Colonic ischemia possibly due to resuscitative endovascular balloon occlusion of the aorta (REBOA) used to manage amniotic fluid embolism: a case report

Combined effect of intermittent hemostasis and a modified external hemorrhage control device in a lethal swine model

Background

Non-compressible torso hemorrhage (NCTH) presents the ultimate challenge in pre-hospital care. While external hemorrhage control devices (EHCDs) such as the Abdominal Aortic and Junctional Tourniquet (AAJT) and SAM Junctional Tourniquet (SJT) have been invented, the current design and application strategy requires further improvement. Therefore, researchers devised a novel apparatus named Modified EHCD (M-EHCD) and implemented intermittent hemostasis (IH) as a preventive measure against ischemia-reperfusion injury. The objective of this study was to ascertain the combined effect of M-EHCD and IH on the hemostatic effect of NCTH.

Methods

Eighteen swine were randomized to M-EHCD, AAJT or SJT. The NCTH model was established by inducing Class Ⅲ hemorrhagic shock and performing a hemi-transection of common femoral artery (CFA). EHCDs were rapidly fastened since the onset of free bleeding (T0min). The IH strategy was implemented by fully releasing M-EHCD at T40min, T70min and T100min, respectively, whereas AAJT and SJT maintained continuous hemostasis (CH) until T120min. All groups underwent CFA bridging at T110min, and EHCDs were removed at T120min. Reperfusion lasted for 60 min, after which euthanasia was performed. Hemodynamics, intra-vesical pressure (IVP), and blood samples were collected periodically. Histological examinations were also conducted.

Results

M-EHCD demonstrated the fastest application time (M-EHCD: 26.38 ± 6.32s vs. SJT: 30.84 ± 5.62s vs. AAJT: 54.28 ± 5.45s, P < 0.001) and reduced free blood loss (M-EHCD: 17.77 ± 9.85g vs. SJT: 51.80 ± 33.70g vs. AAJT: 115.20 ± 61.36g, P = 0.011) compared to SJT and AAJT. M-EHCD exhibited inhibitory effects on heart rate (M-EHCD: 91.83 ± 31.61bpm vs. AAJT: 129.00 ± 32.32bpm vs. SJT: 135.17 ± 21.24bpm, P = 0.041) and shock index. The device's external pressure was lowest in M-EHCD and highest in SJT (P = 0.001). The resultant increase in IVP were still the lowest in M-EHCD (M-EHCD: -0.07 ± 0.45 mmHg vs. AAJT: 27.04 ± 5.03 mmHg vs. SJT: 5.58 ± 2.55 mmHg, P < 0.001). Furthermore, M-EHCD caused the least colonic injury (M-EHCD: 1.17 ± 0.41 vs. AAJT: 2.17 ± 0.41 vs. SJT: 2.17 ± 0.41, P = 0.001). The removal of M-EHCD showed the slightest impact on pH (P < 0.001), while AAJT group was more susceptible to the lethal triad based on the arterial lactate and thrombelastogram results.

Conclusions

M-EHCD + IH protected the organs and reduced the risk of the lethal triad by decreasing disruptions to IVP, hemodynamics, acid-base equilibrium and coagulation. M-EHCD + IH was superior to the hemostatic safety and efficacy of AAJT/SJT + CH.

Resuscitative endovascular balloon occlusion of the aorta: A novel approach for treating amniotic fluid embolism with disseminated intravascular coagulopathy-A report of two cases

We present two critical cases of life-threatening postpartum hemorrhage (PPH) due to amniotic fluid embolism (AFE) complicated by disseminated intravascular coagulopathy (DIC). These cases are the first to show the effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for patient survival. In Case 1, the patient, experiencing critical conditions with severe PPH and DIC despite conventional treatments, including rapid blood transfusion and fibrinogen concentrate, was air-transferred to our hospital, where REBOA was promptly employed before hysterectomy was completed. Case 2 involved an ambulance-transferred patient with massive PPH and DIC despite conventional treatments. Prehospital REBOA was performed to prevent cardiac arrest during transfer, and hysterectomy was performed in the hospital. Given the rapid deterioration associated with AFE, REBOA can serve as a bridge until complete hemostasis to maintain vital signs and control bleeding in patients unresponsive to standard therapies before hemostatic interventions or during transfer.

Partial Versus Complete Resuscitative Endovascular Balloon Occlusion of the Aorta in Exsanguinating Trauma Patients With Non-Compressible Torso Hemorrhage

Hemorrhage is a major cause of death globally, yet our options to control the condition have remained limited. The standard intervention for patients suffering from a non-compressible torso hemorrhage (NCTH) typically involves resuscitative thoracotomy (RT) with aortic cross-clamping. Apart from being extraordinarily invasive, the survival rates for this procedure remain low. Over the years, research has surfaced that offers much promise regarding the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) in exsanguinating patients. Although this type of procedure is not yet universally recognized as a gold standard, it holds some hope for the development of additional research regarding how we can make use of this advancement to improve survival in trauma patients. Complete REBOA (c-REBOA) has not gained wide acceptance due to the undeniable effects it has on normal physiology, metabolic effects, long-term complications, and mortality. Partial REBOA (p-REBOA) is not yet fully validated by research but could potentially be the answer to our problem. The critical question that we should address at this juncture is as follows: how can we improve the survival of patients with an NCTH in the least invasive way possible, while also reducing the feared complications associated with c-REBOA?