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Shan Y, Zhao Y, Li C, Gao J, Song G, Li T. Efficacy of partial and complete resuscitative endovascular balloon occlusion of the aorta in the hemorrhagic shock model of liver injury. World J Emerg Med 2024; 15:10-15. [PMID: 38188550 PMCID: PMC10765071 DOI: 10.5847/wjem.j.1920-8642.2024.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/20/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) can temporarily control traumatic bleeding. However, its prolonged use potentially leads to ischemia-reperfusion injury (IRI). Partial REBOA (pREBOA) can alleviate ischemic burden; however, its security and effectiveness prior to operative hemorrhage control remains unknown. Hence, we aimed to estimate the efficacy of pREBOA in a swine model of liver injury using an experimental sliding-chamber ballistic gun. METHODS Twenty Landrace pigs were randomized into control (no aortic occlusion) (n=5), intervention with complete REBOA (cREBOA) (n=5), continuous pREBOA (C-pREBOA) (n=5), and sequential pREBOA (S-pREBOA) (n=5) groups. In the cREBOA and C-pREBOA groups, the balloon was inflated for 60 min. The hemodynamic and laboratory values were compared at various observation time points. Tissue samples immediately after animal euthanasia from the myocardium, liver, kidneys, and duodenum were collected for histological assessment using hematoxylin and eosin staining. RESULTS Compared with the control group, the survival rate of the REBOA groups was prominently improved (all P<0.05). The total volume of blood loss was markedly lower in the cREBOA group (493.14±127.31 mL) compared with other groups (P<0.01). The pH was significantly lower at 180 min in the cREBOA and S-pREBOA groups (P<0.05). At 120 min, the S-pREBOA group showed higher alanine aminotransferase (P<0.05) but lower blood urea nitrogen compared with the cREBOA group (P<0.05). CONCLUSION In this trauma model with liver injury, a 60-minute pREBOA resulted in improved survival rate and was effective in maintaining reliable aortic pressure, despite persistent hemorrhage. Extended tolerance time for aortic occlusion in Zone I for non-compressible torso hemorrhage was feasible with both continuous partial and sequential partial measures, and the significant improvement in the severity of acidosis and distal organ injury was observed in the sequential pREBOA.
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Affiliation(s)
- Yi Shan
- Department of Emergency Medicine, Chinese PLA Medical School, Beijing 100853, China
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Yang Zhao
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Chengcheng Li
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
- Department of Emergency Medicine, School of Medicine, South China University of Technology, Guangzhou 510006, China
| | - Jianxin Gao
- Department of Emergency Medicine, the First Medical Center of PLA General Hospital, Beijing 100853, China
| | - Guogeng Song
- Department of Emergency Medicine, the Sixth Medical Center of PLA General Hospital, Beijing 100048, China
| | - Tanshi Li
- Department of Emergency Medicine, the First Medical Center of PLA General Hospital, Beijing 100853, China
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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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Thrailkill MA, Gladin KH, Thorpe CR, Roberts TR, Choi JH, Chung KK, Necsoiu CN, Rasmussen TE, Cancio LC, Batchinsky AI. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation. Scand J Trauma Resusc Emerg Med 2021; 29:8. [PMID: 33407759 PMCID: PMC7789715 DOI: 10.1186/s13049-020-00807-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 11/03/2020] [Indexed: 02/07/2023] Open
Abstract
Background In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications. Methods To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data. Results In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times. Conclusions Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.
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Affiliation(s)
- Marianne A Thrailkill
- Glacier Technical Solutions, El Paso, TX, USA.,Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA
| | | | - Catherine R Thorpe
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Oak Ridge Institute for Science and Education, Oak Ridge, TN, USA
| | - Teryn R Roberts
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Jae H Choi
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA.,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA
| | - Kevin K Chung
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Corina N Necsoiu
- Prolonged Field Care Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Todd E Rasmussen
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, USA
| | - Andriy I Batchinsky
- Extracorporeal Life Support Capability Area, United States Army Institute of Surgical Research, JBSA Ft. Sam Houston, San Antonio, TX, 78234, USA. .,Autonomous Reanimation and Evacuation Research Program, The Geneva Foundation, San Antonio, TX, USA.
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Madurska MJ, McLenithan A, Scalea TM, Kundi R, White JM, Morrison JJ, DuBose JJ. A feasibility study of partial REBOA data in a high-volume trauma center. Eur J Trauma Emerg Surg 2021; 48:299-305. [PMID: 33399878 DOI: 10.1007/s00068-020-01561-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 11/19/2020] [Indexed: 01/31/2023]
Abstract
PURPOSE Resuscitative endovascular balloon occlusion of the aorta (REBOA) is used to temporize patients with infradiaphragmatic hemorrhage. Current guidelines advise < 30 min, to avoid ischemia/ reperfusion injury, whenever possible. The technique of partial REBOA (P-REBOA) has been developed to minimize the effects of distal ischemia. This study presents our clinical experience with P-REBOA, comparing outcomes to complete occlusion (C-REBOA). PATIENTS AND METHODS Retrospective analysis of patients' electronic data and local REBOA registry between January 2016 and May 2019. INCLUSION CRITERIA adult trauma patients who received Zone I C-REBOA or P-REBOA for infradiaphragmatic hemorrhage, who underwent attempted exploration in the operating room. Comparison of outcomes based on REBOA technique (P-REBOA vs C-REBOA) and occlusion time (> 30 min, vs ≤ 30 min) RESULTS: 46 patients were included, with 14 treated with P-REBOA. There were no demographic differences between P-REBOA and C-REBOA. Prolonged (> 30 min) REBOA (regardless of type of occlusion) was associated with increased mortality (32% vs 0%, p = 0.044) and organ failure. When comparing prolonged P-REBOA with C-REBOA, there was a trend toward lower ventilator days [19 (11) vs 6 (9); p = 0.483] and dialysis (36.4% vs 16.7%; p = 0.228) with significantly less vasopressor requirement (72.7% vs 33.3%; p = 0.026). CONCLUSION P-REBOA can be delivered in a clinical setting, but is not currently associated with improved survival in prolonged occlusion. In survivors, there is a trend toward lower organ support needs, suggesting that the technique might help to mitigate ischemic organ injury. More clinical data are needed to clarify the benefit of partial occlusion REBOA.
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Affiliation(s)
- Marta J Madurska
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Ashley McLenithan
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, 19131, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Rishi Kundi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Joseph M White
- Division of Vascular Surgery, The Department of Surgery at the Uniformed Services University of the Health Sciences and The Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Jonathan J Morrison
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA.
| | - Joseph J DuBose
- R Adams Cowley Shock Trauma Center, University of Maryland Medical System, 22 S. Greene Street, Baltimore, MD, 21201, USA
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Meyer DE, Mont MT, Harvin JA, Kao LS, Wade CE, Moore LJ. Catheter distances and balloon inflation volumes for the ER-REBOA™ catheter: A prospective analysis. Am J Surg 2019; 219:140-144. [PMID: 31076074 DOI: 10.1016/j.amjsurg.2019.04.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/26/2018] [Revised: 04/08/2019] [Accepted: 04/17/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct used to temporize uncontrolled abdominopelvic hemorrhage. No published clinical data exist that describe average catheter lengths or balloon fill volumes necessary to occlude the aorta. METHODS A prospective, single-institution registry was queried for patients who underwent placement of a Prytime ER-REBOA™ catheter. Demographic, catheter, hemodynamic, and morphometric data were measured. Linear regression analyses were performed to identify variables associated with insertion distances and balloon volumes. RESULTS 45 patients underwent supraceliac REBOA: median catheter insertion distance 45 cm [IQR 42-46], balloon inflation volume 14 mL [IQR 8-19], systolic blood pressure (SBP) augmentation 50 mmHg [IQR 35-55]. 14 patients underwent infrarenal deployment: median catheter insertion distance 28.5 cm [IQR 26.5-32.5], balloon volume 10 mL [IQR 5-15]; SBP augmentation 55 mmHg [IQR 40-65]. Patient body metrics were not associated with catheter length or balloon volume. CONCLUSION A wide range of catheter insertion distances and balloon fill volumes were necessary for correct REBOA positioning and occlusion. No single patient metric accurately correlated with catheter distance or balloon volume. LEVEL OF EVIDENCE Level IV, Prognostic.
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Affiliation(s)
- David E Meyer
- University of Texas Health Sciences Center and the McGovern School of Medicine, Houston, TX, USA.
| | - Megan T Mont
- University of Texas Health Sciences Center and the McGovern School of Medicine, Houston, TX, USA.
| | - John A Harvin
- University of Texas Health Sciences Center and the McGovern School of Medicine, Houston, TX, USA.
| | - Lillian S Kao
- University of Texas Health Sciences Center and the McGovern School of Medicine, Houston, TX, USA.
| | - Charles E Wade
- University of Texas Health Sciences Center, The McGovern School of Medicine, The Center for Translational Injury Research, Houston, TX, USA.
| | - Laura J Moore
- University of Texas Health Sciences Center and the McGovern School of Medicine, Houston, TX, USA.
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Do WS, Chang R, Fox EE, Wade CE, Holcomb JB, Martin MJ. Too fast, or not fast enough? The FAST exam in patients with non-compressible torso hemorrhage. Am J Surg 2019; 217:882-886. [PMID: 30853094 DOI: 10.1016/j.amjsurg.2019.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 11/08/2018] [Revised: 02/06/2019] [Accepted: 02/06/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Focused assessment with sonography for trauma (FAST) performance metrics are unknown in patients with non-compressible torso hemorrhage (NCTH). METHODS Retrospective review of a dedicated NCTH database from four level 1 trauma centers (2008-2012). NCTH was defined as (1) named axial torso vessel disruption; (2) AIS chest or abdomen >2 with shock (base deficit < -4) or truncal operation in ≤ 90 min; or (3) pelvic fracture with ring disruption. Patients were grouped by cavity of hemorrhage source and by shock (SBP ≤ 90). RESULTS 274 patients had a FAST prior to diagnosis of NCTH. FAST was positive in 51% of patients with abdominal/pelvic hemorrhage for a false negative rate (FNR) of 49%. FNR was higher for pelvic (61%) versus abdominal (43%) sources (p = 0.02). There was no difference between FAST negative or positive patients for ISS, shock, length of stay, or mortality (all p = NS). FNR was not improved among the subgroup of NCTH patients with shock (p = NS). CONCLUSION FAST identified abdominal/pelvic hemorrhage in approximately half of NCTH patients, and this was not improved among patients presenting with shock.
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Affiliation(s)
- Woo S Do
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA.
| | - Ronald Chang
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX, USA.
| | - Erin E Fox
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX, USA.
| | - Charles E Wade
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX, USA.
| | - John B Holcomb
- Center for Translational Injury Research, University of Texas Health Science Center, Houston, TX, USA.
| | - Matthew J Martin
- Department of Surgery, Madigan Army Medical Center, Tacoma, WA, USA; Trauma and Emergency Surgery Service, Legacy Emanuel Medical Center, Portland, OR, USA.
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Manzano Nunez R, Naranjo MP, Foianini E, Ferrada P, Rincon E, García-Perdomo HA, Burbano P, Herrera JP, García AF, Ordoñez CA. A meta-analysis of resuscitative endovascular balloon occlusion of the aorta (REBOA) or open aortic cross-clamping by resuscitative thoracotomy in non-compressible torso hemorrhage patients. World J Emerg Surg 2017; 12:30. [PMID: 28725258 PMCID: PMC5512749 DOI: 10.1186/s13017-017-0142-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [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: 06/28/2017] [Accepted: 07/05/2017] [Indexed: 11/30/2022] Open
Abstract
Background The objective of this systematic review and meta-analysis was to determine the effect of REBOA, compared to resuscitative thoracotomy, on mortality and among non-compressible torso hemorrhage trauma patients. Methods Relevant articles were identified by a literature search in MEDLINE and EMBASE. We included studies involving trauma patients suffering non-compressible torso hemorrhage. Studies were eligible if they evaluated REBOA and compared it to resuscitative thoracotomy. Two investigators independently assessed articles for inclusion and exclusion criteria and selected studies for final analysis. We conducted meta-analysis using random effect models. Results We included three studies in our systematic review. These studies included a total of 1276 patients. An initial analysis found that although lower in REBOA-treated patients, the odds of mortality did not differ between the compared groups (OR 0.42; 95% CI 0.17–1.03). Sensitivity analysis showed that the risk of mortality was significantly lower among patients who underwent REBOA, compared to those who underwent resuscitative thoracotomy (RT) (RR 0.81; 95% CI 0.68–0.97). Conclusion Our meta-analysis, mainly from observational data, suggests a positive effect of REBOA on mortality among non-compressible torso hemorrhage patients. However, these results deserve further investigation. Electronic supplementary material The online version of this article (doi:10.1186/s13017-017-0142-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | - Erika Rincon
- Clinical Research Center, Fundación Valle del Lili, Cali, Colombia
| | | | - Paola Burbano
- School of Medicine, Universidad Javeriana Cali, Cali, Valle del Cauca Colombia
| | | | - Alberto F García
- Universidad del Valle, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Carlos A Ordoñez
- Universidad del Valle, Cali, Colombia.,Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
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