1
|
Elansary NN, Stonko DP, Treffalls RN, Abdou H, Madurska MJ, Morrison JJ. Class of hemorrhagic shock is associated with progressive diastolic coronary flow reversal and diminished left ventricular function. Front Physiol 2022; 13:1033784. [PMID: 36589436 PMCID: PMC9795012 DOI: 10.3389/fphys.2022.1033784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction: The relationship between coronary artery flow and left ventricular (LV) function during hemorrhagic shock remains unknown. The aim of this study was to quantify coronary artery flow directionality alongside left ventricular function through the four classes of hemorrhage shock. Methods: Following baseline data collection, swine were exsanguinated into cardiac arrest via the femoral artery using a logarithmic bleed, taking each animal through the four classes of hemorrhagic shock based on percent bleed (class I: 15%; class II: 15%-30%; class III: 30%-40%; class IV: >40%). Telemetry data, left ventricular pressure-volume loops, and left anterior descending artery flow tracings over numerous cardiac cycles were collected and analyzed for each animal throughout. Results: Five male swine (mean 72 ± 12 kg) were successfully exsanguinated into cardiac arrest. Mean left ventricular end-diastolic volume, end-diastolic pressure, and stroke work decreased as the hemorrhagic shock class progressed (p < 0.001). The proportion of diastole spent with retrograde coronary flow was also associated with class of hemorrhagic shock (mean 5.6% of diastole in baseline, to 63.9% of diastole in class IV; p < 0.0001), worsening at each class from baseline through class IV. Preload recruitable stroke work (PRSW) decreased significantly in classes II through IV (p < 0.001). Systemic Vascular Resistance (SVR) is associated with class of hemorrhage shock (p < 0.001). Conclusion: With progressive classes of hemorrhagic shock left ventricular function progressively decreased, and the coronary arteries spent a greater proportion of diastole in retrograde flow, with progressively more negative total coronary flow. Preload recruitable stroke work, a load-independent measure of inotropy, also worsened in severe hemorrhagic shock, indicating the mechanism extends beyond the drop in preload and afterload alone.
Collapse
Affiliation(s)
- Noha N. Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,Department of Surgery, University of Maryland Medical System, Baltimore, MD, United States
| | - David P. Stonko
- Department of Surgery, University of Maryland Medical System, Baltimore, MD, United States
| | - Rebecca N. Treffalls
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Marta J. Madurska
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Jonathan J. Morrison
- Division of Vascular and Endovascular Surgery, Department of Surgery, Mayo Clinic, MN, United States,*Correspondence: Jonathan J. Morrison,
| |
Collapse
|
2
|
Madurska MJ, Abdou H, Elansary NN, Edwards J, Patel N, Stonko DP, Richmond MJ, Scalea TM, Rasmussen TE, Morrison JJ. Whole Blood Selective Aortic Arch Perfusion for Exsanguination Cardiac Arrest: Assessing Myocardial Tolerance to the Duration of Cardiac Arrest. Shock 2022; 57:243-250. [PMID: 35759304 DOI: 10.1097/shk.0000000000001946] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Selective aortic arch perfusion (SAAP) is an endovascular technique that consists of aortic occlusion with perfusion of the coronary and cerebral circulation. It been shown to facilitate return of spontaneous circulation (ROSC) after exanguination cardiac arrest (ECA), but it is not known how long arrest may last before the myocardium can no longer be durably recovered. The aim of this study is to assess the myocardial tolerance to exsanguination cardiac arrest before successful ROSC with SAAP. METHODS Male adult swine (n = 24) were anesthetized, instrumented, and hemorrhaged to arrest. Animals were randomized into three groups: 5, 10, and 15 min of cardiac arrest before resuscitation with SAAP. Following ROSC, animals were observed for 60 min in a critical care environment. Primary outcomes were ROSC, and survival at 1-h post-ROSC. RESULTS Shorter cardiac arrest time was associated with higher ROSC rate and better 1-h survival. ROSC was obtained for 100% (8/8) of the 5-min ECA group, 75% (6/8) of the 10-min group, 43% (3/7) of the 15-min group (P = 0.04). One-hour post-ROSC survival was 75%, 50%, and 14% in 5-, 10-, and 15-min groups, respectively (P = 0.02). One-hour survivors in the 5-min group required less norepinephrine (1.31 mg ± 0.83 mg) compared with 10-SAAP (0.76 mg ± 0.24 mg), P = 0.008. CONCLUSION Whole blood SAAP can accomplish ROSC at high rates even after 10 min of unsupported cardiac arrest secondary to hemorrhage, with some viability beyond to 15 min. This is promising as a tool for ECA, but requires additional optimization and clinical trials.Animal Use Protocol, IACUC: 0919015.
Collapse
Affiliation(s)
- Marta J Madurska
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
| | - Hossam Abdou
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Noha N Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Joseph Edwards
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Neerav Patel
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - David P Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Michael J Richmond
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
- Henry-Jackson Foundation, Bethesda, Maryland
| | - Thomas M Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jonathan J Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| |
Collapse
|
3
|
Edwards J, Abdou H, Patel N, Madurska MJ, Poe K, Bonin JE, Richmond MJ, Rasmussen TE, Morrison JJ. The functional vascular anatomy of the swine for research. Vascular 2022; 30:392-402. [PMID: 33813971 DOI: 10.1177/1708538121996500] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Swine (Sus Scrofa) are utilized broadly in research settings, given similarities to human vessel size and function; however, there are some important differences for clinicians to understand in order to interpret and perform translational research. This review article uses angiograms acquired in the course of a translational research program to present a description of the functional anatomy of the swine. METHODS Digital subtraction angiography and computed tomography angiography were obtained throughout the course of multiple studies utilizing power injection with iodinated contrast. Subtracted two-dimensional images and three-dimensional multiplanar reformations were utilized post image acquisition to create maximal intensity projections and three-dimensional renderings of using open-source software (OsiriX). These imaging data are presented along with vessel measurements for reference. RESULTS An atlas highlighting swine vascular anatomy, with an emphasis on inter-species differences that may influence how studies are conducted and interpreted, was compiled. CONCLUSIONS Swine are utilized in broad-reaching fields for preclinical research. While many similarities between human and swine vasculature exist, there are important differences to consider when conducting and interpreting research. This review article highlights these differences and presents accompanying images to inform clinicians gaining experience in swine research.
Collapse
Affiliation(s)
- Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Kelly Poe
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Janet E Bonin
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Michael J Richmond
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| |
Collapse
|
4
|
Harfouche MN, Madurska MJ, Elansary N, Abdou H, Lang E, DuBose JJ, Kundi R, Feliciano DV, Scalea TM, Morrison JJ. Resuscitative endovascular balloon occlusion of the aorta associated with improved survival in hemorrhagic shock. PLoS One 2022; 17:e0265778. [PMID: 35324991 PMCID: PMC8947416 DOI: 10.1371/journal.pone.0265778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/02/2022] [Indexed: 11/24/2022] Open
Abstract
Background Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is controversial as a hemorrhage control adjunct due to lack of data with a suitable control group. We aimed to determine outcomes of trauma patients in shock undergoing REBOA versus no-REBOA. Methods This single-center, retrospective, matched cohort study analyzed patients ≥16 years in hemorrhagic shock without cardiac arrest (2000–2019). REBOA (R; 2015–2019) patients were propensity matched 2:1 to historic (H; 2000–2012) and contemporary (C; 2013–2019) groups. In-hospital mortality and 30-day survival were analyzed using chi-squared and log rank testing, respectively. Results A total of 102,481 patients were included (R = 57, C = 88,545, H = 13,879). Propensity scores were assigned using age, race, mechanism, lowest systolic blood pressure, lowest Glasgow Coma Score (GCS), and body region Abbreviated Injury Scale scores to generate matched groups (R = 57, C = 114, H = 114). In-hospital mortality was significantly lower in the REBOA group (19.3%) compared to the contemporary (35.1%; p = 0.024) and historic (44.7%; p = 0.001) groups. 30-day survival was significantly higher in the REBOA versus no-REBOA groups. Conclusion In a high-volume center where its use is part of a coordinated hemorrhage control strategy, REBOA is associated with improved survival in patients with noncompressible torso hemorrhage.
Collapse
Affiliation(s)
- Melike N. Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
- * E-mail:
| | | | - Noha Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Eric Lang
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Joseph J. DuBose
- Dell Medical School, University of Texas at Austin, Austin, Texas, United States of America
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - David V. Feliciano
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Thomas M. Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| | - Jonathan J. Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland, United States of America
| |
Collapse
|
5
|
Herrold JA, Adnan S, Romagnoli A, Madurska MJ, Betzold R, DuBose J, Scalea T, Morrison JJ. Certification in endovascular hemostasis for trauma surgeons: Possible and practical? J Trauma Acute Care Surg 2021; 91:775-780. [PMID: 34108419 DOI: 10.1097/ta.0000000000003234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Endovascular hemostasis is commonplace with many practitioners providing services. Accruing sufficient experience during training could allow acute care surgeons (ACSs) to expand their practice. We quantified case load and training opportunities at our center, where dedicated dual-trained ACS/vascular surgery faculty perform these cases. Our aim was to assess whether ACS fellows could obtain sufficient experience in 6 months of their fellowship in order to certify in these techniques, per the requirements of other specialties. METHODS We performed a retrospective case series where we reviewed 6 years (2013-2018) of endovascular activity at an academic, level I trauma center quantifying arterial access, angiography, embolization, stent and stent graft placement, and IVC filter procedures. This was compared with the certification requirements for interventional radiology, vascular surgery, cardiothoracic surgery, and interventional cardiology. RESULTS Between 2013 and 2018, 1,179 patients with a mean ± SD Injury Severity Score of 22.47 ± 13.24, underwent 4960 procedures. Annual rates per procedure, expressed as median (interquartile range), were arterial access 193.5 (181-195.5), diagnostic angiography 352 (321.5-364.5), embolization 90.5 (89.25-93.25), stent placement 24 (13.5-29.25), and IVC filter procedures 16.5 (10-23.75). Our 6-month case volume exceeded or was within 85% of the required number of cases for vascular surgery and interventional radiology training, with the exception of stent-graft deployment for both specialties, and therapeutic procedures for vascular surgery. CONCLUSION The case volume at a large trauma center with a dedicated endovascular trauma service is sufficient to satisfy the case requirements for endovascular certification. Our trainees are already acquiring this experience informally. An endovascular trauma curriculum should now be developed to support certification within ACS fellowship training.
Collapse
|
6
|
Ronaldi AE, Madurska MJ, Bozzay JD, Polcz JE, Baer DG, Burmeister DM, White PW, Rasmussen TE, White JM. Targeted Regional Optimization: Increasing the Therapeutic Window for Endovascular Aortic Occlusion In Traumatic Hemorrhage. Shock 2021; 56:493-506. [PMID: 34014887 DOI: 10.1097/shk.0000000000001814] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ABSTRACT Resuscitative endovascular balloon occlusion of the aorta (REBOA) allows for effective temporization of exsanguination from non-compressible hemorrhage (NCTH) below the diaphragm. However, the therapeutic window for aortic occlusion is time-limited given the ischemia-reperfusion injury generated. Significant effort has been put into translational research to develop new strategies to alleviate the ischemia-reperfusion injury and extend the application of endoaortic occlusion. Targeted regional optimization (TRO) is a partial REBOA strategy to augment proximal aortic and cerebral blood flow while targeting minimal threshold of distal perfusion beyond the zone of partial aortic occlusion. The objective of TRO is to reduce the degree of ischemia caused by complete aortic occlusion while providing control of distal hemorrhage. This review provides a synopsis of the concept of TRO, pre-clinical, translational experiences with TRO and early clinical outcomes. Early results from TRO strategies are promising; however, further studies are needed prior to large-scale implementation into clinical practice.
Collapse
Affiliation(s)
- Alley E Ronaldi
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland
| | - Joseph D Bozzay
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Jeanette E Polcz
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - David M Burmeister
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Paul W White
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Todd E Rasmussen
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Joseph M White
- Walter Reed National Military Medical Center, The Uniformed Services University of the Health Sciences, Bethesda, Maryland
| |
Collapse
|
7
|
Madurska MJ, Scalea TM, Morrison JJ. Reply. J Vasc Surg 2021; 73:741-742. [PMID: 33485504 DOI: 10.1016/j.jvs.2020.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 09/11/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md
| |
Collapse
|
8
|
Madurska MJ, Scalea TM, Morrison JJ. Reply. J Vasc Surg 2021; 73:736-737. [PMID: 33485497 DOI: 10.1016/j.jvs.2020.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Md
| |
Collapse
|
9
|
Madurska MJ, Elansary NN, Pate N, Edwards J, Richmond MJ, Scalea TM, Rasmussen TE, Morrison JJ. O10 Myocardial tolerance to exsanguination and retrieval using whole blood-selective aortic arch perfusion. Br J Surg 2021. [DOI: 10.1093/bjs/znab282.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Exsanguination cardiac arrest is the leading preventable cause of death in trauma. Treatment modalities are limited, and prognosis remains dismal. Selective aortic arch perfusion (SAAP) is an emerging endovascular resuscitation technique consisting of aortic occlusion and perfusion of coronary and cerebral circulation with oxygenated resuscitation fluid. Translational research has demonstrated promising outcomes; however, little is known about the duration of cardiac arrest beyond which the myocardium cannot be resuscitated. The aims of this study are to assess the myocardial tolerance to exsanguination cardiac arrest before successful return of spontaneous circulation (ROSC) following resuscitation with SAAP, and 1-hour survival.
Method
23 male adult swine were anaesthetised and instrumented. Controlled hemorrhage was performed until cardiac arrest defined by MAP <20 mmHg. Animals were randomized into 3 groups: 5, 10 and 15 minutes of cardiac arrest before resuscitation with SAAP. Following ROSC animals were observed for 60 minutes.
Result
Baseline characteristics were similar between groups (P > 0.05). ROSC was 100% (8/8) in the 5 min group, 75% (6/8) and 43% (3/7) in 10- and 15-min groups respectively (P = 0.042). 60 min survival was 75%, 50% and 14% in 5-, 10- and 15-min groups respectively (P = 0.015). 1-hour survivors in the 5 min group required less noradrenaline 23.6 (±7.4) compared to other animals 40.9 (±25.8), (P = 0.008).
Conclusion
Selective aortic arch perfusion is an effective resuscitative tool in eliciting ROSC in a swine model of exsanguination cardiac arrest lasting >5 min. Sustainable resuscitability using SAAP declines after 10 min of exsanguination cardiac arrest.
Take-home Message
SAAP is an emerging resuscitation technique with promising outcomes in exsanguination cardiac arrest and may be a segway to Extracorporeal life support. The time limit for resuscitability of the myocardium lies somewhere between 10 and 15 min after the start of exsanguination cardiac arrest.
Collapse
Affiliation(s)
- M J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
- Henry-Jackson Foundation, Maryland
| | - N N Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
- Henry-Jackson Foundation, Maryland
| | - N Pate
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
| | - J Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
| | - M J Richmond
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
- Henry-Jackson Foundation, Maryland
| | - T M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
| | - T E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - J J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Maryland, USA
| |
Collapse
|
10
|
Harfouche M, Abdou H, Adnan SM, Romagnoli AN, Martinson JR, Madurska MJ, Dubose JJ, Scalea TM, Morrison JJ. Integrating Endovascular and Operative Intervention in Trauma. J Surg Res 2021; 267:82-90. [PMID: 34139394 DOI: 10.1016/j.jss.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 03/15/2021] [Accepted: 04/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patterns of utilization of the hybrid operating room (hybrid-OR) in trauma have not been described. The aim of this study was to describe the sequencing and integration of endovascular and operative interventions in trauma using a hybrid-OR. MATERIALS AND METHODS This is a single-center, retrospective cohort study of trauma patients who underwent both endovascular and operative intervention (2013-2019). Patients were separated into four groups based on procedure patterns: concomitant-linked (C-L), concomitant-independent, serial-linked (S-L) and serial-independent (S-I). The groups were defined as follows: C-L - related endovascular and operative interventions in the same OR; concomitant-independent - unrelated interventions in the same OR; S-L - related interventions in separate ORs; S-I - unrelated interventions in separate ORs. Patient characteristics, procedures performed and time to angiography in each group were analyzed. RESULTS Out of 202 patients, most procedures utilizing the hybrid-OR were for hemorrhage control (84.1%) and were performed in a C-L manner (36.1%). Patients in the C-L group were most likely to undergo lower extremity revascularization and received the most transfusions. Patients in the S-L and S-I groups were more severely injured, had greater severe abdominal injury and were more likely to undergo damage control surgery and solid organ interventions, respectively. The C-L group had the highest percentage of patients to undergo angiography within 12 h (77%, P = 0.053). CONCLUSION The hybrid-OR is an ideal space for hemorrhage control in trauma, but there is room for improvement in the triage of patients with non-compressible torso hemorrhage. Current practice patterns prioritize the hybrid-OR for management of lower extremity injury and are not optimal. Use of the hybrid-OR could be improved by concomitant management of patients with severe abdominal injury requiring damage control surgery.
Collapse
Affiliation(s)
- Melike Harfouche
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Sakib M Adnan
- Department of Surgery, Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - Anna N Romagnoli
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - James R Martinson
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Joseph J Dubose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland.
| |
Collapse
|
11
|
Morrison JJ, Abdou H, Richmond M, Madurska MJ, Elansary N. Development of a Custom Extracorporeal Circuit for Endovascular Resuscitation Research. JEVTM 2021. [DOI: 10.26676/jevtm.v4i2.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: To demonstrate the utility and applicability of in vitro extracorporeal circuits in endovascular resuscitation research.
Methods: The method for building an inexpensive in vitro extracorporeal circuit for endovascular resuscitation research is described. In this study, aortic cannulas and pump combinations were evaluated in the in vitro extracorporeal circuit. Then one aortic cannula and pump set up was evaluated in a post-mortem swine model. Flow data was collected and compared among groups.
Results: The peristaltic pump generated the highest flow as compared to the other pump combinations at any given catheter size. The peristaltic pump combined with the 10 Fr cannula produced the highest flow overall at 2304 mL/min. This same combination produced a peak flow of 886 ml/min at the aortic root in the swine model.
Conclusions: The flow generated in the swine model was less than half of that generated in the in vitro model. However, all flow was channeled through one outflow tract in the in vitro model whereas the swine aorta has several branches of outflow. As such, a 50% reduction in flow or greater is anticipated at the level of the aortic root. An in vitro extracorporeal circuit for endovascular research can be built for less than $10,000, with most of the materials being reusable, and can be used to generate representative data that may be anticipated in a swine model.
Collapse
|
12
|
Abdou H, Madurska MJ, Edwards J, Patel N, Richmond MJ, Galvagno S, Kundi R, DuBose JJ, Scalea TM, Morrison JJ. A technique for open chest selective aortic arch perfusion. J Trauma Acute Care Surg 2021; 90:e158-e162. [PMID: 33496546 DOI: 10.1097/ta.0000000000003092] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Hossam Abdou
- From the R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Patel N, Abdou H, Edwards J, Elansary NN, Poe K, Richmond MJ, Madurska MJ, Rasmussen TE, Morrison JJ. Measuring Cardiac Output in a Swine Model. J Vis Exp 2021. [PMID: 34057452 DOI: 10.3791/62333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Swine are frequently used in medical research given their similar cardiac physiology to that of humans. Measuring cardiac parameters such as stroke volume and cardiac output are essential in this type of research. Contrast ventriculography, thermodilution, and pressure-volume loop (PV-loop) catheters can be used to accurately obtain cardiac performance data depending on which resources and expertise are available. For this study,five Yorkshire swine were anesthetized and intubated. Central venous and arterial access was obtained to place the necessary measurement instruments.A temperature probe was placed in the aortic root. A cold saline bolus was delivered to the right atrium and temperature deflection curve was recorded. Integration of the area under the curve allowed for the calculation of the current cardiac output.A pigtail catheter was percutaneously placed in the left ventricle and 30 mL of iodinated contrast was power injected over 2 seconds. Digital subtraction angiography images were uploaded to volumetric analysis software to calculate the stroke volume and cardiac output. A pressure volume-loop catheter was placed into the left ventricle (LV) and provided continuous pressure and volume data of the LV, which allowed the calculation of both stroke volume and cardiac output.All three methods demonstrated good correlation with each other. The PV-loop catheter and thermodilution exhibited the best correlation with a 3% error and a Pearson coefficient of 0.99, with 95% CI=0.97 to 1.1, (p=0.002). The PV-loop catheter against ventriculography also showed good correlation with a 6% error and a Pearson coefficient of 0.95, 95% CI=0.96 to 1.1 (p=0.01). Finally, thermodilution against ventriculography had a 2% error with r=0.95, 95% CI=0.93 to 1.11, (p=0.01). In conclusion, we state that the PV-loop catheter, contrast ventriculography, and thermodilution each offer certain advantages depending on the researcher's requirements. Each method is reliable and accurate for measuring various cardiac parameters in swine such as the stroke volume and cardiac output.
Collapse
Affiliation(s)
- Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System;
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System
| | - Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System
| | - Noha N Elansary
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System
| | - Kelly Poe
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System
| | - Michael J Richmond
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System
| | | | | |
Collapse
|
14
|
Edwards J, Abdou H, Madurska MJ, Patel N, Richmond MJ, Poliner D, White JM, Rasmussen TE, Scalea TM, Morrison JJ. Selective aortic arch perfusion versus open cardiac massage in exsanguination cardiac arrest: A comparison of coronary pressure dynamics in swine. Resuscitation 2021; 163:1-5. [PMID: 33857557 DOI: 10.1016/j.resuscitation.2021.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/24/2021] [Accepted: 04/01/2021] [Indexed: 10/21/2022]
Abstract
AIM To evaluate the mean aortic-right atrial pressure (AoP-RAP) gradients and mean coronary perfusion pressures (CPPs) observed during open cardiac massage (OCM) versus those obtained with selective aortic arch perfusion (SAAP) in post-mortem hypovolemic swine. METHODS Post-mortum, male swine, utilized in prior studies of hemorrhage, were included in the study. Animals were bled ∼25-50% of circulating volume prior to death. Animals either underwent clamshell thoracotomy and OCM immediately after death was confirmed (n = 6) or underwent SAAP within 5-15 min of death (n = 6). Aortic root and right atrial pressures were recorded continuously during each method of resuscitation using solid state blood pressure catheters. Representative five beat samples were extracted; short, similarly timed segments of SAAP were also extracted. Mean AoP-RAP gradient and CPPs were calculated and compared. RESULTS Mean AoP-RAP gradient and CPP were significantly higher in SAAP animals compared to OCM animals (mean ± SD; 29.1 ± 8.4 vs. 24.5 ± 5.0, p < 0.001; 28.9 ± 8.5 vs. 9.9 ± 6.0, p < 0.001). Mean CPP was not significantly different from mean AoP-RAP gradient in SAAP animals (p = 0.92); mean CPP was significantly lower than mean AoP-RAP gradient in OCM animals (p < 0.001). While 97% of SAAP segments had a CPP > 15 mmHg, only 17% of OCM segments had a CPP > 15 mmHg (p < 0.001). CONCLUSION SAAP appears to create a more favorable and efficient hemodynamic profile for obtaining ROSC when compared to OCM in this preclinical porcine study.
Collapse
Affiliation(s)
- Joseph Edwards
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Hossam Abdou
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Neerav Patel
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Michael J Richmond
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - David Poliner
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Joseph M White
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, USA.
| |
Collapse
|
15
|
Abstract
ABSTRACT The emerging concept of endovascular resuscitation applies catheter-based techniques in the management of patients in shock to manipulate physiology, optimize hemodynamics, and bridge to definitive care. These interventions hope to address an unmet need in the care of severely injured patients, or those with refractory non-traumatic cardiac arrest, who were previously deemed non-survivable. These evolving techniques include Resuscitative Endovascular Balloon Occlusion of Aorta, Selective Aortic Arch Perfusion, and Extracorporeal Membrane Oxygenation and there is a growing literature base behind them. This review presents the up-to-date techniques and interventions, along with their application, evidence base, and controversy within the new era of endovascular resuscitation.
Collapse
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - James D Ross
- Division of Trauma and Acute Care Surgery, Oregon Health and Science University, Portland, Oregon
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, Maryland
| |
Collapse
|
16
|
Madurska MJ, McLenithan A, Scalea TM, Kundi R, White JM, Morrison JJ, DuBose JJ. A feasibility study of partial REBOA data in a high-volume trauma center. Eur J Trauma Emerg Surg 2021; 48:299-305. [PMID: 33399878 DOI: 10.1007/s00068-020-01561-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/19/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporize patients with infradiaphragmatic hemorrhage. Current guidelines advise < 30 min, to avoid ischemia/ reperfusion injury, whenever possible. The technique of partial REBOA (P-REBOA) has been developed to minimize the effects of distal ischemia. This study presents our clinical experience with P-REBOA, comparing outcomes to complete occlusion (C-REBOA). PATIENTS AND METHODS Retrospective analysis of patients' electronic data and local REBOA registry between January 2016 and May 2019. INCLUSION CRITERIA adult trauma patients who received Zone I C-REBOA or P-REBOA for infradiaphragmatic hemorrhage, who underwent attempted exploration in the operating room. Comparison of outcomes based on REBOA technique (P-REBOA vs C-REBOA) and occlusion time (> 30 min, vs ≤ 30 min) RESULTS: 46 patients were included, with 14 treated with P-REBOA. There were no demographic differences between P-REBOA and C-REBOA. Prolonged (> 30 min) REBOA (regardless of type of occlusion) was associated with increased mortality (32% vs 0%, p = 0.044) and organ failure. When comparing prolonged P-REBOA with C-REBOA, there was a trend toward lower ventilator days [19 (11) vs 6 (9); p = 0.483] and dialysis (36.4% vs 16.7%; p = 0.228) with significantly less vasopressor requirement (72.7% vs 33.3%; p = 0.026). CONCLUSION P-REBOA can be delivered in a clinical setting, but is not currently associated with improved survival in prolonged occlusion. In survivors, there is a trend toward lower organ support needs, suggesting that the technique might help to mitigate ischemic organ injury. More clinical data are needed to clarify the benefit of partial occlusion REBOA.
Collapse
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Ashley McLenithan
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, 19131, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Joseph M White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences and The Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA.
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| |
Collapse
|
17
|
Morrison JJ, Abdou H, Richmond M, Madurska MJ, Elansary N. Development of a Custom Extracorporeal Circuit for Endovascular Resuscitation Research. JEVTM 2020. [DOI: 10.26676/jevtm.v40i(2).160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background: To demonstrate the utility and applicability of in vitro extracorporeal circuits in endovascular resuscitation research.
Methods: The method for building an inexpensive in vitro extracorporeal circuit for endovascular resuscitation research is described. In this study, aortic cannulas and pump combinations were evaluated in the in vitro extracorporeal circuit. Then one aortic cannula and pump set up was evaluated in a post-mortem swine model. Flow data was collected and compared among groups.
Results: The peristaltic pump generated the highest flow as compared to the other pump combinations at any given catheter size. The peristaltic pump combined with the 10 Fr cannula produced the highest flow overall at 2304 mL/min. This same combination produced a peak flow of 886 ml/min at the aortic root in the swine model.
Conclusions: The flow generated in the swine model was less than half of that generated in the in vitro model. However, all flow was channeled through one outflow tract in the in vitro model whereas the swine aorta has several branches of outflow. As such, a 50% reduction in flow or greater is anticipated at the level of the aortic root. An in vitro extracorporeal circuit for endovascular research can be built for less than $10,000, with most of the materials being reusable, and can be used to generate representative data that may be anticipated in a swine model.
Collapse
|
18
|
Madurska MJ, Abdou H, Richmond MJ, Elansary NN, Wong PF, Rasmussen TE, Scalea TM, Morrison JJ. Development of a Selective Aortic Arch Perfusion System in a Porcine Model of Exsanguination Cardiac Arrest. J Vis Exp 2020. [PMID: 32925879 DOI: 10.3791/61573] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Hemorrhage constitutes the majority of potentially preventable deaths from trauma. There is growing interest in endovascular resuscitation techniques such as selective aortic arch perfusion (SAAP) for patients in cardiac arrest. This involves active perfusion of the coronary circulation via a thoracic aortic balloon catheter and is approaching clinical application. However, the technique is complex and requires refinement in animal models before human use can be considered. This paper describes a large animal model of exsanguination cardiac arrest treated with a bespoke SAAP system. Swine were anesthetized, instrumented and a splenectomy was performed before a controlled, logarithmic exsanguination was initiated. Animals were heparinized and the shed blood collected in a reservoir. Once cardiac arrest was observed, the blood was pumped through an extra-corporeal circuit into an oxygenator and then delivered through a 10 Fr balloon catheter placed in the thoracic aorta. This resulted in the return of a spontaneous circulation (ROSC) as demonstrated by ECG and aortic root pressure waveform. This model and accompanying SAAP system allow for standardized and reproducible recovery from exsanguination cardiac arrest.
Collapse
Affiliation(s)
| | | | | | | | - Peng F Wong
- Department of Vascular Surgery, The James Cook University Hospital
| | | | | | | |
Collapse
|
19
|
Madurska MJ, Scalea TM, Morrison JJ. Response to Re "A Comparison of Transradial and Transfemoral Access for Splenic Angio-Embolisation in Trauma: A Single Centre Experience". Eur J Vasc Endovasc Surg 2020; 61:347-348. [PMID: 32753306 DOI: 10.1016/j.ejvs.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Centre, University of Maryland Medical System, MD, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Centre, University of Maryland Medical System, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Centre, University of Maryland Medical System, MD, USA.
| |
Collapse
|
20
|
Madurska MJ, Anderson RG, Anderson DJ, McNeill CJ, Jansen JO, Stuart WP, Morrison JJ. Mesenteric vascular disease: A population-based cohort study. Vascular 2020; 29:54-60. [PMID: 32605533 DOI: 10.1177/1708538120937954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Mesenteric vascular disease carries a high risk of mortality and morbidity; however, due to obscure clinical presentation, it can be under-recognized. Currently, epidemiology of mesenteric vascular disease remains poorly defined. The aim of this study is to analyze changes in Scottish mortality rates from mesenteric vascular disease overtime. METHODS This is a retrospective, longitudinal population-based cohort study using data extracted from death certificates and Scottish Index of Multiple Deprivation. All deaths related to a vascular disorder of the intestines recorded as an underlying cause of death between 1979 and 2014 were identified using International Classification of Disease-9 or International Classification of Disease-10 code groups. Data included demographics and location of death. The residence postcodes were used to classify socio-economic status using the Scottish Index of Multiple Deprivation. RESULTS From 2,142,921 deaths over 36 years, 14,530 (0.7%) were due to mesenteric vascular disease with a median (interquartile range) age of 77 and a 2:1 female to male gender ratio. The mean ± standard deviation age significantly increased from 72.6 ± 12.1 in 1979 to 76.8 ± 11.1 in 2014 (p < 0.001, R2 = 0.772). Males were consistently younger than females at the time of death. The two lowest Scottish Index of Multiple Deprivation categories accounted for half of the cohort, throughout the study period (p = 0.068). The adjusted death rate per 100,000 population increased from 7.6 in 1979 to 12.1 in 2014. CONCLUSIONS The reported death rates of mesenteric vascular disease in Scotland between 1979 and 2014 have nearly doubled. Mesenteric vascular disease affects twice as many women as men and is associated with social deprivation. The increased reporting of mesenteric vascular disease is likely due to increased recognition and incidence. These implications should be considered when planning healthcare provision in Scotland.
Collapse
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| | | | | | | | - Jan O Jansen
- University of Alabama at Birmingham Hospital, Birmingham, USA
| | | | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, USA
| |
Collapse
|
21
|
Madurska MJ, Franklin C, Richmond M, Adnan SM, Stansby GP, White JM, Morrison JJ. Improving the safety of resuscitative endovascular balloon occlusion of the aorta - Compliant versus semi-compliant balloon systems. Vascular 2020; 28:612-618. [PMID: 32356682 DOI: 10.1177/1708538120922106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Resuscitative endovascular balloon occlusion of the aorta is an alternative to resuscitative thoracotomy in non-compressible torso haemorrhage. Low-profile, compliant balloon catheter systems have been developed, which can be deployed without the need for fluoroscopy. However, concern exists for over inflation and aortic injury, especially as compliant balloon material can stretch reducing syringe feedback and limiting the effectiveness of a safety valve. An alternative material would be a semi-compliant balloon material, but its performance is unknown. The aim of this study was to compare the inflation characteristics of compliant versus semi-compliant balloon systems and to determine whether a pressure relief safety valve can be practically applied to a semi-compliant balloon catheter as a safety device. METHODS This was an ex vivo study using porcine segments of thoracic aorta. The study consisted of two phases. The first phase involved intermittent inflation of six compliant balloon and six semi-compliant balloon balloons until balloon or aortic rupture. In the second phase, six semi-compliant balloons with the pressure-relief valve set at 0.45 atmospheres were inflated in the aortas until the valve release, followed by injection with additional 30 mL. Data including pressure, volume, balloon working length, diameter and circumferential stretch ratio were collected. RESULTS At failure, mean balloon volume was almost double in compliant balloon group vs semi-compliant balloon group - 49.83 mL (±23.25) and 25.16 mL (±8.93), respectively (p = 0.004), with 36% increase in working length in the compliant balloon group - 81.17 mm (±19.11) vs 59.49 (±4.86) for semi-compliant balloon (p = 0.023). When plotted, the relationship pattern between volume and pressure fit a linear model for the compliant balloon, and a quadratic model for the semi-compliant balloon. Following attempted over inflation with the pressure valve, there was no change in parameters before and after attempted over inflation. CONCLUSIONS The inflation profile differs between balloon designs. In contrast to semi-compliant balloons, compliant balloons will accommodate more volume to mitigate increase in pressure. This does not completely eliminate the risk of over inflation. The inflation characteristics of the semi-compliant balloon permit pairing it with a safety valve, which could lead to a development of a safer balloon technology in the future.
Collapse
Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | | | - Michael Richmond
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Sakib M Adnan
- Department of Surgery, Albert Einstein Healthcare Network, Philadelphia, PA, USA
| | - Gerard P Stansby
- Department of Vascular Surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Joseph M White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| |
Collapse
|
22
|
Adnan SM, Romagnonli AN, Elansary NN, Martinson JR, Madurska MJ, Dubose JJ, Scalea TM, Morrison JJ. Radial versus femoral arterial access for trauma endovascular interventions: A noninferiority study. J Trauma Acute Care Surg 2020; 89:458-463. [DOI: 10.1097/ta.0000000000002740] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
23
|
Adnan SM, Romagnoli AN, Martinson JR, Madurska MJ, Dubose JJ, Scalea TM, Morrison JJ. A Comparison of Transradial and Transfemoral Access for Splenic Angio-Embolisation in Trauma: A Single Centre Experience. Eur J Vasc Endovasc Surg 2020; 59:472-479. [DOI: 10.1016/j.ejvs.2019.11.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 10/26/2019] [Accepted: 11/21/2019] [Indexed: 01/29/2023]
|
24
|
Isaak A, Madurska MJ, Stevenson KS, Gürke L, Kingsmore DB. The management of lower limb arteriovenous grafts in the perioperative period following renal transplantation. Clin Transplant 2020; 34:e13846. [PMID: 32096878 DOI: 10.1111/ctr.13846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 01/24/2020] [Accepted: 02/22/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The presence of a lower limb arteriovenous graft (LL-AVG) is indicative of a group of complex hemodialysis patients who have precarious long-term vascular access. The aim of this study is to describe our experience of the clinical decisions and interactions between LL-AVG and renal transplantation. METHODS The records of 23 patients who received a transplant in the presence of a LL-AVG between 2010 and 2018 were analyzed: firstly, to determine whether patients with a LL-AVG received extended criteria transplants, the implantation procedure, and the management of the LL-AVG in the post-operative period. RESULTS Seventeen patients (74%) had "end-stage access" and were thus considered for all offer stratified by the kidney donor profile index (KDPI) and donor type (DBD or DCD). In eleven patients (48%), a kidney with a high risk of delayed graft function was transplanted. Same-sided renal transplantation occurred in only 35% of cases, and of these, only one LL-AVG was ligated immediately to improve transplant perfusion. CONCLUSION A patient-based approach applied in decision-making on management of the LL-AVG post-transplantation should include (a) the likelihood of delayed graft function, (b) the need for post-operative hemodialysis, (c) the side of proposed transplant compared to the LL-AVG, and (d) local complications.
Collapse
Affiliation(s)
- Andrej Isaak
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Department of Vascular and Endovascular Surgery, University Hospital, Basel, Switzerland
| | - Marta J Madurska
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Karen S Stevenson
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - Lorenz Gürke
- Department of Vascular and Endovascular Surgery, University Hospital, Basel, Switzerland
| | - David B Kingsmore
- Renal and Transplant Surgery, Queen Elizabeth University Hospital, Glasgow, UK.,Department of Vascular and Endovascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| |
Collapse
|
25
|
Davidson AJ, Madurska MJ, Moran B, Morrison JJ, DuBose JJ, Scalea TM. Direct site endovascular repair as salvage procedure after anastomotic breakdown of primary repair following trauma. J Vasc Surg Cases Innov Tech 2019; 5:597-601. [PMID: 31872165 PMCID: PMC6908996 DOI: 10.1016/j.jvscit.2019.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/02/2019] [Indexed: 11/22/2022]
Abstract
A 16-year-old boy presented to a level I trauma center after multiple gun shot wounds and a motorcycle crash. He was in profound hemorrhagic shock and had multiple traumatic injuries, including a right common iliac arterial injury. The vessel was shunted for damage control and subsequently repaired primarily. On hospital day 18, he experienced dehiscence of the anastomosis requiring urgent surgery. The artery was ultimately repaired with an expandable polytetrafluoroethylene stent graft deployed in an open fashion through the site of injury. We discuss the use of stent grafts as an interesting alternative to suture repair after anastomotic disruption.
Collapse
Affiliation(s)
- Anders J Davidson
- Department of Surgery, UC Davis Medical Center, Sacramento, Calif.,Department of General Surgery, David Grant Medical Center, Travis Air Force Base, Calif
| | - Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Benjamin Moran
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Md
| |
Collapse
|
26
|
Chow JH, Richards JE, Morrison JJ, Galvagno SM, Tanaka KA, Madurska MJ, Rock P, Scalea TM, Mazzeffi MA. Viscoelastic Signals for Optimal Resuscitation in Trauma: Kaolin Thrombelastography Cutoffs for Diagnosing Hypofibrinogenemia (VISOR Study). Anesth Analg 2019; 129:1482-1491. [PMID: 31743167 DOI: 10.1213/ane.0000000000004315] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Acute traumatic coagulopathy is common in trauma patients. Prompt diagnosis of hypofibrinogenemia allows for early treatment with cryoprecipitate or fibrinogen concentrate. At present, optimal cutoffs for diagnosing hypofibrinogenemia with kaolin thrombelastography (TEG) have not been established. We hypothesized that kaolin kaolin-TEG parameters, such as kinetic time (K-time), α-angle, and maximum amplitude (MA), would accurately diagnose hypofibrinogenemia (fibrinogen <200 mg/dL) and severe hypofibrinogenemia (fibrinogen <100 mg/dL). METHODS Adult trauma patients (injury severity score >15) presenting to our trauma center between October 2015 and October 2017 were identified retrospectively. All patients had a traditional plasma fibrinogen measurement and kaolin-TEG performed within 15 minutes of each other and within 1 hour of admission. Some patients had additional measurements after. Receiver operating characteristic (ROC) curve analysis was performed to evaluate whether K-time, α-angle, and MA could diagnose hypofibrinogenemia and severe hypofibrinogenemia. Area under the ROC curve (AUROC) was calculated for each TEG parameter with a bootstrapped 99% confidence interval (CI). Further, ROC analysis was used to estimate ideal cutoffs for diagnosing hypofibrinogenemia and severe hypofibrinogenemia by maximizing sensitivity and specificity. In addition, likelihood ratios were also calculated for different TEG variable cutoffs to diagnose hypofibrinogenemia and severe hypofibrinogenemia. RESULTS Seven hundred twenty-two pairs of TEGs and traditional plasma fibrinogen measurements were performed in 623 patients with 99 patients having additional pairs of tests after the first hour. MA (AUROC = 0.84) and K-time (AUROC = 0.83) better diagnosed hypofibrinogenemia than α-angle (AUROC = 0.8; P = .03 and P < .001 for AUROC comparisons, respectively). AUROCs statistically improved for each parameter when severe hypofibrinogenemia was modeled as the outcome (P < .001). No differences were found between parameters for diagnosing severe hypofibrinogenemia (P > .05 for all comparisons). The estimated optimal cutoffs for diagnosing hypofibrinogenemia were 1.5 minutes for K-time (95% CI, 1.4-1.6), 70.0° for α-angle (95% CI, 69.8-71.0), and 60.9 mm for MA (95% CI, 59.2-61.8). The estimated optimal cutoffs for diagnosing severe hypofibrinogenemia were 2.4 minutes for K-time (95% CI, 1.7-2.8), 60.6° for α-angle (95% CI, 57.2-67.3), and 51.2 mm for MA (95% CI, 49.0-56.2). Currently recommended K-time and α-angle cutoffs from the American College of Surgeons had low sensitivity for diagnosing hypofibrinogenemia (3%-29%), but sensitivity improved to 74% when using optimal cutoffs. CONCLUSIONS Kaolin-TEG parameters can accurately diagnose hypofibrinogenemia and severe hypofibrinogenemia in trauma patients. Currently recommended cutoffs for the treatment of hypofibrinogenemia are skewed toward high specificity and low sensitivity. Many patients are likely to be undertreated for hypofibrinogenemia using current national guidelines.
Collapse
Affiliation(s)
- Jonathan H Chow
- From the Department of Anesthesiology, Division of Critical Care, University of Maryland School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Adnan SM, Romagnoli AN, Madurska MJ, DuBose JJ, Scalea TM, Morrison JJ. IF16. Safety and Efficacy of Radial Access for the Management of Endovascular Trauma. J Vasc Surg 2019. [DOI: 10.1016/j.jvs.2019.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
28
|
Sadeghi M, Nilsson KF, Larzon T, Pirouzram A, Toivola A, Skoog P, Idoguchi K, Kon Y, Ishida T, Matsumara Y, Matsumoto J, Reva V, Maszkowski M, Bersztel A, Caragounis E, Falkenberg M, Handolin L, Kessel B, Hebron D, Coccolini F, Ansaloni L, Madurska MJ, Morrison JJ, Hörer TM. The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry. Eur J Trauma Emerg Surg 2018; 44:491-501. [PMID: 28801841 PMCID: PMC6096626 DOI: 10.1007/s00068-017-0813-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/04/2017] [Indexed: 11/09/2022]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes. METHODS REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported. RESULTS Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion. CONCLUSIONS This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.
Collapse
Affiliation(s)
- M Sadeghi
- Västmanlands Hospital Västerås, Department of Vascular Surgery, Örebro University, Örebro, Sweden
| | - K F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, 701 85, Örebro, Sweden
| | - T Larzon
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, 701 85, Örebro, Sweden
| | - A Pirouzram
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, 701 85, Örebro, Sweden
| | - A Toivola
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, 701 85, Örebro, Sweden
| | - P Skoog
- Department of Vascular Surgery, Örebro University, Örebro, Sweden
| | - K Idoguchi
- Senshu Trauma and Critical Care Center, Rinku General Medical Center, Izumisano, Japan
| | - Y Kon
- Emergency and Critical Care Center, Hachinohe City Hospital, Hachinohe, Japan
| | - T Ishida
- Emergency and Critical Care Center, Ohta Nishinouchi Hospital, Koriyama, Japan
| | - Y Matsumara
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
- R Adams Cowley Shock Trauma Center, University of Maryland, College Park, MD, USA
| | - J Matsumoto
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Kawasaki, Japan
| | - V Reva
- Department of War Surgery, Kirov Military Medical Academy, Saint Petersburg, Russia
- Dzhanelidze Research Institute of Emergency Medicine, Saint Petersburg, Russia
| | - M Maszkowski
- Västmanlands Hospital Västerås, Department of Vascular Surgery, Örebro University, Örebro, Sweden
| | - A Bersztel
- Västmanlands Hospital Västerås, Department of Vascular Surgery, Örebro University, Örebro, Sweden
| | - E Caragounis
- Sahlgrenska University Hospital, Department of Surgery, University of Gothenburg, Gothenburg, Sweden
| | - M Falkenberg
- Department of Radiology, Örebro University, Örebro, Sweden
| | - L Handolin
- Helsinki University Hospital, Department of Orthopedics and Traumatology, University of Helsinki, Helsinki, Finland
| | - B Kessel
- Department of Surgery, Hillel Yaffe Medical Centre, Hadera, Israel
| | - D Hebron
- Department of Surgery, Hillel Yaffe Medical Centre, Hadera, Israel
| | - F Coccolini
- Department of Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - L Ansaloni
- Department of Surgery, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - M J Madurska
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - J J Morrison
- Department of Vascular Surgery, Queen Elizabeth University Hospital, Glasgow, UK
| | - T M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, 701 85, Örebro, Sweden.
| |
Collapse
|
29
|
Abstract
INTRODUCTION Liver surgery is widely used as a treatment modality for various liver pathologies. Despite significant improvement in clinical care, operative strategies, and technology over the past few decades, liver surgery is still risky, and optimal preoperative planning and anatomical assessment are necessary to minimize risks of serious complications. 3D printing technology is rapidly expanding, and whilst appliactions in medicine are growing, but its applications in liver surgery are still limited. This article describes the development of models of hepatic structures specific to a patient diagnosed with an operable hepatic malignancy. METHODS Anatomy data were segmented and extracted from computed tomography and magnetic resonance imaging of the liver of a single patient with a resectable liver tumor. The digital data of the extracted anatomical surfaces was then edited and smoothed, resulting in a set of digital 3D models of the hepatic vein, portal vein with tumor, biliary tree with gallbladder, and hepatic artery. These were then 3D printed. RESULTS The final models of the liver structures and tumor provided good anatomical detail and representation of the spatial relationships between the liver tumor and adjacent hepatic structures and could be easily manipulated and explored from different angles. CONCLUSIONS A graspable, patient-specific, 3D printed model of liver structures could provide an improved understanding of the complex liver anatomy and better navigation in difficult areas and allow surgeons to anticipate anatomical issues that might arise during the operation. Further research into adequate imaging, liver-specific volumetric software, and segmentation algorithms are worth considering to optimize this application.
Collapse
Affiliation(s)
| | | | | | - Paul Rea
- 3 University of Glasgow, Glasgow, UK
| | | |
Collapse
|