Medical University, Ministry of Health of Russia, Saint-Petersburg, Russian Federation
| | | |
Collapse
|
15
|
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: 26] [Impact Index Per Article: 8.7] [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.
Collapse
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
| | | |
Collapse
|
16
|
Sutherland M, Shepherd A, Kinslow K, McKenney M, Elkbuli A. REBOA Use, Practices, Characteristics, and Implementations Across Various US Trauma Centers. Am Surg 2021; 88:1097-1103. [PMID: 33522260 DOI: 10.1177/0003134820988813] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hemorrhage accounts for >30% of trauma-related mortalities. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporary hemostasis in the civilian population remains controversial. We aim to investigate REBOA practices through analysis of surgeon and trauma center characteristics, implementation, patient characteristics, and overall opinions. METHODS An anonymous 30-question standardized online survey on REBOA use was administered to active trauma surgeon members of the Eastern Association for the Surgery of Trauma. RESULTS A total of 345 responses were received, and 130/345 (37.7%) reported REBOA being favorable, 42 (12.2%) reported REBOA unfavorably, and 173 (50.1%) were undecided. The majority of respondents (87.6%) reported REBOA performance in the trauma bay. 170 (49.3%) of respondents reported having deployed REBOA at least once over the past 2 years. 80.0% reported blunt trauma being the most common mechanism of injury in REBOA patients. Resuscitative endovascular balloon occlusion of the aorta deployment in zone 3 of the aorta was significantly higher in patients reported to suffer a pelvic fracture or pelvic hemorrhage, whereas REBOA deployment in zone 1 was significantly higher among patients reported to suffer hepatic, splenic, or other intra-abdominal hemorrhage (P < .05). CONCLUSION Among survey respondents, frequency of REBOA use was low along with knowledge of clear indications for use. While current REBOA usage among respondents appeared to model current guidelines, additional research regarding REBOA indications, ideal patient populations, and outcomes is needed in order to improve REBOA perception in trauma surgeons and increase frequency of use.
Collapse
Affiliation(s)
- Mason Sutherland
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Aaron Shepherd
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Kyle Kinslow
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| | - Mark McKenney
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA.,Department of Surgery, University of South Florida, Tampa, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, 14506Kendall Regional Medical Center, Miami, FL, USA
| |
Collapse
|
17
|
Nieto-Calvache AJ, Hidalgo-Cardona A, Lopez-Girón MC, Rodriguez F, Ordoñez C, Garcia AF, Mejia M, Pabón-Parra MG, Burgos-Luna JM. Arterial thrombosis after REBOA use in placenta accreta spectrum: a case series. J Matern Fetal Neonatal Med 2020; 35:4031-4034. [PMID: 33207992 DOI: 10.1080/14767058.2020.1846178] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The use of resuscitative endovascular balloon of the aorta (REBOA) is a useful strategy for bleeding control in placenta accreta spectrum (PAS) management. The incidence of complications associated with this procedure is variable. We report three cases of arterial thrombosis associated with REBOA, and we also analyze the factors that facilitated its occurrence. CASE REPORT Three women with PAS, presented common femoral and external iliac arterial thrombosis after REBOA use. Among the contributing factors probably associated with thrombosis, we identified the absence of ultrasound guidance for vascular access and the not using of heparin during aortic occlusion. CONCLUSIONS REBOA use is not exempt from complications and must be performed by experienced groups applying strategies to reduce the risks of complications.
Collapse
Affiliation(s)
| | | | | | - Fernando Rodriguez
- Fundación Valle del Lili, Trauma and Emergency Surgery Department, Cali, Colombia
| | - Carlos Ordoñez
- Fundación Valle del Lili, Trauma and Emergency Surgery Department, Cali, Colombia
| | - Alberto F Garcia
- Fundación Valle del Lili, Trauma and Emergency Surgery Department, Cali, Colombia
| | - Mauricio Mejia
- Radiology Department, Fundación Valle del Lili, Cali, Colombia
| | | | - Juan M Burgos-Luna
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia
| |
Collapse
|
18
|
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.
Collapse
|
19
|
Herbert K, Buchbinder L, Seshachellam V, Lee L. Resuscitative Endovascular Balloon Occlusion of the Aorta and Concomitant Tranexamic Acid for Cesarean Hysterectomy Complicated by Common Femoral Artery Thrombosis: A Case Report. Cureus 2020; 12:e11197. [PMID: 33269128 PMCID: PMC7704019 DOI: 10.7759/cureus.11197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2020] [Indexed: 11/06/2022] Open
Abstract
With increasing cesarean delivery rates, placenta accreta spectrum (PAS) disorders are occurring more frequently and represent a significant cause of peripartum hemorrhage. Different modalities have been explored to control blood loss during cesarean hysterectomies for PAS disorders, including administration of tranexamic acid (TXA) and balloon occlusion strategies. We present a case of a cesarean hysterectomy for a placenta percreta with the use of TXA and arterial balloon occlusion complicated by a lower extremity arterial thrombus requiring emergent thrombectomy. The outcome of this case suggests using caution with concomitant use of TXA and arterial balloon occlusion.
Collapse
Affiliation(s)
- Katherine Herbert
- Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, USA
| | - Lindsey Buchbinder
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Vishwas Seshachellam
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| | - Linden Lee
- Department of Anesthesiology, McGovern Medical School University of Texas Health Science Center, Houston, USA
| |
Collapse
|
20
|
Whittington JR, Pagan ME, Nevil BD, Kalkwarf KJ, Sharawi NE, Hughes DS, Sandlin AT. Risk of vascular complications in prophylactic compared to emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) in the management of placenta accreta spectrum. J Matern Fetal Neonatal Med 2020; 35:3049-3052. [PMID: 32781879 DOI: 10.1080/14767058.2020.1802717] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare prophylactic and emergent resuscitative endovascular balloon occlusion of the aorta (REBOA) catheter placement in the management of placenta accreta spectrum (PAS). STUDY DESIGN Retrospective chart review of all patients with PAS (January 2018 to January 2020) at a single tertiary center who underwent prophylactic or emergent REBOA for cesarean hysterectomy for PAS. RESULTS A total of 16 pregnant patients with PAS underwent percutaneous REBOA placement by acute care surgeons in collaboration with a multi-disciplinary PAS team. The REBOA catheter was placed prophylactically in 11 cases and emergently in 5 cases. No complications occurred in the prophylactic placement group. In the emergent placement group, 3 of 4 surviving patients had vascular access site complications requiring intervention. CONCLUSION A multidisciplinary approach for the management of PAS utilizing REBOA is feasible in the setting of both planned and emergent cesarean hysterectomy and can aid in the control of acute hemorrhage. The risk for vascular access site complications related to REBOA catheter placement is higher in the emergent setting compared to prophylactic placement.
Collapse
Affiliation(s)
- Julie R Whittington
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Megan E Pagan
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bryan D Nevil
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle J Kalkwarf
- Department of Surgery, Division of Acute Care Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Nadir El Sharawi
- Department of Anesthesia, Division of Obstetric Anesthesia, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Dawn S Hughes
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam T Sandlin
- Department of Obstetrics & Gynecology, Division of Maternal Fetal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
21
|
Ji SM, Cho C, Choi G, Song J, Kwon MA, Park JH, Kim S. Successful management of uncontrolled postpartum hemorrhage due to morbidly adherent placenta with Resuscitative endovascular balloon occlusion of the aorta during emergency cesarean section - A case report. Anesth Pain Med (Seoul) 2020; 15:314-318. [PMID: 33329830 PMCID: PMC7713836 DOI: 10.17085/apm.19051] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 08/30/2019] [Accepted: 10/11/2019] [Indexed: 11/23/2022] Open
Abstract
Background Morbidly adherent placenta (MAP) may cause life-threatening postpartum hemorrhage (PPH) requiring massive transfusions. Furthermore, it could endanger the lives of both mother and baby. Despite various efforts, such as adjuvant endovascular embolization and hysterectomy, massive PPH due to MAP still occurs and is difficult to overcome. Case Herein, we described the case of a 40-year-old woman with placenta previa totalis who experienced massive bleeding during a cesarean section. We used resuscitative endovascular balloon occlusion of the aorta (REBOA) and it improved the condition of the surgical field and the hemodynamic stability of the patient temporarily. The patient was successfully managed without further complications. Conclusions REBOA can be used as a rescue procedure for uncontrolled bleeding situations in patients with MAPs. Anesthesiologists should consider and recommend REBOA as another resuscitative therapeutic option in the case of massive PPH.
Collapse
Affiliation(s)
- Sung Mi Ji
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Chaemin Cho
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Gunhwa Choi
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Jaegyok Song
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Min A Kwon
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Jeong Heon Park
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| | - Seokkon Kim
- Department of Anesthesiology and Pain Medicine, Dankook University College of Medicine, Cheonan, Korea
| |
Collapse
|
22
|
Nieto-Calvache AJ, López-Girón MC, Nieto-Calvache A, Messa-Bryon A, Benavides-Calvache JP, Burgos-Luna JM. A nationwide survey of centers with multidisciplinary teams for placenta accreta patient care in Colombia, observational study. J Matern Fetal Neonatal Med 2020; 35:2331-2337. [PMID: 32627610 DOI: 10.1080/14767058.2020.1786052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction: MAP is associated with severe morbidity and maternal mortality. Therefore, it requires that patients with this condition to be attended in centers that have trained personnel and specific infrastructure. We aimed to identify the hospitals in Colombia that count on the minimum amount of medical specialties to manage this pathological condition and describe their general care practices.Methodology: Observational study in 87 obstetric tertiary care centers in Colombia. The requested information was collected using a predesigned survey, applied to the reported hospitals, and stored in an electronic database.Results: Eighty-six hospitals were identified as possessing the capacity to care for women with accreta, of which 71 provided information (82.55% compliance). Although 83.09% of hospitals choose to treat patients with accreta, only 36.6% has a fixed group of specialists, 32.21% did not have interventional radiology, 25.36% did not have a blood bank, and 67.79% did not have intraoperative cell recovery devices; 77.46% of the surveyed hospitals had cared for five or fewer patients with accreta per year.Conclusion: Most hospitals manage a low number of MAP cases per year, which are handled by shift specialists and not by a fixed group of professionals, which increases the difficulty of achieving expertise.
Collapse
Affiliation(s)
- Albaro J Nieto-Calvache
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia.,Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
| | | | | | - Adriana Messa-Bryon
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia.,Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
| | | | - Juan M Burgos-Luna
- Fundación Valle del Lili, Abnormally Invasive Placenta Clinic, Cali, Colombia.,Clinical Postgraduate Department, Universidad Icesi, Cali, Colombia
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Ribeiro Júnior MAF, Maurício AD, Costa CTK, Néder PR, Augusto SDS, Di-Saverio S, Brenner M. Expanding indications and results for the use of resuscitative endovascular balloon occlusion of the aorta - REBOA. ACTA ACUST UNITED AC 2019; 46:e20192334. [PMID: 31859727 DOI: 10.1590/0100-6991e-20192334] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 09/01/2019] [Indexed: 08/29/2023]
Abstract
Currently, resuscitative endovascular balloon occlusion of the aorta (REBOA) is used in trauma surgery for controlling non-compressible torso hemorrhages, as a less invasive option and with fewer physiologic disturbances compared with an invasive emergent thoracotomy for aortic cross-clamping. This can allow improvements in hemodynamic parameters until definitive surgery is performed. REBOA is also used in trauma to prevent hemodynamic collapse in patients who are in severe hemorrhagic shock, as a method to maintain perfusion of the brain and heart while decreasing distal bleeding until hemorrhage control can take place. The major complications reported are acute kidney injury, lower leg amputations, and even death. As experience with REBOA in emergency surgery grows, new indications have been described in the literature. The aim of this study was to assess the expansion of the use of REBOA in other areas of medicine, as well as evaluating the current published series. We performed an online search of PubMed, Medline and SciELO with the term "REBOA" in the last five years, and the articles included were the 14 specifically describing the use of REBOA for non-traumatic conditions. The results suggest that the use of REBOA led to improved bleeding control and increased arterial pressure, reducing blood transfusion requirements and allowing patients to survive to definitive treatment of injuries. In conclusion, the expanded use of REBOA for non-traumatic emergencies appears to be effective. However, prospective studies and well-established protocols for specific indications should be developed to maximize patient outcomes.
Collapse
Affiliation(s)
- Marcelo Augusto Fontenelle Ribeiro Júnior
- Hospital Moriah, Serviço de Cirurgia do Trauma, São Paulo, SP, Brasil.,Instituto de Assistência Médica ao Servidor Público Estadual de São Paulo (IAMSPE), Programa de de Pós-Graduação Stricto sensu em Ciências da Saúde, São Paulo, SP, Brasil
| | | | | | | | | | - Salomone Di-Saverio
- Cambridge University NHS Foundation Trust, Cambridge Biomedical Campus, Department of Surgery, Cambridge, UK, Inglaterra
| | - Megan Brenner
- Riverside University Health System, Surgical Research, Moreno Valley, CA, Estados Unidos da América
| |
Collapse
|
25
|
Nieto-Calvache AJ, Salas LF, Duran EJ, Benavides SO, Ordoñez-Delgado CA, Rodriguez-Holguin F. Estimation of fetal radiation absorbed dose during the prophylactic use of aortic occlusion balloon for abnormally invasive placenta. J Matern Fetal Neonatal Med 2019; 34:3181-3186. [PMID: 31630590 DOI: 10.1080/14767058.2019.1678144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
PURPOSE Abnormally invasive placenta is an important cause of maternal morbidity, and its primary complication is massive bleeding. Strategies for preventing bleeding include arterial endovascular occlusion. One concern with the use of intra-arterial occlusion balloons is radiation exposure to the fetus, which occurs while determining balloon position. In this study, we sought to determine the radiation absorbed dose by the fetus during intra-aortic occlusion balloon placement in patients with abnormally invasive placenta. MATERIALS AND METHODS We estimated the fetal absorbed dose and the entrance skin dose in the vaginal fundus and lumbar skin, respectively, using thermoluminescent dosimeter crystals, during intra-aortic balloon positioning using the mobile X-ray image intensifier system (C-arm) in digital radiography mode, directly in surgery room, without transfer to angiographic suite. We also performed a mannequin-based simulation to validate the entrance skin dose measurement technique. RESULTS Ten women undergoing surgical management of an abnormally invasive placenta, in whom the location of the intra-aortic occlusion balloon was verified using plain radiography with C-arm in the surgery room, were included in the study. Following maternal and fetal radiation exposure, the entrance skin dose and radiation absorbed dose by the fetus were 1.31 ± 0.96 mGy and 0.27 ± 0.28 mGy, respectively, with radiation exposure durations of <1 s. CONCLUSIONS There were no complications with the use of REBOA, the radiation absorbed dose by the fetus, entrance skin dose, and duration of radiation exposure during intra-aortic occlusion balloon placement were lower than those reported for other vascular occlusion techniques, being this a safe procedure.
Collapse
Affiliation(s)
- A J Nieto-Calvache
- Abnormally Invasive Placenta Clinic, High Complexity Obstetric Unit, Fundación Valle Del Lili, Cali, Colombia.,Health Science Faculty, Universidad ICESI, Cali, Colombia
| | - L F Salas
- Department of Medical Physics and Radiation Protection, Fundación Valle de Lili, Cali, Colombia
| | - E J Duran
- Department of Medical Physics and Radiation Protection, Fundación Valle de Lili, Cali, Colombia.,Department of Physics, Universidad Del Cauca, Popayán, Colombia
| | - S O Benavides
- Department of Medical Physics and Radiation Protection, Fundación Valle de Lili, Cali, Colombia
| | - C A Ordoñez-Delgado
- Abnormally Invasive Placenta Clinic, High Complexity Obstetric Unit, Fundación Valle Del Lili, Cali, Colombia.,Department of Trauma Surgery, Fundación Valle Del Lili, Cali, Colombia
| | - F Rodriguez-Holguin
- Abnormally Invasive Placenta Clinic, High Complexity Obstetric Unit, Fundación Valle Del Lili, Cali, Colombia.,Department of Trauma Surgery, Fundación Valle Del Lili, Cali, Colombia
| |
Collapse
|