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Smith MC, Medvecz AJ, Smith MR, Streams JR, Dennis BM. Computed tomography scanning is feasible in select patients with REBOA catheter deployment. Injury 2024; 55:111387. [PMID: 38360518 DOI: 10.1016/j.injury.2024.111387] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Rapidly localizing and controlling bleeding is central to treating hemorrhagic shock. While REBOA allows temporary control, identifying the source of bleeding remains challenging. CT imaging with REBOA in place may provide information to direct hemorrhage control. The purpose of this study is to provide a descriptive summary of data comparing patients who did and did not undergo CT scan following REBOA deployment. Our hypothesis was that performing CT scan after REBOA placement in select patients is safe and can guide management of hemorrhagic shock. METHODS We queried the AAST AORTA registry for patients receiving REBOA at our level 1 trauma center from May 2017 to December 2021. Clinical data was obtained through the Trauma Registry of the American College of Surgeons (TRACS). Comparison groups were those who underwent CT scan after REBOA deployment versus those who did not undergo CT scan after REBOA deployment. The primary outcome was inhospital mortality, and secondary outcomes included hospital-, ICU-, and ventilator-free days. RESULTS 61 patients underwent CT scan with REBOA in place; 25 patients proceeded directly to hemorrhage control. Patients with REBOA prior to CT were more likely to have blunt mechanism, higher ISS, pelvic bleeding, and zone 3 REBOA placement. Mortality was not significantly different (51 % vs. 64 %). Patients who underwent CT with REBOA were more likely to undergo hemorrhage control in interventional radiology (43 % vs. 0 %). There was no difference in hospital-, ICU-, and ventilator-free days. DISCUSSION We demonstrate the feasibility of performing CT in select trauma patients who undergo REBOA. We describe a pathway to enable expeditious workup and management of these patients. Optimal hemorrhage control management is impacted by CT scans when it can be performed. It is important to note that this is a severely injured patient population, and mortality is high even when hemorrhage is controlled. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael C Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA.
| | - Andrew J Medvecz
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Melissa R Smith
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Jill R Streams
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
| | - Bradley M Dennis
- Vanderbilt University Medical Center, Division of Acute Care Surgery 404 Medical Arts Building, 1211 21st Avenue South, Nashville, TN 37212, USA
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Li RF, Gong XF, Xu HB, Lin JT, Zhang HG, Suo ZJ, Wu JL. Age affects vascular morphology and predictiveness of anatomical landmarks for aortic zones in trauma patients: implications for resuscitative endovascular balloon occlusion of the aorta. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02512-z. [PMID: 38656432 DOI: 10.1007/s00068-024-02512-z] [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: 02/22/2024] [Accepted: 03/30/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE Understanding the vascular morphology is fundamental for resuscitative endovascular balloon occlusion of the aorta. This study aimed to evaluate the effect of aging on length and diameter of aorta and iliac arteries in trauma patients, and to investigate the predictiveness of anatomical landmarks for aortic zones. METHODS A total of 235 patients in a regional trauma center registry from September 1, 2018, to January 3, 2024, participated in the study. Reconstruction of computed tomography was applied to the torso area. The marginal diameter and length of aorta and iliac arteries were measured. Anatomical landmark distances and aortic marginal lengths were compared. RESULTS The length and diameter of aorta and iliac arteries increased with age, and a tortuous and enlarged morphology was observed in older patients. There was a good regression between age and diameter of the aorta. Neither the jugular notch, the xiphisternal joint, nor the umbilicus could reliably represent specific margins of aortic zones. The distance between the mid-sternum and femoral artery (427 ± 25 to 442 ± 25 mm for right, and 425 ± 28 to 440 ± 26 mm for left) was predictive for zone 1 in all groups. The distance between the lower one-third junction of the xiphisternum to the umbilicus and femoral artery (232 ± 19 to 240 ± 17 mm for right, and 229 ± 20 to 237 ± 19 mm for left) was predictive for zone 3 aorta. CONCLUSION Aging increases the length and diameter of aorta and iliac arteries, with a tortuous and enlarged morphology in geriatric populations. The mid-sternum and the lower one-third junction of the xiphisternum to the umbilicus were predictive landmarks for zone 1 and zone 3, respectively.
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Affiliation(s)
- Rui-Fa Li
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Xue-Fang Gong
- Department of Pulmonary and Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Hong-Bo Xu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Jin-Tuan Lin
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Hai-Gang Zhang
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Zhi-Jun Suo
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China
| | - Jing-Lan Wu
- Department of Critical Care Medicine, Huazhong University of Science and Technology Union Shenzhen Hospital, No. 89 Taoyuan Road, Nanshan District, Shenzhen, 510182, Guangdong, China.
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Martínez Hernández A, Chorro R, Climent A, Lazaro-Paulina FG, Martínez García V. Has the balloon really burst? Analysis of "the UK- REBOA randomized clinical trial". Am J Surg 2024:S0002-9610(24)00233-2. [PMID: 38670836 DOI: 10.1016/j.amjsurg.2024.04.016] [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: 02/19/2024] [Revised: 04/08/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Uncontrolled hemorrhagic shock is a leading cause of early death after injury. Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents a paradigm shift in achieving hemodynamic stability and its implementation still remain controversial in different settings. The recently published UK-REBOA Randomized Clinical Trial aimed to determine the effectiveness of REBOA in patients with hemorrhagic shock, concluding its increased mortality compared with standard care alone. METHODS An adjustment of the statistical analysis was performed and a comprehensive analysis was proposed to address the study's limitations and demonstrate that these conclusions cannot be considered as benchmarks. RESULTS Primary and secondary outcomes were analyzed using Bayesian logistic regression and generalized linear models suitable for the outcome distribution. No statistically significant differences were observed between the two groups for the primary outcome (p-value 0.3341) nor in most of the secondary outcomes. The results of the principal stratum analyses (to account for intercurrent events) also did not show significant differences after the statistical analysis tests. CONCLUSION It cannot be stated that REBOA increases mortality compared with standard care alone in trauma patients with exsanguinating hemorrhage. Further studies and adequate simulation training programs in REBOA are critical to its successful implementation within a trauma system and to identify the optimum settings and patients.
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Affiliation(s)
- Andreu Martínez Hernández
- Department of General and Visceral Surgery, General University Hospital, Castellon, Spain; Department of Medicine, Jaume I University, Castellon, Spain; Prehospital Critical Care Training Group, Javea, Spain.
| | - Rosanna Chorro
- Emergency Medicine Department, Mayo Clinic, Rochester, MN, USA; Prehospital Critical Care Training Group, Javea, Spain
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Taheri BD, Fisher AD, Eisenhauer IF, April MD, Rizzo JA, Guliani SS, Flarity KM, Cripps M, Bebarta VS, Wohlauer MV, Schauer SG. The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings. Transfusion 2024. [PMID: 38581267 DOI: 10.1111/trf.17823] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 03/17/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. STUDY DESIGN AND METHODS We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. RESULTS We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. DISCUSSION We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.
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Affiliation(s)
- Branson D Taheri
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
- Air Education and Training Command, Air Force Institute of Technology, Wright-Patterson Air Force Base, Dayton, Ohio, USA
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrew D Fisher
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
- Texas Army National Guard, Austin, Texas, USA
| | - Ian F Eisenhauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Emergency Medicine, Denver Health, Denver, Colorado, USA
- Navy Medicine Leader and Professional Development Command, Bethesda, Maryland, USA
| | - Michael D April
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- 14th Field Hospital, Fort Stewart, Georgia, USA
| | - Julie A Rizzo
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Brooke Army Medical Center, JBSA, Fort Sam Houston, Texas, USA
| | - Sundeep S Guliani
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Kathleen M Flarity
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael Cripps
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Vikhyat S Bebarta
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Max V Wohlauer
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Steven G Schauer
- University of Colorado Center for Combat Medicine and Battlefield (COMBAT) Research, Aurora, Colorado, USA
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
- Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, Colorado, USA
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Tullos A, Wunnava S, Medina D, Sheahan C, Chawla A, Torrance B, Brooke A, Donovan M, Palit T, Sheahan M. Vascular complications secondary to resuscitative endovascular balloon occlusion of the aorta placement at a Level 1 Trauma Center. J Vasc Surg 2024:S0741-5214(24)00499-3. [PMID: 38493898 DOI: 10.1016/j.jvs.2024.03.020] [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: 10/18/2023] [Revised: 03/05/2024] [Accepted: 03/10/2024] [Indexed: 03/19/2024]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to manage severe hemorrhagic shock. Popularized in medical care during military conflicts, the concept has emerged as a lifesaving technique that is utilized around the United States. Literature on risks of REBOA placement, especially vascular injuries, are not well-reported. Our goal was to assess the incidence of vascular injury from REBOA placement and the risk factors associated with injury and death among these patients at our institution. METHODS We performed a retrospective cohort study of all patients who underwent REBOA placement between September 2017 and June 2022 at our Level 1 Trauma Center. The primary outcome variable was the presence of an injury related to REBOA insertion or use. Secondary outcomes studied were limb loss, the need for dialysis, and mortality. Data were analyzed using descriptive statistics, χ2, and t-tests as appropriate for the variable type. RESULTS We identified 99 patients who underwent REBOA placement during the study period. The mean age of patients was 43.1 ± 17.2 years, and 67.7% (67/99) were males. The majority of injuries were from blunt trauma (79.8%; 79/99). Twelve of the patients (12.1%; 12/99) had a vascular injury related to REBOA placement. All but one required intervention. The complications included local vessel injury (58.3%; 7/12), distal embolization (16.7%; 2/12), excessive bleeding requiring vascular consult (8.3%; 1/12), pseudoaneurysm requiring intervention (8.3%; 1/12), and one incident of inability to remove the REBOA device (8.3%; 1/12). The repairs were performed by vascular surgery (75%; 9/12), interventional radiology (16.7%; 2/12), and trauma surgery (8.3%; 1/12). There was no association of age, gender, race, and blunt vs penetrating injury to REBOA-related complications. Mortality in this patient population was high (40.4%), but there was no association with REBOA-related complications. Ipsilateral limb loss occurred in two patients with REBOA-related injuries, but both were due to their injuries and not to REBOA-related ischemia. CONCLUSIONS Although vascular complications are not unusual in REBOA placement, there does not appear to be an association with limb loss, dialysis, or mortality if they are addressed promptly. Close coordination between vascular surgeons and trauma surgeons is essential in patients undergoing REBOA placement.
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Affiliation(s)
- Amanda Tullos
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Sanjay Wunnava
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Daniela Medina
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Claudie Sheahan
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Amit Chawla
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Bruce Torrance
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Amadis Brooke
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Melissa Donovan
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Tapash Palit
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA
| | - Malachi Sheahan
- Division of Vascular and Endovascular Surgery, School of Medicine, LSU Health Sciences Center, New Orleans, LA.
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Wikström MB, Stene-Hurtsén A, Åström J, Hörer TM, Nilsson KF. The effect of an endovascular Heaney maneuver to achieve total hepatic isolation on survival, hemodynamic stability, retrohepatic bleeding, and collateral flow in a porcine model. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02482-2. [PMID: 38456908 DOI: 10.1007/s00068-024-02482-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/19/2024] [Indexed: 03/09/2024]
Abstract
PURPOSE Combining resuscitative endovascular balloon occlusion of the aorta (REBOA) and the inferior vena cava (REBOVC) with open surgery is a new hybrid approach for treating retrohepatic vena caval injuries. We compared endovascular total hepatic isolation with supraceliac REBOA ± suprahepatic REBOVC and no occlusion in experimental retrohepatic vena cava bleeding regarding survival, bleeding volume, hemodynamic stability, and arterial collateral blood flow. METHODS Twenty-five anesthetized pigs (n = 6-7/group) were randomized to REBOA; REBOA + REBOVC; REBOA + infra and suprahepatic REBOVC + portal vein occlusion (endovascular Heaney maneuver, four-balloon-occlusion, 4BO) or no occlusion. After balloon inflation, free bleeding was initiated from an open sheath in the retrohepatic vena cava. Bleeding volume, right internal thoracic artery (RITA) blood flow, hemodynamics, and arterial blood variables were measured until death or up to 90 min. RESULTS The REBOA group had a longer median survival time (63 min) compared with the 4BO (24 min, P = 0.02) and no occlusion (30 min, P = 0.02) groups, not versus the REBOA + REBOVC group (49 min, P > 0.05). The first 15 min accumulated bleeding was comparable in all groups (P > 0.05); Thereafter, bleeding volume was higher in the REBOA group versus the 4BO group (P < 0.05), not versus the other groups. RITA blood flow and MAP were higher in the REBOA group versus the other groups after 10 min of bleeding (P < 0.05). CONCLUSIONS Endovascular Heaney maneuver was not beneficial for survival or hemodynamic stability in this porcine model, whereas supraceliac REBOA was. Anatomical differences in thoracoabdominal collaterals between pigs and humans must be considered when interpreting these results.
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Affiliation(s)
- Maria B Wikström
- Department of Emergency, Arvika Hospital, Region Värmland, Arvika, Sweden.
- School of Medical Sciences, Örebro University, Örebro, Sweden.
| | - Anna Stene-Hurtsén
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Region Örebro Län, Sweden
| | - Jens Åström
- Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Region Dalarna, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Region Örebro Län, Sweden
| | - Kristofer F Nilsson
- School of Medical Sciences, Örebro University, Örebro, Sweden
- Department of Cardiothoracic and Vascular Surgery, Department of Surgery, Örebro University Hospital and Faculty of Medicine and Health, Örebro University, Örebro, Region Örebro Län, Sweden
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Epstein L, Grigorian A, Matsushima K, Nahmias J, Dilday J, Demetriades D. Propensity Score Analysis of Resuscitative Endovascular Balloon Occlusion of the Aorta: Zone-1 Versus Zone-3 Resuscitative Endovascular Balloon Occlusion of the Aorta Odds of Mortality. J Surg Res 2024; 295:660-665. [PMID: 38104529 DOI: 10.1016/j.jss.2023.11.049] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/07/2023] [Accepted: 11/12/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION There are two zones for the placement of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in trauma patients: above the mesenteric vessels (Zone-1) or below the renal arteries (Zone-3). Zone-1 REBOA diverts blood away from the visceral organs which leads to a systemic inflammatory response and reperfusion injury. We hypothesized that patients undergoing Zone-1 REBOA placement had a higher odds of mortality. METHODS The 2017-2019 Trauma Quality Improvement Program database was queried for patients undergoing either Zone-1 or Zone-3 REBOA. We excluded all patients with prehospital cardiac arrest. We compared Zone-1 versus Zone-3 REBOA using a 1:2 propensity-score model, matching for age, mechanism, sex, hypotension, tachycardia, blunt solid organ injury grade, pelvic fracture, and injuries to the aorta, iliac artery, iliac vein, and inferior vena cava. RESULTS We matched 130 Zone-1 REBOA patients to 260 Zone-3 REBOA patients. There were no statistically significant differences in the matched variables (P > 0.05). Compared to Zone-3 REBOA, patients with Zone-1 REBOA who survived ≥48 h had similar rates of acute kidney injury (18.6% versus 10.9%, P = 0.19). Zone-1 REBOA patients had a higher mortality rate (71.4% versus 48.8%, P = 0.002) and mortality odds ratio (OR) (OR 1.85, OR 1.18-2.89, P = 0.007). Zone-1 REBOA remained associated with a higher odds of mortality after controlling for traumatic brain injury and injury severity score (OR 1.86, OR 1.18-2.92, P = 0.007). CONCLUSIONS Compared to Zone-3, using a REBOA in Zone-1 is associated with higher odds of mortality. The use of REBOA Zone-1 deployment should be done with caution.
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Affiliation(s)
- Larissa Epstein
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California.
| | - Kazuhide Matsushima
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, University of California, Irvine, Orange, California
| | - Joshua Dilday
- Department of Surgery, University of Southern California, Los Angeles, California
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Pagano KM, Fokin AA, Parra M, Puente I. Stop exsanguination by inflation: management of aorta-esophageal fistula bleeding. J Surg Case Rep 2024; 2024:rjae120. [PMID: 38463737 PMCID: PMC10924743 DOI: 10.1093/jscr/rjae120] [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: 01/31/2024] [Accepted: 02/13/2024] [Indexed: 03/12/2024] Open
Abstract
Aortoesophageal fistula is rare and typically presents itself to the emergency department as Chiari's Triad of mid-thoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval. However, fatal bleeding may be the first and last presentation of an aortoesophageal fistula. When a patient experiences massive hematemesis without witnesses, EMS may assume that bleed is of a traumatic mechanism. We present a case of a 59-year-old male with no previous medical history who was transported to a trauma center unconscious and with massive bleeding of unknown origin. Computed tomography revealed a thoracic aortic aneurysm and an aortoesophageal fistula. Bleeding was not controlled and the patient expired. Trauma bay personnel should follow an algorithm which includes a prompt tamponade of the bleed using a Sengstaken-Blakemore tube or esophageal balloon paralleled by massive transfusion and obtaining an early computed tomography scan to manage patients with massive gastroesophageal bleeding until appropriate surgical interventions can be initiated.
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Affiliation(s)
- Kristina M Pagano
- Department of Surgery, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th St AHC2, Miami, FL 33199, United States
| | - Alexander A Fokin
- Department of Trauma and Acute Care Surgery, Delray Medical Center, 5352 Linton Blvd, Delray Beach, FL 33484, United States
| | - Michael Parra
- Department of Trauma and Acute Care Surgery, Broward County Health Care System, 1800 NW 49th Street, STE. 110, Fort Lauderdale, FL 33309, United States
| | - Ivan Puente
- Department of Trauma and Acute Care Surgery, Broward County Health Care System, 1800 NW 49th Street, STE. 110, Fort Lauderdale, FL 33309, United States
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Kim HE, Chu SE, Jo YH, Chiang WC, Jang DH, Chang CH, Oh SH, Chen HA, Park SM, Sun JT, Lee DK. Effect of resuscitative endovascular balloon occlusion of the aorta in nontraumatic out-of-hospital cardiac arrest: a multinational, multicenter, randomized, controlled trial. Trials 2024; 25:118. [PMID: 38347550 PMCID: PMC10863125 DOI: 10.1186/s13063-024-07928-x] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/16/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a significant public health issue worldwide and is associated with low survival rates and poor neurological outcomes. The generation of optimal coronary perfusion pressure (CPP) via high-quality chest compressions is a key factor in enhancing survival rates. However, it is often challenging to provide adequate CPP in real-world cardiopulmonary resuscitation (CPR) scenarios. Based on animal studies and human trials on improving CPP in patients with nontraumatic OHCA, resuscitative endovascular balloon occlusion of the aorta (REBOA) is a promising technique in these cases. This study aims to investigate the benefits of REBOA adjunct to CPR compared with conventional CPR for the clinical management of nontraumatic OHCA. METHODS This is a parallel-group, randomized, controlled, multinational trial that will be conducted at two urban academic tertiary hospitals in Korea and Taiwan. Patients aged 20-80 years presenting with witnessed OHCA will be enrolled in this study. Eligible participants must fulfill the inclusion criteria, and written informed consent should be collected from their legal representatives. Patients will be randomly assigned to the intervention (REBOA-CPR) or control (conventional CPR) group. The intervention group will receive REBOA and standard advanced cardiovascular life support (ACLS). Meanwhile, the control group will receive ACLS based on the 2020 American Heart Association guidelines. The primary outcome is the return of spontaneous circulation (ROSC). The secondary outcomes include sustained ROSC, survival to admission, survival to discharge, neurological outcome, and hemodynamic changes. DISCUSSION Our upcoming trial can provide essential evidence regarding the efficacy of REBOA, a mechanical method for enhancing CPP, in OHCA resuscitation. Our study aims to determine whether REBOA can improve treatment strategies for patients with nontraumatic OHCA based on clinical outcomes, thereby potentially providing valuable insights and guiding further advancements in this critical public health area. TRIAL REGISTRATION ClinicalTrials.gov NCT06031623. Registered on September 9, 2023.
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Affiliation(s)
- Hee Eun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 13620, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
| | - Sheng-En Chu
- Department of Emergency Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nan-Ya South Rd, Ban-Qiao Dist., New Taipei City, Taiwan
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 13620, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yunlin, Taiwan
| | - Dong-Hyun Jang
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
- Department of Public Healthcare Service, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chin-Hao Chang
- National Taiwan University Hospital Statistical Consulting Unit, Taipei, Taiwan
| | - So Hee Oh
- Medical Research Collaborating Center, SMG-SNU Boramae Medical Center Seoul, Seoul, Republic of Korea
| | - Hsuan-An Chen
- Department of Emergency Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nan-Ya South Rd, Ban-Qiao Dist., New Taipei City, Taiwan
| | - Seung Min Park
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 13620, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jen-Tang Sun
- Department of Emergency Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nan-Ya South Rd, Ban-Qiao Dist., New Taipei City, Taiwan.
| | - Dong Keon Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 13620, 82, Gumi-ro 173beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do, Republic of Korea.
- Department of Emergency Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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10
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Paran M, McGreevy D, Hörer TM, Khan M, Dudkiewicz M, Kessel B. International registry on aortic balloon occlusion in major trauma: Partial inflation does not improve outcomes in abdominal trauma. Surgeon 2024; 22:37-42. [PMID: 37652801 DOI: 10.1016/j.surge.2023.08.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 08/05/2023] [Accepted: 08/14/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method for temporary hemorrhage control used in haemodynamically unwell patients with severe bleeding. In haemodynamically unwell abdominal trauma patients, laparotomy remains the initial procedure of choice. Using REBOA in patients as a bridge to laparotomy is a novel option whose feasibility and efficacy remain unclear. We aimed to assess the clinical outcome in patients with abdominal injury who underwent both REBOA placement and laparotomy. METHODS This is a retrospective study, including trauma patients with an isolated abdominal injury who underwent both REBOA placement and laparotomy, during the period 2011-2019. All data were collected via the Aortic Balloon Occlusion Trauma Registry database. RESULTS One hundred and three patients were included in this study. The main mechanism of trauma was blunt injury (62.1%) and the median injury severity score (ISS) was 33 (14-74). Renal failure and multi-organ dysfunction syndrome (MODS) occurred in 15.5% and 35% of patients, respectively. Overall, 30-day mortality was 50.5%. Post balloon inflation systolic blood pressure (SBP) >80 mmHg was associated with lower 24-h mortality (p = 0.007). No differences in mortality were found among patients who underwent partial occlusion vs. total occlusion of the aorta. CONCLUSIONS Our results support the feasibility of REBOA use in patients with isolated abdominal injury, with survival rates similar to previous reports for haemodynamically unstable abdominal trauma patients. Post-balloon inflation SBP >80 mmHg was associated with a significant reduction in 24-h mortality rates, but not 30-day mortality. Total aortic occlusion was not associated with increased mortality, MODS, and complication rates compared with partial occlusion.
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Affiliation(s)
- Maya Paran
- Pediatric and Adolescent Surgery, Schneider Children's Medical Center of Isral, Affiliated with Sackler School of Medicine, Tel-Aviv University, Tel-aviv, Israel.
| | - David McGreevy
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Tal M Hörer
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Department of General Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mansoor Khan
- Brighton and Sussex Medical School, Brighton, UK
| | - Mickey Dudkiewicz
- Hillel Yaffe Medical Center, Affiliated with The Rappaport Medical School, Technion, Haifa, Israel
| | - Boris Kessel
- Division of General Surgery and Trauma, Hillel Yaffe Medical Center, Affiliated with The Rappaport Medical School, Technion, Haifa, Israel
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11
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Vrancken SM, de Vroome M, van Vledder MG, Halm JA, Van Lieshout EMM, Borger van der Burg BLS, Hoencamp R, Verhofstad MHJ, van Waes OJF. Non-compressible truncal and junctional hemorrhage: A retrospective analysis quantifying potential indications for advanced bleeding control in Dutch trauma centers. Injury 2024; 55:111183. [PMID: 37981519 DOI: 10.1016/j.injury.2023.111183] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 10/06/2023] [Accepted: 11/03/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Truncal and junctional hemorrhage is the leading cause of potentially preventable deaths in trauma patients. To reduce this mortality, the application of advanced bleeding control techniques, such as resuscitative endovascular balloon occlusion of the aorta (REBOA), junctional tourniquets, Foley catheters, or hemostatic agents should be optimized. This study aimed to identify trauma patients with non-compressible truncal and junctional hemorrhage (NCTJH) who might benefit from advanced bleeding control techniques during initial trauma care. We hypothesized that there is a substantial cohort of Dutch trauma patients that can possibly benefit from advanced bleeding control techniques. METHODS Adult trauma patients with an Abbreviated Injury Scale ≥3 in the torso, neck, axilla, or groin region, who were presented between January 1st, 2014 and December 31st, 2018 to two Dutch level-1 trauma centers, were identified from the Dutch Trauma Registry. Potential indications for advanced bleeding control in patients with NCTJH were assessed by an expert panel of three trauma surgeons based on injury characteristics, vital signs, response to resuscitation, and received treatment. RESULTS In total, 1719 patients were identified of whom 249 (14.5 %) suffered from NCTJH. In 153 patients (60.6 %), hemorrhagic shock could have been mitigated or prevented with advanced bleeding control techniques. This group was younger and more heavily injured: median age of 40 versus 48 years and median ISS 33 versus 22 as compared to the entire cohort. The mortality rate in these patients was 31.8 %. On average, each of the included level-1 trauma centers treated an NCTJH patient every 24 days in whom a form of advanced bleeding control could have been beneficial. CONCLUSIONS More than half of included Dutch trauma patients with NCTJH may benefit from in-hospital application of advanced bleeding control techniques, such as REBOA, during initial trauma care. Widespread implementation of these techniques in the Dutch trauma system may contribute to reduction of mortality and morbidity from non-compressible truncal and junctional hemorrhage.
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Affiliation(s)
- Suzanne M Vrancken
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Trauma Research Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.
| | - Matthijs de Vroome
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G van Vledder
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jens A Halm
- Trauma Research Unit, Department of Surgery, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | | | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital, Leiderdorp, the Netherlands; Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands; Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Oscar J F van Waes
- Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands; Defense Healthcare Organization, Ministry of Defense, Utrecht, the Netherlands
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12
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Miyake Y, Okishio Y, Shibata N, Kawashima S, Nasu T, Ueda K. Survival of a hemodynamically unstable pediatric liver trauma patient with aortic balloon occlusion catheter during air transport: A case report. Acute Med Surg 2024; 11:e955. [PMID: 38655505 PMCID: PMC11036130 DOI: 10.1002/ams2.955] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/07/2024] [Indexed: 04/26/2024] Open
Abstract
Background The utility of resuscitative endovascular balloon occlusion of the aorta (REBOA) in children remains unclear. Case Presentation An 11-year-old patient with liver trauma with massive extravasation was transported to a local hospital, where an emergency trauma surgery was unavailable. Following the placement of REBOA as a bridge to hemostasis, she was transferred to our hospital by a firefighting helicopter with balloon occlusion. Immediately, she underwent damage control laparotomy and transcatheter arterial embolization. She was subsequently discharged from the hospital 6 months after the accident without complications. Conclusion REBOA as a bridge to hemostasis may be useful for pediatric patients.
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Affiliation(s)
- Yuichi Miyake
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Yuko Okishio
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Naoaki Shibata
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
- Department of Emergency MedicineNational Hospital Organization Minami Wakayama Medical CenterWakayamaJapan
| | - Shuji Kawashima
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Toru Nasu
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
- Department of Emergency MedicineKatsuragi HospitalOsakaJapan
| | - Kentaro Ueda
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
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13
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Maruyama S, Wada D, Yoshihara T, Saito F, Yoshiya K, Nakamori Y, Kuwagata Y. Treatment strategy for severe trauma patients requiring aortic occlusion for impending cardiopulmonary arrest in the hybrid emergency room. Acute Med Surg 2024; 11:e928. [PMID: 38293705 PMCID: PMC10825068 DOI: 10.1002/ams2.928] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
Aim Computed tomography (CT) is useful in trauma care. Severely ill trauma patients may not tolerate whole-body CT even without patient transfer. This study examined clinical flow of severe trauma patients requiring aortic occlusion (AO) such as resuscitative thoracotomy or REBOA in the hybrid emergency room (ER) and investigated patient clinical courses prioritizing CT first versus resuscitation including AO first. Methods This retrospective, single-center observational study included consecutive trauma patients visiting our ER between May 2016 and February 2023. Patients were divided into the CT first group (whole-body CT preceded AO) and AO first group (AO preceded whole-body CT) and into two subgroups: AO after CT (AO/interventions for hemorrhage performed just after CT in the CT first group), and CT after AO (CT or damage control surgery performed after AO in the AO first group). We investigated 28-day survival rates. Results Survival probability by TRISS method was 49% (range: 3.3-94) in the CT first group (n = 6) and 20% (range: 0.7-45) in the AO first group (n = 7). Actual 28-day survival rates were 50% and 57%, respectively. Survival rates of the AO after CT subgroup (CT first group) were 75% (3/4) and 0% (0/2), respectively, and those of the CT after AO subgroup (AO first group) were 25% (1/4) and 100% (3/3), respectively. Conclusion In severe trauma patients with low predicted probability of survival treated in the hybrid ER, survival rates might be better if resuscitation including AO is performed before CT and if damage control surgery is performed first before CT.
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Affiliation(s)
- Shuhei Maruyama
- Department of Emergency and Critical Care MedicineKansai Medical University Medical CenterOsakaJapan
| | - Daiki Wada
- Department of Emergency and Critical Care MedicineKansai Medical University Medical CenterOsakaJapan
| | - Tomoyuki Yoshihara
- Department of Emergency and Critical Care MedicineKansai Medical University Medical CenterOsakaJapan
| | - Fukuki Saito
- Department of Emergency and Critical Care MedicineKansai Medical University Medical CenterOsakaJapan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care MedicineKansai Medical University Medical CenterOsakaJapan
| | - Yasushi Nakamori
- Department of Emergency and Critical Care MedicineKansai Medical University Medical CenterOsakaJapan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care MedicineKansai Medical University HospitalOsakaJapan
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14
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Hilbert-Carius P, Streibert F, Ebert D, Vogt A, Beese M, Tongers J, Hofmann G, Braun J. [Effect of a 1-day " REBOA course" on the theoretical and practical skills for the prehospital REBOA setting : Experiences from the RIBCAP-HEMS project]. Anaesthesiologie 2023; 72:871-877. [PMID: 37999740 DOI: 10.1007/s00101-023-01359-0] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/06/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) represents an endovascular procedure for aortic occlusion. The procedure can be used for temporary hemorrhage control as a bridge until surgical treatment for noncompressible abdominal or pelvic bleeding and to improve coronary and cerebral perfusion pressure during cardiopulmonary resuscitation. The prehospital administration is challenging and currently hardly possible in Germany. In the REBOA in bleeding and cardiac arrest in the prehospital care by helicopter emergency medical service (RIBCAP-HEMS) project, the prehospital use of REBOA will be tested in a feasibility study. This article describes the training course on the procedure in preparation for prehospital use, which was conducted before the start of the aforementioned feasibility study for the emergency physicians and paramedics (HEMS-TC) of the DRF Air Rescue Base in Halle (Saale). The course provided the necessary theoretical and practical skills to apply REBOA in the prehospital setting to patients in extremis in a safe, indications-conform and time-critical manner. The fact that all emergency physicians of the two air ambulances Christoph 84 and Christoph 85 in Halle are specialists in anesthesiology with corresponding experience in the placement of invasive arterial catheters proved to be advantageous. The training course was able to significantly improve the theoretical and practical abilities of the participants. The results of the currently ongoing study must show whether the procedure can be usefully integrated into the prehospital care of patients in extremis.
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Affiliation(s)
- Peter Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Schmerztherapie, Bergmannstrost BG Klinikum Halle (Saale) gGmbH, Merseburgerstr. 165, 06112, Halle (Saale), Deutschland.
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland.
| | - Fridolin Streibert
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Schmerztherapie, Bergmannstrost BG Klinikum Halle (Saale) gGmbH, Merseburgerstr. 165, 06112, Halle (Saale), Deutschland
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland
| | - Daniel Ebert
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Alexander Vogt
- Universitätsklinik und Poliklinik für Innere Medizin III (Kardiologie, Angiologie, Internistische Intensivmedizin), Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Matthias Beese
- DRF Luftrettung, Station Halle, Christoph Sachsen-Anhalt (CHX 84) und Christoph Halle (CHX 85), Halle (Saale), Deutschland
- Klinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Jörn Tongers
- Universitätsklinik und Poliklinik für Innere Medizin III (Kardiologie, Angiologie, Internistische Intensivmedizin), Universitätsklinikum Halle (Saale), Halle (Saale), Deutschland
| | - Gunther Hofmann
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - Jörg Braun
- DRF Luftrettung, Filderstadt, Deutschland
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15
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Perlman R, Tsai K, Lo J. Trauma Anesthesiology Perioperative Management Update. Adv Anesth 2023; 41:143-162. [PMID: 38251615 DOI: 10.1016/j.aan.2023.06.003] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Anesthesia for patients with life-threatening injuries is an essential part of post-accident care. Unfortunately, there is variability in trauma anesthesia care and numerous nonstandardized methods of working with patients remain. Uncertainty exists as to when and how best to intubate trauma patients, the use of vasopressors, and the appropriate management of severe traumatic brain injury. Some physicians recommend prehospital rapid sequence intubation, whereas others use bag-mask ventilation at lower pressures with no cricoid pressure and early transport to a trauma center. Overall, the absence of uniformity in trauma anesthesia care underlines the need for continued study and dialogue to define best practices and optimize patient outcomes.
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Affiliation(s)
- Ryan Perlman
- Trauma Anesthesia, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA.
| | - Kevin Tsai
- Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
| | - Jessie Lo
- Trauma Education Program, Department of Anaesthesia, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, North Tower, Suite 8211, Los Angeles, CA 90048, USA
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16
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Aoki M, Matsumura Y, Izawa Y, Hayashi Y. Ultrasound assessment is useful for evaluating balloon volume of resuscitative endovascular balloon occlusion of the aorta. Eur J Trauma Emerg Surg 2023; 49:2479-2484. [PMID: 37430175 DOI: 10.1007/s00068-023-02309-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/20/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Endovascular balloon occlusion of the aorta (EBOA) increases proximal arterial pressure but may also induce life-threatening ischemic complications. Although partial REBOA (P-REBOA) mitigates distal ischemia, it requires invasive monitoring of femoral artery pressure for titration. In this study, we aimed to titrate P-REBOA to prevent high-degree P-REBOA using ultrasound assessment of femoral arterial flow. METHODS Proximal (carotid) and distal (femoral) arterial pressures were recorded, and perfusion velocity of distal arterial pressures was measured by pulse wave Doppler. Systolic and diastolic peak velocities were measured among all ten pigs. Total REBOA was defined as a cessation of distal pulse pressure, and maximum balloon volume was documented. The balloon volume (BV) was titrated at 20% increments of maximum capacity to adjust the degree of P-REBOA. The distal/proximal arterial pressure gradient and the perfusion velocity of distal arterial pressures were recorded. RESULTS Proximal blood pressure increased with increasing BV. Distal pressure decreased with increasing BV, and distal pressure sharply decreased by > 80% of BV. Both systolic and diastolic velocities of the distal arterial pressure decreased with increasing BV. Diastolic velocity could not be recorded when the BV of REBOA was > 80%. CONCLUSION The diastolic peak velocity in the femoral artery disappeared when %BV was > 80%. Evaluation of the femoral artery pressure by pulse wave Doppler may predict the degree of P-REBOA without invasive arterial monitoring.
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Affiliation(s)
- Makoto Aoki
- Advanced Medical Emergency Department and Critical Care Center, Japan Red Cross Maebashi Hospital, Maebashi, Japan
| | - Yosuke Matsumura
- Department of Intensive Care, Chiba Emergency Medical Center, Chiba, Japan.
| | - Yoshimitsu Izawa
- Department of Emergency and Critical Care Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Yosuke Hayashi
- Department of Emergency and Critical Care Medicine, Japan Red Cross Narita Hospital, Narita, Japan
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17
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Roderick E, Ricaurte D, Croteau A, Gates J, Bass S, Jain AK, Keating J. The Implementation of a Resuscitative Endovascular Balloon Occlusion of the Aorta ( REBOA) Program at a Level 1 New England Trauma Center: Feasibility and Early Outcomes. Am Surg 2023; 89:5474-5479. [PMID: 36757849 DOI: 10.1177/00031348231156759] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
OBJECTIVES We evaluated the feasibility of implementing a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) program at our urban level 1 trauma center and evaluated early outcomes. DESIGN A multidisciplinary committee including physicians (trauma surgery, emergency medicine, vascular surgery, and interventional radiology) and nurses created clinical practice guidelines for the placement of REBOA at our institution. All trauma surgeons and critical care board certified emergency medicine physicians were trained in placement and nurses received management training. A formal review process was implemented to identify areas for improvement. Finally, we instituted refresher training to maintain REBOA competency. Trauma patients with noncompressible torso hemorrhage from blunt or penetrating injuries who were partial or nonresponders to blood product resuscitation were included. Pregnant patients, children, or patients with significant hemothorax or suspected aortic or cardiac injury were excluded. RESULTS Over seven months, eight catheters were successfully placed, all on the first attempt, including six in Zone 3 and two in Zone 1. All Zone 3 catheters were placed for pelvic fracture-related bleeding which were subsequently embolized. The Zone 1 catheters were placed immediately preoperatively for intraabdominal bleeding. Upon committee review, one critique was made regarding zone selection. One patient developed an arteriovenous fistula after placement which resolved without intervention. There were no other complications and all patients survived to discharge. CONCLUSIONS An REBOA program is feasible and safe following a comprehensive multidisciplinary effort. The efforts described here can be utilized by similar trauma programs for adaptation of this endovascular approach to bleeding control.
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Affiliation(s)
| | - Daniel Ricaurte
- Department of Trauma and Critical Care, Hartford Hospital, CT, USA
| | - Alfred Croteau
- Department of Trauma and Critical Care, Hartford Hospital, CT, USA
| | - Jonathan Gates
- Department of Trauma and Critical Care, Hartford Hospital, CT, USA
| | - Stacy Bass
- Department of Interventional Radiology, Hartford Hospital, CT, USA
| | - A K Jain
- Department of Vascular Surgery, Hartford Hospital, CT, USA
| | - Jane Keating
- Department of Trauma and Critical Care, Hartford Hospital, CT, USA
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18
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Maiga AW, Zuckerwise LC, Crispens MA, Sorabella LL, Prescott LS, Brown AJ, Gunter OL, Dennis BM. Early Femoral Access by Acute Care Surgeons: A Multidisciplinary Approach to Prevent Maternal Exsanguination in Placenta Accreta Spectrum. Am Surg 2023; 89:4973-4976. [PMID: 36524878 DOI: 10.1177/00031348221146956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) use has expanded to the obstetric condition of placenta accreta spectrum (PAS). Early reports of REBOA for PAS describe prophylactic catheter deployment. We developed a multidisciplinary approach to PAS, with early femoral artery access and selective REBOA deployment. We compared morbidity, mortality, and blood loss before and after implementation of our multidisciplinary protocol for PAS. Prior to, femoral access was obtained only emergently, and maternal death occurred in 2/3 cases (66%). Following protocol implementation, there was one maternal death (6%). There were no access-related complications. We have not yet needed to deploy the REBOA during PAS cases. In contrast to urgent hemorrhage control or prophylactic REBOA deployment, routine early femoral arterial access and selective REBOA deployment as part of a multidisciplinary team approach is a novel strategy for managing PAS. Our experience suggests most PAS cases do not require prophylactic REBOA deployment.
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Affiliation(s)
- Amelia W Maiga
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lisa C Zuckerwise
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marta A Crispens
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura L Sorabella
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lauren S Prescott
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Alaina J Brown
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Oliver L Gunter
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Bradley M Dennis
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, USA
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19
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Brede JR, Rehn M. The end of balloons? Our take on the UK- REBOA trial. Scand J Trauma Resusc Emerg Med 2023; 31:69. [PMID: 37908007 PMCID: PMC10619299 DOI: 10.1186/s13049-023-01142-5] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is increasingly used. The recently published UK-REBOA trial aimed to investigate patients suffering haemorrhagic shock and randomized to standard care alone or REBOA as adjunct to standard care and concludes that REBOA may increase the mortality. MAIN BODY In this commentary we try to balance the discussion on use of REBOA and address limitations in the UK-REBOA trial that may have influenced the outcome of the study. CONCLUSION The situation is complex, and the patients are in extremis. In summary, we do not think this is the end of balloons.
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Affiliation(s)
- Jostein Rødseth Brede
- Department of Emergency Medicine and Pre-Hospital Services, St. Olav's University Hospital, Prinsesse Kristinas Gate 3, 7006, Trondheim, Norway.
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway.
- Department of Anaesthesiology and Intensive Care Medicine, St. Olav's University Hospital, Trondheim, Norway.
| | - Marius Rehn
- Department of Research and Development, Norwegian Air Ambulance Foundation, Oslo, Norway
- Division of Prehospital Services, Air Ambulance Department, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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20
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Birrenbach T, Wespi R, Hautz WE, Berger J, Schwab PR, Papagiannakis G, Exadaktylos AK, Sauter TC. Development and usability testing of a fully immersive VR simulation for REBOA training. Int J Emerg Med 2023; 16:67. [PMID: 37803269 PMCID: PMC10559413 DOI: 10.1186/s12245-023-00545-6] [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: 02/12/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potentially life-saving procedure for bleeding trauma patients. Being a rare and complex procedure performed in extreme situations, repetitive training of REBOA teams is critical. Evidence-based guidelines on how to train REBOA are missing, although simulation-based training has been shown to be effective but can be costly and complex. We aimed to determine the feasibility and acceptance of REBOA training using a fully immersive virtual reality (VR) REBOA simulation, as well as assess the confidence in conducting the REBOA procedure before and after the training. METHODS Prospective feasibility pilot study of prehospital emergency physicians and paramedics in Bern, Switzerland, from November 2020 until March 2021. Baseline characteristics of trainees, prior training and experience in REBOA and with VR, variables of media use (usability: system usability scale, immersion/presence: Slater-Usoh-Steed, workload: NASA-TLX, user satisfaction: USEQ) as well as confidence prior and after VR training were accessed. RESULTS REBOA training in VR was found to be feasible without relevant VR-specific side-effects. Usability (SUS median 77.5, IQR 71.3-85) and sense of presence and immersion (Slater-Usoh-Steed median 4.8, IQR 3.8-5.5) were good, the workload without under-nor overstraining (NASA-TLX median 39, IQR 32.8-50.2) and user satisfaction high (USEQ median 26, IQR 23-29). Confidence of trainees in conducting REBOA increased significantly after training (p < 0.001). CONCLUSIONS Procedural training of the REBOA procedure in immersive virtual reality is possible with a good acceptance and high usability. REBOA VR training can be an important part of a training curriculum, with the virtual reality-specific advantages of a time- and instructor-independent learning.
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Affiliation(s)
- T Birrenbach
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland.
| | - R Wespi
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland
| | - W E Hautz
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland
| | - J Berger
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland
| | - P R Schwab
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland
- Schutz und Rettung Bern, Sanitätspolizei Bern, Bern, Switzerland
| | - G Papagiannakis
- ORamaVR SA, Geneva, Switzerland
- Institute of Computer Science, Foundation for Research and Technology, Hellas, Heraklion, Greece
- Department of Computer Science, University of Crete, Heraklion, Greece
| | - A K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland
| | - T C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse 16C, Bern, CH-3010, Switzerland
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21
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Herold J, Notov D, Reeps C, Schaser KD, Kamin K, Mäder M, Kleber C. Limb salvage in traumatic hemipelvectomy: case series with surgical management and review of the literature. Arch Orthop Trauma Surg 2023; 143:6177-6192. [PMID: 37314526 PMCID: PMC10491572 DOI: 10.1007/s00402-023-04913-y] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 05/19/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Traumatic hemipelvectomies are rare and serious injuries. The surgical management was described in several case studies, with primary amputation often performed to save the patient's life. METHODS We report of two survivors with complete traumatic hemipelvectomy resulting in ischemia and paralyzed lower extremity. Due to modern emergency medicine and reconstructive surgery, limb salvage could be attained. Long-term outcome with quality of life was assessed one year after the initial accident. RESULTS AND CONCLUSIONS The patients were able to mobilize themselves and live an independent life. The extremities remained without function and sensation. Urinary continence and sexual function were present and the colostomy could be relocated in both patients. Both patients support limb salvage, even having difficulties and follow-up treatments. Concomitant cases are required to consolidate the findings. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J Herold
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany.
| | - D Notov
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - C Reeps
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - K D Schaser
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - K Kamin
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - M Mäder
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital Carl Gustav Carus, Dresden, Germany
| | - C Kleber
- Department of Orthopedic, Trauma and Plastic Surgery, University Hospital of Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
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22
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Treffalls RN, Scheidt J, Lee C, Laverty RB, DuBose JJ, Scalea TM, Moore LJ, Podbielski JM, Inaba K, Piccinini A, Kauvar DS. Arterial Access Complications Following Percutaneous Femoral Access in 24-Hour Resuscitative Endovascular Balloon Occlusion of the Aorta Survivors. J Surg Res 2023; 290:203-208. [PMID: 37271068 DOI: 10.1016/j.jss.2023.05.004] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 06/06/2023]
Abstract
INTRODUCTION With the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) comes the potential for vascular access site complications (VASCs) and limb ischemic sequelae. We aimed to determine the prevalence of VASC and associated clinical and technical factors. METHODS A retrospective cohort analysis of 24-h survivors undergoing percutaneous REBOA via the femoral artery in the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute care surgery registry between Oct 2013 and Sep 2021 was performed. The primary outcome was VASC, defined as at least one of the following: hematoma, pseudoaneurysm, arteriovenous fistula, arterial stenosis, or the use of patch angioplasty for arterial closure. Associated clinical and procedural variables were examined. Data were analyzed using Fisher exact test, Mann-Whitney-U tests, and linear regression. RESULTS There were 34 (7%) cases with VASC among 485 meeting inclusion criteria. Hematoma (40%) was the most common, followed by pseudoaneurysm (26%) and patch angioplasty (21%). No differences in demographics or injury/shock severity were noted between cases with and without VASC. The use of ultrasound (US) was protective (VASC, 35% versus no VASC, 51%; P = 0.05). The VASC rate in US cases was 12/242 (5%) versus 22/240 (9.2%) without US. Arterial sheath size >7 Fr was not associated with VASC. US use increased over time (R2 = 0.94, P < 0.001) with a stable rate of VASC (R2 = 0.78, P = 0.61). VASC were associated with limb ischemia (VASC, 15% versus no VASC, 4%; P = 0.006) and arterial bypass procedures (VASC 3% versus no VASC 0%; P < 0.001) but amputation was uncommon (VASC, 3% versus no VASC, 0.4%; P = 0.07). CONCLUSIONS Percutaneous femoral REBOA had a 7% VASC rate which was stable over time. VASC are associated with limb ischemia but need for surgical intervention and/or amputation is rare. The use of US-guided access appears to be protective against VASC and is recommended for use in all percutaneous femoral REBOA procedures.
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Affiliation(s)
| | - Justin Scheidt
- Department of Surgery, Brooke Army Medical Center, Texas
| | - Christina Lee
- Department of Surgery, Brooke Army Medical Center, Texas
| | | | | | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Laura J Moore
- University of Texas Health Sciences Center - Houston, Houston, Texas
| | | | - Kenji Inaba
- Los Angeles County + University of Southern California Hospital, Los Angeles, California
| | - Alice Piccinini
- Los Angeles County + University of Southern California Hospital, Los Angeles, California
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23
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Mobin FU, Renaldo AC, Carrasco Perez E, Jordan JE, Neff LP, Williams TK, Johnson MA, Rahbar E. Investigating the variability in pressure-volume relationships during hemorrhage and aortic occlusion. Front Cardiovasc Med 2023; 10:1171904. [PMID: 37680564 PMCID: PMC10482261 DOI: 10.3389/fcvm.2023.1171904] [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: 02/22/2023] [Accepted: 08/01/2023] [Indexed: 09/09/2023] Open
Abstract
Introduction The pressure-volume (P-V) relationships of the left ventricle are the classical benchmark for studying cardiac mechanics and pumping function. Perturbations in the P-V relationship (or P-V loop) can be informative and guide the management of heart failure, hypovolemia, and aortic occlusion. Traditionally, P-V loop analyses have been limited to a single-beat P-V loop or an average of consecutive P-V loops (e.g., 10 cardiac cycles). While there are several algorithms to obtain single-beat estimations of the end-systolic and end-diastolic pressure-volume relations (i.e., ESPVR and EDPVR, respectively), there remains a need to better evaluate the variations in P-V relationships longitudinally over time. This is particularly important when studying acute and transient hemodynamic and cardiac events, such as active hemorrhage or aortic occlusion. In this study, we aim to investigate the variability in P-V relationships during hemorrhagic shock and aortic occlusion, by leveraging on a previously published porcine hemorrhage model. Methods Briefly, swine were instrumented with a P-V catheter in the left ventricle of the heart and underwent a 25% total blood volume hemorrhage over 30 min, followed by either Zone 1 complete aortic occlusion (i.e., REBOA), Zone 1 endovascular variable aortic control (EVAC), or no occlusion as a control, for 45 min. Preload-independent metrics of cardiac performance were obtained at predetermined time points by performing inferior vena cava occlusion during a ventilatory pause. Continuous P-V loop data and other hemodynamic flow and pressure measurements were collected in real-time using a multi-channel data acquisition system. Results We developed a custom algorithm to quantify the time-dependent variance in both load-dependent and independent cardiac parameters from each P-V loop. As expected, all pigs displayed a significant decrease in the end-systolic pressures and volumes (i.e., ESP, ESV) after hemorrhage. The variability in response to hemorrhage was consistent across all three groups. However, upon introduction of REBOA, we observed significantly high levels of variability in both load-dependent and independent cardiac metrics such as ESP, ESV, and the slope of ESPVR (Ees). For instance, pigs receiving REBOA experienced a 342% increase in ESP from hemorrhage, while pigs receiving EVAC experienced only a 188% increase. The level of variability within the EVAC group was consistently less than that of the REBOA group, which suggests that the EVAC group may be more supportive of maintaining healthier cardiac performance than complete occlusion with REBOA. Discussion In conclusion, we successfully developed a novel algorithm to reliably quantify the single-beat and longitudinal P-V relations during hemorrhage and aortic occlusion. As expected, hemorrhage resulted in smaller P-V loops, reflective of decreased preload and afterload conditions; however, the cardiac output and heart rate were preserved. The use of REBOA and EVAC for 44 min resulted in the restoration of baseline afterload and preload conditions, but often REBOA exceeded baseline pressure conditions to an alarming level. The level of variability in response to REBOA was significant and could be potentially associated to cardiac injury. By quantifying each P-V loop, we were able to capture the variability in all P-V loops, including those that were irregular in shape and believe that this can help us identify critical time points associated with declining cardiac performance during hemorrhage and REBOA use.
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Affiliation(s)
- Fahim Usshihab Mobin
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Virginia Tech, Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
- Advanced Computational Cardiovascular Lab for Trauma, Hemorrhagic Shock & Critical Care, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Antonio C. Renaldo
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Virginia Tech, Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
- Advanced Computational Cardiovascular Lab for Trauma, Hemorrhagic Shock & Critical Care, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Enrique Carrasco Perez
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - James E. Jordan
- Advanced Computational Cardiovascular Lab for Trauma, Hemorrhagic Shock & Critical Care, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - Lucas P. Neff
- Advanced Computational Cardiovascular Lab for Trauma, Hemorrhagic Shock & Critical Care, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Certus Critical Care™ Inc., Salt Lake City, UT, United States
| | - Timothy K. Williams
- Advanced Computational Cardiovascular Lab for Trauma, Hemorrhagic Shock & Critical Care, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Certus Critical Care™ Inc., Salt Lake City, UT, United States
- Department of Vascular and Endovascular Surgery, Wake Forest University School of Medicine, Winston Salem, NC, United States
| | - M. Austin Johnson
- Certus Critical Care™ Inc., Salt Lake City, UT, United States
- Department of Surgery, Division of Emergency Medicine, The University of Utah, Salt Lake City, UT, United States
| | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest University School of Medicine, Winston Salem, NC, United States
- Virginia Tech, Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
- Advanced Computational Cardiovascular Lab for Trauma, Hemorrhagic Shock & Critical Care, Wake Forest University School of Medicine, Winston Salem, NC, United States
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24
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Shaw J, Brenner M. Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results. Semin Vasc Surg 2023; 36:250-257. [PMID: 37330238 DOI: 10.1053/j.semvascsurg.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 06/19/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.
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Affiliation(s)
- Joanna Shaw
- Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, California, 90024
| | - Megan Brenner
- Department of Surgery, UCLA David Geffen School of Medicine, 10833 Le Conte Avenue #72, Los Angeles, California, 90024.
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25
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Lopachin T, Treager CD, Sulava EF, Stuart SM, Bohan ML, Boboc M, Fernandez P, Bianchi WD, McGowan AJ, Friedrich EE. Ultrasound Localization of Resuscitative Endovascular Balloon Occlusion of the Aorta in a Human Cadaver Model. J Spec Oper Med 2023:8MDD-BY4I. [PMID: 37169530 DOI: 10.55460/8mdd-by4i] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
OBJECTIVE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a method of gaining proximal control of noncompressible torso hemorrhage (NCTH). Catheter placement is traditionally confirmed with fluoroscopy, but few studies have evaluated whether ultrasound (US) can be used. METHODS Using a pressurized human cadaver model, a certified REBOA placer was shown one of four randomized cards that instructed them to place the REBOA either correctly or incorrectly in Zone 1 (the distal thoracic aorta extending from the celiac artery to the left subclavian artery) or Zone 3 (in the distal abdominal aorta, from the aortic bifurcation to the lowest renal artery). Once the REBOA was placed, 10 US-trained locators were asked to confirm balloon placement via US. The participants were given 3 minutes to determine whether the catheter had been correctly placed, repeating this 20 times on two cadavers. RESULTS Overall, US exhibited an average sensitivity of 83%, specificity of 76%, and accuracy of 80%. For Zone 1, US showed a sensitivity of 78% and specificity of 83%, and for Zone 3, a sensitivity of 88% and specificity of 76%. In addition, US exhibited a likelihood positive ratio (LR+) of 3.73 and a likelihood negative ratio (LR-) of 0.22 for either position, with similar numbers for Zone 1 (+4.57, -0.26) and Zone 3 (+3.16, -0.16). CONCLUSION Ultrasound could prove to be a useful tool for confirming placement of a REBOA catheter, especially in austere environments.
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26
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Ye Y, Li J, Liu S, Zhao Y, Wang Y, Chu Y, Peng W, Lu C, Liu C, Zhou J. Efficacy of resuscitative endovascular balloon occlusion of the aorta for hemorrhage control in patients with abnormally invasive placenta: a historical cohort study. BMC Pregnancy Childbirth 2023; 23:333. [PMID: 37165316 PMCID: PMC10170700 DOI: 10.1186/s12884-023-05649-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 04/26/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Patients with abnormally invasive placenta (AIP) are at high risk of massive postpartum hemorrhage. Resuscitative endovascular balloon occlusion of the aorta (REBOA), as an adjunct therapeutic strategy for hemostasis, offers the obstetrician an alternative for treating patients with AIP. This study aimed to evaluate the role of REBOA in hemorrhage control in patients with AIP. METHODS This was a historical cohort study with prospectively collected data between January 2014 to July 2021 at a single tertiary center. According to delivery management, 364 singleton pregnant AIP patients desiring uterus preservation were separated into two groups. The study group (balloon group, n = 278) underwent REBOA during cesarean section, whereas the reference group (n = 86) did not undergo REBOA. Surgical details and maternal outcomes were collected. The primary outcome was estimated blood loss and the rate of uterine preservation. RESULTS A total of 278 (76.4%) participants experienced REBOA during cesarean section. The patients in the balloon group had a smaller blood loss during cesarean Sect. (1370.5 [752.0] ml vs. 3536.8 [1383.2] ml; P < .001) and had their uterus salvaged more often (264 [95.0%] vs. 23 [26.7%]; P < .001). These patients were also less likely to be admitted to the intensive care unit after delivery (168 [60.4%] vs. 67 [77.9%]; P = .003) and had a shorter operating time (96.3 [37.6] min vs. 160.6 [45.5] min; P < .001). The rate of neonatal intensive care unit admission (176 [63.3%] vs. 52 [60.4%]; P = .70) and total maternal medical costs ($4925.4 [1740.7] vs. $5083.2 [1705.1]; P = .13) did not differ between the two groups. CONCLUSIONS As a robust hemorrhage-control technique, REBOA can reduce intraoperative hemorrhage in patients with AIP. The next step is identifying associated risk factors and defining REBOA inclusion criteria to identify the subgroups of AIP patients who may benefit more.
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Affiliation(s)
- Yuanhua Ye
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Jing Li
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Shiguo Liu
- Prenatal Diagnosis Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yang Zhao
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yanhua Wang
- Interventional Medical Center, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, China
| | - Yijing Chu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Wei Peng
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Caixia Lu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Chong Liu
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China
| | - Jun Zhou
- Department of Obstetrics and Gynecology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, Shandong Province, 266003, China.
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Qiu J, Chen X, Wu D, Zhang X, Cheng D. One-dimensional analysis method of pulsatile blood flow in arterial network for REBOA operations. Comput Biol Med 2023; 159:106898. [PMID: 37062253 DOI: 10.1016/j.compbiomed.2023.106898] [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: 12/06/2022] [Revised: 03/07/2023] [Accepted: 04/09/2023] [Indexed: 04/18/2023]
Abstract
Based on the generalized Darcy model, here we develop a linear one-dimensional (1D) composite model to predict the effects of the inserted balloon under REBOA operations on the dynamic characteristics of blood flow in flexible arterial networks. We first consider the effect of the decrease of cardiac output under different degrees of blood loss through employing the fourth-order lumped parameter model of cardiovascular system. Then, the effect of the inserted balloon is included by developing the relation between flow resistance and occlusion ratio with the neural network approach. Finally, the accuracy of the developed 1D composite model for REBOA operations, which can be solved analytically in the frequency domain, is verified by comparing to computational fluid dynamics (CFD) simulations. It is demonstrated that the 1D model is able to reproduce main features of the systemic circulation under balloon occlusion of the aorta during REBOA surgery. The 1D composite model could substantially reduce the computational time, which makes it possible to give the instant prediction of the working parameters during RABOA operations.
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Affiliation(s)
- Jiade Qiu
- College of Chemical Engineering, Beijing University of Chemical Technology, Beijing, 100029, China
| | - Xin Chen
- College of Chemical Engineering, Beijing University of Chemical Technology, Beijing, 100029, China
| | - Dengfeng Wu
- College of Chemical Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
| | - Xianren Zhang
- College of Chemical Engineering, Beijing University of Chemical Technology, Beijing, 100029, China
| | - Daojian Cheng
- College of Chemical Engineering, Beijing University of Chemical Technology, Beijing, 100029, China.
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28
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Takata T, Yamada K, Yamamoto M, Kondo H. REBOA Zone Estimation from the Body Surface Using Semantic Segmentation. J Med Syst 2023; 47:42. [PMID: 36995484 DOI: 10.1007/s10916-023-01938-z] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 03/06/2023] [Indexed: 03/31/2023]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular procedure for hemorrhage control. In REBOA, the balloon must be placed in the precise place, but it may be performed without X-ray fluoroscopy. This study aimed to estimate the REBOA zones from the body surface using deep learning for safe balloon placement. A total of 198 abdominal computed tomography (CT) datasets containing the regions of the REBOA zones were collected from open data libraries. Then, depth images of the body surface generated from the CT datasets and the images corresponding to the zones were labeled for deep learning training and validation. DeepLabV3+, a deep learning semantic segmentation model, was employed to estimate the zones. We used 176 depth images as training data and 22 images as validation data. A nine-fold cross-validation was performed to generalize the performance of the network. The median Dice coefficients for Zones 1-3 were 0.94 (inter-quarter range: 0.90-0.96), 0.77 (0.60-0.86), and 0.83 (0.74-0.89), respectively. The median displacements of the zone boundaries were 11.34 mm (5.90-19.45), 11.40 mm (4.88-20.23), and 14.17 mm (6.89-23.70) for the boundary between Zones 1 and 2, between Zones 2 and 3, and between Zone 3 and out of zone, respectively. This study examined the feasibility of REBOA zone estimation from the body surface only using deep learning-based segmentation without aortography.
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Affiliation(s)
- Takeshi Takata
- Advanced Comprehensive Research Organization, Teikyo University, Tokyo, Japan.
| | - Kentaro Yamada
- Dotter Interventional Institute, Oregon Health & Science University, Portland, OR, USA
| | - Masayoshi Yamamoto
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Hiroshi Kondo
- Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
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29
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Hilbert-Carius P, Schmalbach B, Wrigge H, Schmidt M, Abu-Zidan FM, Aschenbrenner U, Streibert F. Do we need pre-hospital resuscitative endovascular balloon occlusion of the aorta ( REBOA) in the civilian helicopter emergency medical services (HEMS)? Intern Emerg Med 2023; 18:627-637. [PMID: 36463569 DOI: 10.1007/s11739-022-03158-8] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 11/20/2022] [Indexed: 12/05/2022]
Abstract
Pre-hospital resuscitative endovascular balloon occlusion of the aorta (REBOA) can be a life-saving procedure for patients with non-compressible torso hemorrhage. We aimed to evaluate the potential eligibility for REBOA in trauma patients of a civilian helicopter emergency medical service (HEMS) using a stepwise approach. A retrospective analysis using the electronic database (HEMSDER) of "DRF Luftrettung" HEMS covering the period from January 2015 to June 2021 was performed. Trauma patients aged ≥ 16 years and with a National Advisory Committee for Aeronautics (NACA) score of ≥ 4 were assessed for potential REBOA eligibility using two different decision trees based on assumed severe bleeding due to injuries of the abdomen, pelvis, and/or lower extremities and different vital signs on the scene and at hospital handover. Non-parametric statistical methods were used for comparison. A total of 22.426 patients met the inclusion criteria for data analysis. Of these, 0.15-2.24% were possible candidates for pre-hospital REBOA. No significant differences between groups on scene and at hospital handover regarding demographics, assumed injuries, and pre-hospital interventions were found. In the on-scene group, 21.1% of the patients remained unstable even at hospital handover despite pre-hospital care. In the handover group, 42.8% of the patients seemed initially stable but then deteriorated during the pre-hospital course. The number of potential pre-hospital REBOA in severely injured patients with a NACA score of ≥ 4 is < 3% or can be even < 1% if more strict criteria are used. There are some patients who may benefit from pre-hospital REBOA as a life-saving procedure. Further research on earlier diagnosis of life-threatening bleeding and proper indications of REBOA in trauma patients is needed.
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Affiliation(s)
- Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bergmannstrost BG Hospital, Merseburgerstr. 165, 06179, Halle (Saale), Germany.
- DRF Luftrettung (German Air Rescue) HEMS, Christoph 84 and 85, Halle (Saale), Germany.
| | - Bjarne Schmalbach
- Wissenschaftlicher Arbeitskreis (Scientific Working Group) of DRF Luftrettung, Filderstadt, Germany
| | - Hermann Wrigge
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bergmannstrost BG Hospital, Merseburgerstr. 165, 06179, Halle (Saale), Germany
- Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Merve Schmidt
- Wissenschaftlicher Arbeitskreis (Scientific Working Group) of DRF Luftrettung, Filderstadt, Germany
| | - Fikri M Abu-Zidan
- Consultant of Statistics and Research Methodology, The Research Office, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Ulf Aschenbrenner
- Wissenschaftlicher Arbeitskreis (Scientific Working Group) of DRF Luftrettung, Filderstadt, Germany
- DRF Luftrettung (German Air Rescue) HEMS, Christoph Dortmund, Dortmund, Germany
| | - Fridolin Streibert
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Bergmannstrost BG Hospital, Merseburgerstr. 165, 06179, Halle (Saale), Germany
- DRF Luftrettung (German Air Rescue) HEMS, Christoph 84 and 85, Halle (Saale), Germany
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Fiedler MO, Böckler D, Giese H, Popp E, Schmitt FCF, Weigand MA, Erhart P. Case report: Resuscitative endovascular balloon occlusion after iatrogenic injury of the common iliac artery during neurosurgical dorsal lumbar microdiscectomy. Front Med (Lausanne) 2023; 10:1112847. [PMID: 36817774 PMCID: PMC9933979 DOI: 10.3389/fmed.2023.1112847] [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: 11/30/2022] [Accepted: 01/10/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction and importance This case report describes resuscitative endovascular balloon occlusion (REBOA) of the aorta in a patient with life-threatening iatrogenic bleeding of the right common iliac artery during elective dorsal lumbar spine surgery. REBOA is an emergency procedure for temporary intra-aortic balloon occlusion being increasingly reported and published since its inauguration in 1954. The interdisciplinary management of hemorrhage and technical notes for a successful REBOA procedure will be presented. Case presentation A 53-year-old female patient was admitted to the neurosurgery clinic suffering from left-sided L5 radiculopathy. During surgery, the anterior longitudinal ligament was perforated and an arterial vessel was lacerated. The patient became hemodynamically unstable demanding prompt supine repositioning and cardiopulmonary resuscitation (CPR). REBOA enabled cardiovascular stabilization after 90 min of CPR and laparotomy with vascular reconstruction and contributed to the survival of the patient without major clinical deficits. The patient was discharged from the ICU after 7 days. Clinical discussion Resuscitative endovascular balloon occlusion of the aorta is an emergency procedure to control life-threatening hemorrhage. REBOA should be available on-scene and applied by well-trained vascular surgery personnel to control vascular complications or extend to emergency laparotomy and thoracotomy with aortic cross-clamping in case of in-hospital non-controllable hemorrhages. In case of ongoing CPR, we recommend surgical groin incision, open puncture of the pulseless common femoral artery, and aortic balloon inflation in REBOA zone I. Hereby, fast access and CPR optimization for heart and brain perfusion are maintained. Conclusion Training for REBOA is the decisive factor to control selected cases of in-house and outpatient massive arterial abdominal bleeding complications.
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Affiliation(s)
- Mascha O. Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany,*Correspondence: Mascha O. Fiedler,
| | - Dittmar Böckler
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Henrik Giese
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Erik Popp
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix C. F. Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A. Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Philipp Erhart
- Department of Vascular and Endovascular Surgery, Heidelberg University Hospital, Heidelberg, Germany
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Vandenbriele C, Nijs S, Rega F, Balthazar T. A femoral Impella TM CP plus REBOA for combined cardiogenic and haemorrhagic shock. Acta Cardiol 2023; 78:267-268. [PMID: 36729027 DOI: 10.1080/00015385.2023.2169436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Christophe Vandenbriele
- Department of Cardiovascular Sciences, University Hospitals Leuven, Leuven, Belgium.,Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Stefaan Nijs
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tim Balthazar
- Department of Cardiology, University Hospitals Brussel, Jette, Belgium
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Chien CY, Lewis MR, Dilday J, Biswas S, Luo Y, Demetriades D. Worse outcomes with resuscitative endovascular balloon occlusion of the aorta in severe pelvic fracture: A matched cohort study. Am J Surg 2023; 225:414-419. [PMID: 36253317 DOI: 10.1016/j.amjsurg.2022.09.057] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 08/20/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Severe pelvic fracture is the most common indication for resuscitative endovascular balloon occlusion of the aorta (REBOA). This matched cohort study investigated outcomes with or without REBOA use in isolated severe pelvic fractures. METHODS Trauma Quality Improvement Program database study, included patients with isolated severe pelvic fracture (AIS≥3), excluded associated injuries with AIS >3 for any region other than lower extremity. REBOA patients were propensity score matched to similar patients without REBOA. Outcomes were mortality and complications. RESULTS 93 REBOA patients were matched with 279 without. REBOA patients had higher rates of in-hospital mortality (32.3% vs 19%, p = 0.008), higher rates of venous thromboembolism (14% vs 6.5%, p = 0.023) and DVT (11.8% vs 5.4%, p = 0.035). In multivariate analysis, REBOA use was independently associated with increased mortality and venous thromboembolism. CONCLUSIONS REBOA in severe pelvic fractures is associated with higher rates of mortality, venous thromboembolism.
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Affiliation(s)
- Chih-Ying Chien
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Department of General Surgery, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Meghan R Lewis
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Joshua Dilday
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Subarna Biswas
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States
| | - Yong Luo
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States; Trauma Center & Critical Care Medicine, The Second Affiliated Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, China
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, CA, United States.
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Carlsen MIS, Aalberg NK, Sandø AD, Skrede S, Gisvold SE, Uleberg O. The use of Resuscitative Endovascular Balloon Occlusion of the Aorta in a pregnant woman with a ruptured splenic aneurysm and haemorrhagic shock: A case report. Acta Anaesthesiol Scand 2023; 67:230-232. [PMID: 36357321 PMCID: PMC10099586 DOI: 10.1111/aas.14172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/12/2022]
Affiliation(s)
| | | | | | - Solveig Skrede
- Department Gynaecology and Obstetrics, St. Olav's University Hospital, Trondheim, Norway
| | - Sven Erik Gisvold
- Department of Anaesthesia and Intensive Care, St. Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Oddvar Uleberg
- Department of Emergency Medicine and Pre-hospital services, St. Olav's University Hospital, Trondheim, Norway
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Webster LA, Little O, Villalobos A, Nguyen J, Nezami N, Lilly M, Dariushnia S, Gandhi R, Kokabi N. REBOA: Expanding Applications From Traumatic Hemorrhage to Obstetrics and Cardiopulmonary Resuscitation, From the AJR Special Series on Emergency Radiology. AJR Am J Roentgenol 2023; 220:16-22. [PMID: 35920708 DOI: 10.2214/AJR.22.27932] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged over the past decade as a technique to control life-threatening hemorrhage and treat hemorrhagic shock, being increasingly used to treat noncompressible traumatic torso hemorrhage. Reports during this time also support the use of a REBOA device for an expanding range of indications including nontraumatic abdominal hemorrhage, postpartum hemorrhage, placenta accreta spectrum (PAS) disorder, and cardiopulmonary resuscitation (CPR). The strongest available evidence supports REBOA as a lifesaving adjunct to definitive surgical management in trauma and as a method to help avoid hysterectomy in select patients with postpartum hemorrhage or PAS disorder. In comparison with initial descriptions of complete REBOA inflation, techniques for partial REBOA inflation have been introduced to achieve hemodynamic stability while minimizing adverse events relating to reperfusion injuries. Fluoroscopy-free REBOA has been described in various settings, including trauma, obstetrics, and out-of-hospital cardiac arrest. As the use of REBOA expands outside the trauma setting and into nontraumatic abdominal hemorrhage, obstetrics, and CPR, it is imperative for radiologists to become familiar with this technology, its proper placement, and its potential adverse sequelae.
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35
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Kelly C, Stoecklein HH, Brant-Zawadzki G, Hoareau G, Daley J, Selzman C, Youngquist S, Johnson A. TEE guided REBOA deflation following ROSC for non-traumatic cardiac arrest. Am J Emerg Med 2023; 63:182.e5-182.e7. [PMID: 36280542 DOI: 10.1016/j.ajem.2022.10.013] [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: 09/20/2022] [Accepted: 10/09/2022] [Indexed: 11/05/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is most commonly used to manage non-compressible torso hemorrhage. It is also emerging as a promising treatment for non-traumatic refractory cardiac arrest. Aortic occlusion during chest compressions increases cardio-cerebral perfusion, increasing the potential for sustained return of spontaneous circulation (ROSC) or serving as a bridge to extracorporeal cardiopulmonary resuscitation (ECPR). Optimal patient selection and post-ROSC management in such cases is uncertain and not well reported in the literature. We present a case of non-traumatic out-of-hospital cardiac arrest in which REBOA was placed in the emergency department with subsequent ROSC. Transesophageal echocardiography was used to guide post-ROSC REBOA management and balloon deflation.
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Affiliation(s)
- Christopher Kelly
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA.
| | - H Hill Stoecklein
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Guillaume Hoareau
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - James Daley
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
| | - Craig Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | - Scott Youngquist
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
| | - Austin Johnson
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT, USA
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36
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Ko HJ, Koo HF, Al-Saadi N, Froghi S. A comparison of mortality and indicators of treatment success of resuscitative endovascular balloon occlusion of aorta ( REBOA): a systematic review and meta-analysis. Indian J Thorac Cardiovasc Surg 2023; 39:27-36. [PMID: 36590045 PMCID: PMC9794671 DOI: 10.1007/s12055-022-01413-3] [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: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/12/2022] [Indexed: 11/11/2022] Open
Abstract
Background Emergency resuscitative thoracotomy (RT) is a recognised method of controlling non-compressible torso haemorrhage (NCTH) often in adjunct to emergency surgery. Recently, there is much debate regarding resuscitative endovascular balloon occlusion of aorta (REBOA) on its role in civilian trauma cases in controlling NCTH. This study aims to provide an updated review on in-hospital mortality rates in patients who underwent REBOA versus RT and standard care without REBOA (non-REBOA) and to identify the potential indicators of REBOA survival. Methods Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were used to perform the study. All adult trauma cases were included, while pre-hospital, military and non-English studies were excluded. A literature search was done on studies from 01 January 2005 to 30 June 2020 using EMBASE, MEDLINE and COCHRANE databases. Risk of bias was assessed using the Methodological Index for Non-Randomised Studies (MINORS) tool. Meta-analysis was conducted using a random effects model and the DerSimonian and Laird estimation method. A significance level of p < 0.05 was used. Results Twenty-five studies were included in this study. The odds of in-hospital mortality of patients who underwent REBOA compared to RT was 0.18 (p < 0.01, 0.12-0.26). The odds of in-hospital survival of patients who underwent REBOA compared to non-REBOA was 1.28 (p = 0.62, 0.46-3.53). There was a significant difference found between survivors and non-survivors in terms of their pre-REBOA systolic blood pressure (SBP) (19.26 mmHg, p < 0.01), post-REBOA SBP (20.73 mmHg, p < 0.01), duration of aortic occlusion (- 40.57 min, p < 0.01) and injury severity score (- 8.50, p < 0.01). Conclusions REBOA has a potential for wider application in civilian settings, with our study demonstrating lower in-hospital mortality compared to RT. Prospective multi-centre studies are needed for further evaluation of the indications and feasibility of REBOA.Level of Evidence + Study Type: Level IV. Systematic review with meta-analysis. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-022-01413-3.
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Affiliation(s)
- Ho Juen Ko
- University College London, London, UK
- Department of HPB & Liver Transplantation, Division of Surgery & Interventional Sciences, Royal Free Hospital, Pond Street, Hampstead, NW2 2QG London UK
| | | | - Nina Al-Saadi
- Vascular Surgery Glenfield Hospital UHL NHS Trust, Leicester, UK
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Chavez MA, Weinberg JA, Jacobs JV, Soe-Lin H, Chapple KM, Ryder M, Conley I, Bogert JN. Commonly performed pelvic binder modifications for femoral access may hinder binder efficacy. Am J Surg 2022; 224:1464-1467. [PMID: 35623945 DOI: 10.1016/j.amjsurg.2022.04.032] [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: 07/01/2021] [Revised: 03/06/2022] [Accepted: 04/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pelvic fractures are common and potentially life-threatening. Pelvic circumferential compression devices (PCCD) can temporize hemorrhage, but more invasive strategies that involve femoral access may be necessary for definitive treatment. The aim of our study was to evaluate the efficacy of PCCDs reducing open book pelvic fractures when utilizing commonly described modifications and placement adjustments that allow for access to the femoral vasculature. METHODS Open book pelvic fractures were created in adult cadavers. Three commercially available PCCDs were used to reduce fractures. The binders were properly placed, moved caudally, or moved cranially and modified. Fracture reduction rates were then recorded. RESULTS The pelvic fracture was completely reduced with every PCCD tested when properly placed. Reduction rates decreased with improper placement and modifications. CONCLUSION Modifying PCCD placement to allow femoral access decreased the effectiveness of these devices Clinicians should be aware of this possibility when caring for critically injured trauma patients with pelvic fractures.
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Affiliation(s)
- Marin A Chavez
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan A Weinberg
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Jordan V Jacobs
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Hahn Soe-Lin
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Kristina M Chapple
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States
| | - Madison Ryder
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - Ian Conley
- Ira A. Fulton School of Engineering at Arizona State University, 699 S. Mill Ave. Tempe, Arizona, 85281, United States
| | - James N Bogert
- St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd. Phoenix, Arizona, 85013, United States.
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Caicedo Y, Gallego LM, Clavijo HJ, Padilla-Londoño N, Gallego CN, Caicedo-Holguín I, Guzmán-Rodríguez M, Meléndez-Lugo JJ, García AF, Salcedo AE, Parra MW, Rodríguez-Holguín F, Ordoñez CA. Resuscitative endovascular balloon occlusion of the aorta in civilian pre-hospital care: a systematic review of the literature. Eur J Med Res 2022; 27:202. [PMID: 36253841 PMCID: PMC9575194 DOI: 10.1186/s40001-022-00836-3] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/22/2022] [Indexed: 11/25/2022] Open
Abstract
Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a damage control tool with a potential role in the hemodynamic resuscitation of severely ill patients in the civilian pre-hospital setting. REBOA ensures blood flow to vital organs by early proximal control of the source of bleeding. However, there is no consensus on the use of REBOA in the pre-hospital setting. This article aims to perform a systematic review of the literature about the feasibility, survival, indications, complications, and potential candidates for civilian pre-hospital REBOA. Methods A literature search was conducted using Medline, EMBASE, LILACS and Web of Science databases. Primary outcome variables included overall survival and feasibility. Secondary outcome variables included complications and potential candidates for endovascular occlusion. Results The search identified 8 articles. Five studies described the use of REBOA in pre-hospital settings, reporting a total of 47 patients in whom the procedure was attempted. Pre-hospital REBOA was feasible in 68–100% of trauma patients and 100% of non-traumatic patients with cardiac arrest. Survival rates and complications varied widely. Pre-hospital REBOA requires a coordinated and integrated emergency health care system with a well-trained and equipped team. The remaining three studies performed a retrospective analysis identifying 784 potential REBOA candidates. Conclusions Pre-hospital REBOA could be a feasible intervention for a significant portion of severely ill patients in the civilian setting. However, the evidence is limited. The impact of pre-hospital REBOA should be assessed in future studies. Supplementary Information The online version contains supplementary material available at 10.1186/s40001-022-00836-3.
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Affiliation(s)
- Yaset Caicedo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Linda M Gallego
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia
| | - Hugo Jc Clavijo
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Natalia Padilla-Londoño
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Cindy-Natalia Gallego
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia
| | - Isabella Caicedo-Holguín
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Instituto de Ciencias Biomédicas, Facultad de Medicina, Universidad de Chile, Av. Libertador Bernardo O'Higgins 1058, Santiago de Chile, Región Metropolitana, Chile
| | - Juan J Meléndez-Lugo
- Department of Surgery, Caja Costarricense del Seguro Social, Av. 2nda - 4rta Cl. 5nta - 7tima, San José, Costa Rica
| | - Alberto F García
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cl. 13 # 100 - 00, Valle del Cauca, Cali, Colombia
| | - Alexander E Salcedo
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cl. 13 # 100 - 00, Valle del Cauca, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Department of Surgery, Hospital Universitario del Valle, Cl. 5 # 36 - 08, Valle del Cauca, Cali, Colombia
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, 1600 S Andrews Ave, Fort Lauderdale, FL, USA
| | - Fernando Rodríguez-Holguín
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia
| | - Carlos A Ordoñez
- Facultad de Medicina, Universidad Icesi, Cl. 18 No. 122 - 135, Valle del Cauca, Cali, Colombia. .,Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra. 98 No. 18 - 49, Valle del Cauca, 760032, Cali, Colombia. .,Division of Trauma and Acute Care Surgery, Department of Surgery, Universidad del Valle, Cl. 13 # 100 - 00, Valle del Cauca, Cali, Colombia.
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Daley J, Buckley R, Kisken KC, Barber D, Ayyagari R, Wira C, Aydin A, Latich I, Lozada JCP, Joseph D, Marino A, Mojibian H, Pollak J, Chaar CO, Bonz J, Belsky J, Coughlin R, Liu R, Sather J, Van Tonder R, Beekman R, Fults E, Johnson A, Moore C. Emergency department initiated resuscitative endovascular balloon occlusion of the aorta ( REBOA) for out-of-hospital cardiac arrest is feasible and associated with improvements in end-tidal carbon dioxide. J Am Coll Emerg Physicians Open 2022; 3:e12791. [PMID: 36176506 PMCID: PMC9463569 DOI: 10.1002/emp2.12791] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/20/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Out-of-hospital cardiac arrest (OHCA) claims the lives of approximately 350,000 people in the United States each year. Resuscitative endovascular balloon occlusion of the aorta (REBOA) when used as an adjunct to advanced cardiac life support may improve cardio-cerebral perfusion. Our primary research objective was to determine the feasibility of emergency department (ED)-initiated REBOA for OHCA patients in an academic urban ED. Methods This was a single-center, single-arm, early feasibility trial that used REBOA as an adjunct to advanced cardiac life support (ACLS) in OHCA. Subjects under 80 years with witnessed OHCA and who received cardiopulmonary rescuitation (CPR) within 6 minutes were eligible. Results Five patients were enrolled between February 2020 and April 2021. The procedure was successful in all patients and 4 of 5 (80%) patients had transient return of spontaneous circulation (ROSC) after aortic occlusion. Unfortunately, all patients re-arrested soon after intra-aortic balloon deflation and none survived to hospital admission. At 30 seconds post-aortic occlusion, investigators noted a statistically significant increase in end tidal carbon dioxide of 26% (95% confidence interval, 10%, 44%). Conclusion Initiating REBOA for OHCA patients in an academic urban ED setting is feasible. Aortic occlusion during chest compressions is temporally associated with improvements in end tidal carbon dioxide 30 seconds after aortic occlusion. Four of 5 patients achieved ROSC after aortic occlusion; however, deflation of the intra-aortic balloon quickly led to re-arrest and death in all patients. Future research should focus on the utilization of partial-REBOA to prevent re-arrest after ROSC, as well as the optimal way to incorporate this technique with other endovascular reperfusion strategies.
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Martin SC, Hauser N, Renaldo AC, Lane M, Jordan JE, Qadri HI, Mouser N, Rahbar E, Williams TK, Neff LP. Unmasking the Confounder: The Inherent Physiologic Variability of Swine During an Automated Experimental Model of Ischemia-Reperfusion Injury. Am Surg 2022; 88:1838-1844. [PMID: 35392677 DOI: 10.1177/00031348221084967] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to determine the magnitude of the inherent inter-animal physiologic variability by automating a porcine Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) protocol to minimize external influences that might alter physiology and confound experimental results. METHODS Swine (n = 42) underwent a controlled 30% blood volume hemorrhage followed by 30 minutes of REBOA (ie, ischemic phase). The animals were weaned from REBOA autonomously over 15 minutes, beginning the reperfusion phase, while continuing to provide partial flow balloon support to maintain a target proximal mean arterial pressure (pMAP) of 65 mmHg. Simultaneously, shed blood was re-transfused as part of the resuscitation efforts. Physiologic data were continuously recorded, and serum samples were serially collected. Baseline characteristics, variance in vital signs, and 8-isoprostane levels were quantified during hemorrhage, REBOA, and reperfusion phases. RESULTS There was no significant difference in baseline physiology across animals (P > .05). Hemodynamic variability was highest for pMAP during the ischemic phase (P = .001) and for distal mean arterial pressure (dMAP) during the weaning/reperfusion phase (P = .001). The latter finding indicated the variable physiologic response to ischemia-reperfusion injury, as the automated balloon support required by each animal to maintain pMAP was highly variable. Circulating 8-isoprostane variance was significantly higher following the start of reperfusion compared to baseline levels (P = .001). DISCUSSION Despite subjecting animals to a highly consistent ischemia-reperfusion injury through automation, we noted significant variability in the hemodynamic and biochemical response. These findings illustrate the inherent physiologic variability and potential limitations of porcine large animal models for the study of shock.
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Affiliation(s)
| | - Nathaniel Hauser
- Department of Biomedical Engineering, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Antonio C Renaldo
- Department of Biomedical Engineering, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Magan Lane
- Department of Vascular and Endovascular Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - James E Jordan
- Department of Cardiothoracic Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Hisham I Qadri
- 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Elaheh Rahbar
- Department of Biomedical Engineering, 12279Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Timothy K Williams
- Department of Vascular and Endovascular Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
| | - Lucas P Neff
- Department of General Surgery, 12280Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
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van der Burg BLSB, Vrancken S, van Dongen TTCF, Wamsteker T, Rasmussen T, Hoencamp R. Comparison of aortic zones for endovascular bleeding control: age and sex differences. Eur J Trauma Emerg Surg 2022; 48:4963-4969. [PMID: 35794255 DOI: 10.1007/s00068-022-02033-7] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/05/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To gain insight into anatomical variations between sexes and different age groups in intraluminal distances and anatomical landmarks for correct insertion of resuscitative endovascular balloon occlusion of the aorta (REBOA) without fluoroscopic confirmation. MATERIALS All non-trauma patients receiving a computed tomography angiography (CT-A) scan of the aorta, iliac bifurcation and common femoral arteries from 2017 to 2019 were eligible for inclusion. METHODS Central luminal line distances from the common femoral artery (CFA) to the aortic occlusion zones were measured and diameters of mid zone I, II and III were registered. Anatomical landmarks and correlations were assessed. A simulated REBOA placement was performed using the Joint Trauma System Clinical Practice Guideline (JTSCPG). RESULTS In total, 250 patients were included. Central luminal line (CLL) measurements from mid CFA to aortic bifurcation (p = 0.000), CLL measurements from CFA to mid zone I, II and III (p = 0.000) and zone I length (p = 0.000) showed longer lengths in men. The length of zone I and III (p = 0.000), CLL distance measurements from the right CFA to mid zone I (p = 0.000) and II (p = 0.013) and aortic diameters measured at mid zone I, II and III increased in higher age groups (p = 0.000). Using the JTSCPG guideline, successful deployment occurred in 95/250 (38.0%) in zone III and 199/250 (79.6%) in zone I. Correlation between mid-sternum and zone I is 100%. Small volume aortic occlusion balloons (AOB) have poor occlusion rates in zone I (0-2.8%) and III (4.4-34.4%). CONCLUSIONS Men and older age groups have longer CLL distances to zone I and III and introduction depths of AOB must be adjusted. The risk of not landing in zone III with standard introduction depths is high and balloon position for zone III REBOA is preferably confirmed using fluoroscopy. Mid-sternum can be used as a landmark in all patient groups for zone I. In older patients, balloon catheters with larger inflation volumes must be considered for aortic occlusion.
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Affiliation(s)
| | - Suzanne Vrancken
- Department of Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
| | | | - Tom Wamsteker
- Department of Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
| | | | - Rigo Hoencamp
- Department of Surgery, Alrijne Hospital Leiderdorp, Simon Smitweg 1, 2353GA, Leiderdorp, The Netherlands
- Defense Healthcare Organization, Ministry of Defense, Utrecht, The Netherlands
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Liu J, Zhang J, Xie S, Liu Y, Zhou X, Li Z, Han X. The Effects of Increasing Aortic Occlusion Times at the Level of the Highest Renal Artery (Zone II) in the Normovolemic Rabbit Model. Acad Radiol 2022; 29:986-93. [PMID: 34400077 DOI: 10.1016/j.acra.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/10/2021] [Accepted: 07/14/2021] [Indexed: 11/20/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effects of increasing zone II resuscitative endovascular balloon occlusion of the aorta (REBOA) occlusion times on physiological, end-organ and inflammatory responses in rabbits to assess the safe aortic occlusion time in a normovolemic rabbit model. METHODS The zone ll aorta was occluded with a balloon in 32 rabbits (8 animals each for 15, 30, 60, and 90 min). 8 rabbits served as a control. ELISAs were used to examine the serum levels of ALT, AST, Cr, BUN, MDA, SOD, IL-8, IL-6, and TNF-α; HE staining was used to identify the morphological changes in the kidney; RT-PCR was used to detect the mRNA levels of IL-6, IL-8, TNF-α and NF-κB in the kidney and uterus; and Western blotting was used to measure the protein expression levels of IL-6, IL-8, TNF-α and NF-κB in the kidney and uterus. RESULTS Plasma concentrations of liver markers, kidney markers, inflammatory factors and oxidative stress indicators were significantly increased at the end of reperfusion in the 30 min, 60 min and 90 min groups. Damage to the kidney occurred in the 30 min, 60 min and 90 min groups. The mRNA and protein expression levels of IL-6, IL-8, TNF-α and NF-κB in the kidney and uterus were significantly increased at the end of reperfusion in the 30 min group, and as the time of occlusion extended, these levels continued to increase. CONCLUSION Activation of systemic inflammation and ischaemia-reperfusion injury of end-organs occurred when the occlusion time reached 30 min. Therefore, 15 min should be regarded as a safe period of REBOA in zone II.
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McCracken BM, Ward KR, Tiba MH. A review of two emerging technologies for pre-hospital treatment of non-compressible abdominal hemorrhage. Transfusion 2022; 62 Suppl 1:S313-S322. [PMID: 35748670 PMCID: PMC9542827 DOI: 10.1111/trf.16961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 03/14/2022] [Accepted: 03/21/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Brendan M McCracken
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Kevin R Ward
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Mohamad Hakam Tiba
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA.,The Max Harry Weil Institute for Critical Care Research and Innovation, University of Michigan, Ann Arbor, Michigan, USA
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Bini JK, Hardman C, Morrison J, Scalea TM, Moore LJ, Podbielski JM, Inaba K, Piccinini A, Kauvar DS, Cannon J, Spalding C, Fox C, Moore E, DuBose JJ; AAST AORTA Study Group. Survival benefit for pelvic trauma patients undergoing Resuscitative Endovascular Balloon Occlusion of the Aorta: Results of the AAST Aortic Occlusion for Resuscitation in Trauma Acute Care Surgery (AORTA) Registry. Injury 2022; 53:2126-32. [PMID: 35341594 DOI: 10.1016/j.injury.2022.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 02/23/2022] [Accepted: 03/05/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Aortic occlusion (AO) to facilitate the acute resuscitation of trauma and acute care surgery patients in shock remains a controversial topic. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an increasingly deployed method of AO. We hypothesized that in patients with non-compressible hemorrhage below the aortic bifurcation, the use of REBOA instead of open AO may be associated with a survival benefit. METHODS From the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry, we identified 1494 patients requiring AO from 45 Level I and 4 Level II trauma centers. Presentation, intervention, and outcome variables were analyzed to compare REBOA vs open AO in patients with non-compressible hemorrhage below the aortic bifurcation. RESULTS From December 2014 to January 2019, 217 patients with Zone 3 REBOA or Open AO who required pelvic packing, pelvic fixation or pelvic angio-embolization were identified. Of these, 109 AO patients had injuries isolated to below the aortic bifurcation (REBOA, 84; open AO, 25). Patients with intra-abdominal or thoracic sources of bleeding, above deployment Zone 3 were excluded. Overall mortality was lower in the REBOA group (35.% vs 80%, p <.001). Excluding patients who arrived with CPR in progress, the REBOA group had lower mortality (33.33% vs. 68.75%, p = 0.012). Of the survivors, systemic complications were not significantly different between groups. In the REBOA group, 16 patients had complications secondary to vascular access. Intensive care lengths of stay and ventilator days were both significantly shorter in REBOA patients who survived to discharge. CONCLUSIONS This study compared outcomes for patients with hemorrhage below the aortic bifurcation treated with REBOA to those treated with open AO. Survival was significantly higher in REBOA patients compared to open AO patients, while complications in survivors were not different. Given the higher survival in REBOA patients, we conclude that REBOA should be used for patients with hemorrhagic shock secondary to pelvic trauma instead of open AO. LEVEL III EVIDENCE Therapeutic.
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Jansen JO, Cochran C, Boyers D, Gillies K, Lendrum R, Sadek S, Lecky F, MacLennan G, Campbell MK. The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta ( REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial). Trials 2022; 23:384. [PMID: 35550642 PMCID: PMC9097076 DOI: 10.1186/s13063-022-06346-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 03/03/2022] [Accepted: 04/23/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Haemorrhage is the most common cause of preventable death after injury. REBOA is a novel technique whereby a percutaneously inserted balloon is deployed in the aorta, providing a relatively quick means of temporarily controlling haemorrhage and augmenting cerebral and coronary perfusion, until definitive control of haemorrhage can be attained. The aim of the UK-REBOA trial is to establish the clinical and cost-effectiveness of a policy of standard major trauma centre treatment plus REBOA, as compared with standard major trauma centre treatment alone, for the management of uncontrolled torso haemorrhage caused by injury. METHODS Pragmatic, Bayesian, group-sequential, randomised controlled trial, performed in 16 major trauma centres in England. We aim to randomise 120 injured patients with suspected exsanguinating haemorrhage to either standard major trauma centre care plus REBOA or standard major trauma centre care alone. The primary clinical outcome is 90-day mortality. Secondary clinical outcomes include 3-h, 6-h, and 24-h mortality; in-hospital mortality; 6-month mortality; length of stay (in hospital and intensive care unit); 24-h blood product use; need for haemorrhage control procedure (operation or angioembolisation); and time to commencement of haemorrhage control procedure (REBOA, operation, or angioembolisation). The primary economic outcome is lifetime incremental cost per QALY gained, from a health and personal social services perspective. DISCUSSION This study, which is the first to randomly allocate patients to treatment with REBOA or standard care, will contribute high-level evidence on the clinical and cost-effectiveness of REBOA in the management of trauma patients with exsanguinating haemorrhage and will provide important data on the feasibility of implementation of REBOA into mainstream clinical practice. TRIAL REGISTRATION ISRCTN16184981.
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Affiliation(s)
- Jan O Jansen
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK.
- Department of Surgery, Center for Injury Science, University of Alabama at Birmingham, 1808 7th Ave S, Birmingham, AL, 35294, USA.
| | - Claire Cochran
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Dwayne Boyers
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Robbie Lendrum
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Sam Sadek
- Barts Health NHS Trust, Royal London Hospital, St. Bartholomew's Hospital, London, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Graeme MacLennan
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
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Stonko DP, Edwards J, Abdou H, Elansary NN, Lang E, Savidge SG, Hicks CW, Morrison JJ. The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA. Front Physiol 2022; 13:871073. [PMID: 35615678 PMCID: PMC9125334 DOI: 10.3389/fphys.2022.871073] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/04/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is used for aortic control in hemorrhagic shock despite little quantification of its mechanism of resuscitation or cardiac injury. The goal of this study was to use pressure-volume (PV) loop analysis and direct coronary blood flow measurements to describe the physiologic changes associated with the clinical use of REBOA. Methods: Swine underwent surgical and vascular access to measure left ventricular PV loops and left coronary flow in hemorrhagic shock and subsequent placement of occlusive REBOA, partial REBOA, and no REBOA. PV loop characteristics and coronary flow are compared graphically with PV loops and coronary waveforms, and quantitatively with measures of the end systolic and end pressure volume relationship, and coronary flow parameters, with accounting for multiple comparisons. Results: Hemorrhagic shock was induced in five male swine (mean 53.6 ± 3.6 kg) as demonstrated by reduction of stroke work (baseline: 3.1 vs. shock: 1.2 L*mmHg, p < 0.01) and end systolic pressure (ESP; 109.8 vs. 59.6 mmHg, p < 0.01). ESP increased with full REBOA (178.4 mmHg; p < 0.01), but only moderately with partial REBOA (103.0 mmHg, p < 0.01 compared to shock). End systolic elastance was augmented from baseline to shock (1.01 vs. 0.39 ml/mmHg, p < 0.01) as well as shock compared to REBOA (4.50 ml/mmHg, p < 0.01) and partial REBOA (3.22 ml/mmHg, p = 0.01). Percent time in antegrade coronary flow decreased in shock (94%-71.8%, p < 0.01) but was rescued with REBOA. Peak flow increased with REBOA (271 vs. shock: 93 ml/min, p < 0.01) as did total flow (peak: 2136, baseline: 424 ml/min, p < 0.01). REBOA did not augment the end diastolic pressure volume relationship. Conclusion: REBOA increases afterload to facilitate resuscitation, but the penalty is supraphysiologic coronary flows and imposed increase in LV contractility to maintain cardiac output. Partial REBOA balances the increased afterload with improved aortic system compliance to prevent injury.
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Affiliation(s)
- David P. Stonko
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, United States
| | - Joseph Edwards
- 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
| | - Noha N. Elansary
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Eric Lang
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Samuel G. Savidge
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jonathan J. Morrison
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical System, Baltimore, MD, United States,*Correspondence:Jonathan J. Morrison,
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Knapp J, Jakob DA, Haltmeier T, Lehmann B, Hautz WE. [Resuscitative endovascular balloon occlusion of the aorta in severely injured patients in the emergency trauma room: a case series]. Anaesthesist 2022; 71:599-607. [PMID: 35254464 PMCID: PMC9352627 DOI: 10.1007/s00101-022-01100-3] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/01/2022] [Accepted: 02/13/2022] [Indexed: 11/27/2022]
Abstract
Hemorrhage is the cause of death in 30-40% of severely injured patients due to trauma and the most frequent avoidable cause of death. In civilian emergency medical services, the majority of life-threatening hemorrhages are found in incompressible body regions (e.g. abdomen and pelvis). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has therefore been discussed in recent years as a lifesaving procedure for temporary bleeding control in multiple trauma patients. Since August 2020 REBOA is implented in the treatment of seriously injured patients in the emergency department of the University Hospital of Bern. In this case series we report on our experiences in all seven patients in whom we performed this procedure during the first year.
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Affiliation(s)
- Jürgen Knapp
- Klinik für Anästhesiologie und Schmerztherapie, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz.
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Spital Schwyz, Schwyz, Schweiz.
- Klinik für Anästhesiologie und Schmerztherapie, Universitätsspital Bern, Universität Bern, Freiburgstraße, 3010, Bern, Schweiz.
| | - Dominik A Jakob
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Tobias Haltmeier
- Klinik für Viszerale Chirurgie und Medizin, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Beat Lehmann
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
| | - Wolf E Hautz
- Universitäres Notfallzentrum, Inselspital, Universitätsspital Bern, Universität Bern, Bern, Schweiz
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Ando H, Kaszynski RH, Goto H. On-site placement of resuscitative endovascular balloon occlusion of the aorta ( REBOA) in a hemorrhagic shock patient: A successful endeavor involving long-distance air transport. Am J Emerg Med 2021:S0735-6757(21)01026-3. [PMID: 35012802 DOI: 10.1016/j.ajem.2021.12.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 11/22/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is primarily utilized in traumatic non-compressible torso hemorrhage. We present a 49-year-old male with hemorrhagic shock necessitating on-site REBOA placement on an island 986 km away from the nearest critical care center. The patient experienced sudden pain in the right costal margin and visited the local clinic where computed tomography revealed a massive intra-abdominal hemorrhage and a renal artery aneurysm. An emergency care physician was deployed via fixed-wing aircraft who positioned the REBOA on-site in the thoracic aorta. Partial balloon inflation (partial REBOA) and intermittent inflation/deflation (intermittent REBOA) was repeated throughout the 5-h return flight. Despite prolonged REBOA placement, no safety issues or ischemic complications were documented and parent artery occlusion was subsequently performed via interventional radiology at our facility. The patient was later discharged home in a good state of health. On-site REBOA placement is not only applicable to trauma but also internal hemorrhaging due to non-traumatic causes. Partial and intermittent REBOA successfully stabilized circulation, prevented organ ischemia and facilitated long-distance patient transport in the present case.
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Renaldo AC, Lane MR, Shapiro SR, Mobin F, Jordan JE, Williams TK, Neff LP, Gayzik FS, Rahbar E. Development of a computational fluid dynamic model to investigate the hemodynamic impact of REBOA. Front Physiol 2022; 13:1005073. [PMID: 36311232 PMCID: PMC9606623 DOI: 10.3389/fphys.2022.1005073] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a lifesaving intervention for major truncal hemorrhage. Balloon-tipped arterial catheters are inserted via the femoral artery to create a temporary occlusion of the aorta, which minimizes the rate of internal bleeding until definitive surgery can be conducted. There is growing concern over the resultant hypoperfusion and potential damage to tissues and organs downstream of REBOA. To better understand the acute hemodynamic changes imposed by REBOA, we developed a three-dimensional computational fluid dynamic (CFD) model under normal, hemorrhage, and aortic occlusion conditions. The goal was to characterize the acute hemodynamic changes and identify regions within the aortic vascular tree susceptible to abnormal flow and shear stress. Methods: Hemodynamic data from established porcine hemorrhage models were used to build a CFD model. Swine underwent 20% controlled hemorrhage and were randomized to receive a full or partial aortic occlusion. Using CT scans, we generated a pig-specific aortic geometry and imposed physiologically relevant inlet flow and outlet pressure boundary conditions to match in vivo data. By assuming non-Newtonian fluid properties, pressure, velocity, and shear stresses were quantified over a cardiac cycle. Results: We observed a significant rise in blood pressure (∼147 mmHg) proximal to REBOA, which resulted in increased flow and shear stress within the ascending aorta. Specifically, we observed high levels of shear stress within the subclavian arteries (22.75 Pa). Alternatively, at the site of full REBOA, wall shear stress was low (0.04 ± 9.07E-4 Pa), but flow oscillations were high (oscillatory shear index of 0.31). Comparatively, partial REBOA elevated shear levels to 84.14 ± 19.50 Pa and reduced flow oscillations. Our numerical simulations were congruent within 5% of averaged porcine experimental data over a cardiac cycle. Conclusion: This CFD model is the first to our knowledge to quantify the acute hemodynamic changes imposed by REBOA. We identified areas of low shear stress near the site of occlusion and high shear stress in the subclavian arteries. Future studies are needed to determine the optimal design parameters of endovascular hemorrhage control devices that can minimize flow perturbations and areas of high shear.
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Affiliation(s)
- Antonio C. Renaldo
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston Salem, NC, United States
- Virginia Tech—Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
| | - Magan R. Lane
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Sophie R. Shapiro
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Fahim Mobin
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston Salem, NC, United States
- Virginia Tech—Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
| | - James E. Jordan
- Department of Cardiothoracic Surgery, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Timothy K. Williams
- Department of Vascular and Endovascular Surgery, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Lucas P. Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - F. Scott Gayzik
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston Salem, NC, United States
- Virginia Tech—Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
- Center for Injury Biomechanics, Wake Forest School of Medicine, Winston Salem, NC, United States
| | - Elaheh Rahbar
- Department of Biomedical Engineering, Wake Forest School of Medicine, Winston Salem, NC, United States
- Virginia Tech—Wake Forest University School of Biomedical Engineering and Sciences, Blacksburg, VA, United States
- Center for Injury Biomechanics, Wake Forest School of Medicine, Winston Salem, NC, United States
- *Correspondence: Elaheh Rahbar,
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Parra MW, Ordoñez CA, Mejia D, Caicedo Y, Lobato JM, Castro OJ, Uribe JA, Velásquez F. Damage control approach to refractory neurogenic shock: a new proposal to a well-established algorithm. Colomb Med (Cali) 2021; 52:e4164800. [PMID: 34908624 PMCID: PMC8634278 DOI: 10.25100/cm.v52i2.4800] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/13/2021] [Accepted: 06/25/2021] [Indexed: 12/02/2022] Open
Abstract
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is commonly used as an adjunct to resuscitation and bridge to definitive control of non-compressible torso hemorrhage in patients with hemorrhagic shock. It has also been performed for patients with neurogenic shock to support the central aortic pressure necessary for cerebral, coronary and spinal cord perfusion. Although volume replacement and vasopressors are the cornerstones of the management of neurogenic shock, we believe that a REBOA can be used as an adjunct in carefully selected cases to prevent prolonged hypotension and the risk of further anoxic spinal cord injury. This manuscript aims to propose a new damage control algorithmic approach to refractory neurogenic shock that includes the use of a REBOA in Zone 3. There are still unanswered questions on spinal cord perfusion and functional outcomes using a REBOA in Zone 3 in trauma patients with refractory neurogenic shock. However, we believe that its use in these case scenarios can be beneficial to the overall outcome of these patients.
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Affiliation(s)
- Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale, FL - USA
| | - Carlos A Ordoñez
- Fundación Valle del Lili. Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad del Valle, Facultad de Salud, Escuela de Medicina, Department of Surgery. Division of Trauma and Acute Care Surgery, Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - David Mejia
- Hospital Pablo Tobon Uribe, Department of Surgery, Medellin, Colombia.,Universidad de Antioquia, Department of Surgery, Medellin, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
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