Basic endovascular skills for trauma course

Brenner, Megan; Hoehn, Melanie; Pasley, Jason; DuBose, Joseph J.; Stein, Deborah M.; Scalea, Thomas M.

doi:10.1097/ta.0000000000000310

Cited by 162 publications

(87 citation statements)

References 25 publications

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“…Moreover, the present study is the first of its kind to take an in-depth look at the critical period of balloon deflation utilizing a technique currently taught as best practice in REBOA training courses. (9, 18) Our findings highlight that the period of balloon deflation after REBOA is dynamic and difficult to predict. Weaning from REBOA may be an overlooked, yet critical area for future study given the risk of cardiovascular collapse and hypotension reported in the literature.…”

Section: Discussionmentioning

confidence: 79%

“…(7) In an attempt to mitigate the physiologic impact of balloon deflation following REBOA, current practice recommendations advocate slow and methodical balloon deflation to gradually reintroduce distal aortic flow. (8, 9) In theory, graded balloon deflation reduces physiologic derangement by creating a protracted washout of distal ischemic metabolites, while simultaneously providing partial proximal hemodynamic support. Yet, anecdotal evidence suggests even graded balloon deflation may result in hemodynamic instability.…”

Section: Introductionmentioning

confidence: 99%

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Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Davidson

Russo

Ferencz

et al. 2017

Journal of Trauma and Acute Care Surgery

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Introduction To avoid potential cardiovascular collapse after Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), current guidelines recommend methodically deflating the balloon over 5 minutes to gradually reperfuse distal tissue beds. However, anecdotal evidence suggests that this approach may still result in unpredictable aortic flow rates and hemodynamic instability. We sought to characterize aortic flow dynamics following REBOA as the balloon is deflated in accordance with current practice guidelines. Methods Eight Yorkshire-cross swine were splenectomized, instrumented, and subjected to rapid 25% total blood volume hemorrhage. After 30 minutes of shock, animals received 60 minutes of zone 1 REBOA with a low-profile REBOA catheter. During subsequent resuscitation with shed blood, the aortic occlusion balloon was gradually deflated in stepwise fashion at the rate of 0.5 mL every 30 seconds until completely deflated. Aortic flow rate and proximal mean arterial pressure (MAP) were measured continuously over the period of balloon deflation. Results Graded balloon deflation resulted in variable initial return of aortic flow (median 78 seconds, IQR 68–105sec). A rapid increase in aortic flow during a single balloon deflation step was observed in all animals (Median 819 mL/min IQR 664-1241mL/min) and corresponded with an immediate decrease in proximal MAP (Median 30 mmHg IQR 14.5–37mmHg). Total balloon volume and time to return of flow demonstrated no correlation (r2=0.016). Conclusion This study is the first to characterize aortic flow during balloon deflation following REBOA. A steep inflection point occurs during balloon deflation that results in an abrupt increase in aortic flow and a concomitant decrease in MAP. Furthermore, the onset of distal aortic flow was inconsistent across study animals and did not correlate with initial balloon volume or relative deflation volume. Future studies to define the factors that impact aortic flow during balloon deflation are needed to facilitate controlled reperfusion following REBOA.

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Section: Discussionmentioning

confidence: 79%

Section: Introductionmentioning

confidence: 99%

Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Davidson

Russo

Ferencz

et al. 2017

Journal of Trauma and Acute Care Surgery

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“…Although the severity and proportion of complications related to REBOA deployment were low in the DuBose series, another report by Saito et al [26] documented serious adverse events that ultimately ended in lower limb amputations in 2 of 14 patients. However, REBOA is an evolving endovascular technology, and new strategies such as improvements in endovascular skills training [27, 28] and the advent of smaller diameter catheters [29] may improve the safety related to its deployment [30]. …”

Section: Discussionmentioning

confidence: 99%

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

et al. 2017

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BackgroundThe 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.MethodsRelevant 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.ResultsWe 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).ConclusionOur 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 materialThe 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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“…For patients with poly-system trauma, a less invasive resuscitation strategy such as a resuscitative endovascular balloon occlusion (REBOA) may have a future application as it provides the same proximal hemorrhage control without opening the chest. REBOA has been introduced clinically in adult trauma patients[19] and the skill set to perform this resuscitative procedure can be learned in a relatively short period of time without prior endovascular training[20]. The minimally invasive nature of REBOA may also reduce the adverse risks to providers associated with EDT, which have been argued to not outweigh the survival benefit[21, 22].…”

Section: Discussionmentioning

confidence: 99%

Pediatric emergency department thoracotomy: A 40-year review

Moore

Bensard

2016

Journal of Pediatric Surgery

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Background/purpose Emergency department thoracotomy (EDT) has been proposed to be futile in the pediatric patient population. This extreme procedure has survival rates of 0 to 26% in the non-adult population. When taking into consideration that the mechanism of injury is one of the strongest predictors of survival, we hypothesize that the low survival rate in pediatric patients is attributable to a higher rate of blunt trauma compared to their adolescent counterparts. Methods Prospective data collected from our level 1 trauma center from 1974 - 2014 on all patients undergoing EDT at our institution was evaluated for age 18 or younger. Patient predictor variables included injury mechanism, injury pattern, and detected cardiac activity in the field. Outcomes included successful resuscitation (re-establish of blood pressure and taken to operating room) and overall survival. Patients were dichotomized by age into pediatric (age ≤ 15 yrs) and adolescent (16-18yrs) categories. Results 1691 patients who underwent EDT were evaluated for age of 18 or less, which included 179 patents (11%). Overall survival in the adult population was 6.1%, compared to 3.4% in the non-adult population (p=0.157). Pediatric patients were more likely to sustain blunt injury than adolescents (72% vs 32% p<0.001). This also corresponded to differences in anatomic injury patterns and more multisystem trauma (52% vs 44% p=0.001). Adolescents had significantly higher survival rates than pediatric patients (5% vs 0% p=0.036). Conclusion In non-adult patients undergoing EDT, adolescents have a higher survival rate than pediatric patients. The pediatric population had a significantly lower incidence of penetrating trauma and higher incidence of head injury. The discrepancy in survival between adolescent and pediatric patients appears to be attributable due to differences in mechanism. Therefore, those pediatric patients with penetrating thoracic injuries may still benefit from EDT.

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Basic endovascular skills for trauma course

Cited by 162 publications

References 25 publications

Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

Incremental balloon deflation following complete resuscitative endovascular balloon occlusion of the aorta results in steep inflection of flow and rapid reperfusion in a large animal model of hemorrhagic shock

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

Pediatric emergency department thoracotomy: A 40-year review

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