Changes in peripheral arterial blood pressure after resuscitative endovascular balloon occlusion of the aorta (REBOA) in non-traumatic cardiac arrest patients

Abstract

Background Resuscitative endovascular balloon occlusion of the aorta (REBOA) may be an adjunct treatment to cardiopulmonary resuscitation (CPR). Aortic occlusion may increase aortic pressure and increase the coronary perfusion pressure and the cerebral blood flow. Peripheral arterial blood pressure is often measured during or after CPR, however, changes in peripheral blood pressure after aortic occlusion is insufficiently described. This study aimed to assess changes in peripheral arterial blood pressure after REBOA in patients with out of hospital cardiac arrest. Methods A prospective observational study performed at the helicopter emergency medical service in Trondheim (Norway). Eligible patients received REBOA as adjunct treatment to advanced cardiac life support. Peripheral invasive arterial blood pressure and end-tidal CO2 (EtCO2) was measured before and after aortic occlusion. Differences in arterial blood pressures and EtCO2 before and after occlusion was analysed with Wilcoxon Signed Rank test. Results Five patients were included to the study. The median REBOA procedural time was 11 min and median time from dispatch to aortic occlusion was 50 min. Two patients achieved return of spontaneous circulation. EtCO2 increased significantly 60 s after occlusion, by a mean of 1.16 kPa (p = 0.043). Before occlusion the arterial pressure in the compression phase were 43.2 (range 12–112) mmHg, the mean pressure 18.6 (range 4–27) mmHg and pressure in the relaxation phase 7.8 (range − 7 – 22) mmHg. After aortic occlusion the corresponding pressures were 114.8 (range 23–241) mmHg, 44.6 (range 15–87) mmHg and 14.8 (range 0–29) mmHg. The arterial pressures were significant different in the compression phase and as mean pressure (p = 0.043 and p = 0.043, respectively) and not significant in the relaxation phase (p = 0.223). Conclusion This study is, to our knowledge, the first to assess the peripheral invasive arterial blood pressure response to aortic occlusion during CPR in the pre-hospital setting. REBOA application during CPR is associated with a significantly increase in peripheral artery pressures. This likely indicates improved central aortic blood pressure and warrants studies with simultaneous peripheral and central blood pressure measurement during aortic occlusion. Trial registration The study is registered in ClinicalTrials.gov (NCT03534011).

Advanced interventions in the pre-hospital resuscitation of patients with non-compressible haemorrhage after penetrating injuries

“…It may also limit the extent of ischaemic cardiac injury which has been observed to kill patients even after haemorrhage control has been achieved [ 19 ]. In addition, both techniques reduce pressures below the level of the aortic occlusion, thereby limiting blood loss [ 20 , 21 ]. RT further offers the opportunity to treat cardiac tamponade and control intrathoracic haemorrhage.…”

“…Alternatively, REBOA can be used in combination with volume resuscitation, external cardiac massage and low-dose titrated vasopressors [ 13 ]. As with aortic cross clamping, in addition to reducing distal pressures and therefore blood loss [ 20 , 31 ] an important effect of REBOA is augmentation of the diastolic and mean arterial blood pressure proximal to the balloon, thereby improving coronary and cerebral perfusion. In TCA, this effect is likely best achieved with zone I REBOA (with supra-coeliac balloon inflation) rather than zone III REBOA (with a balloon position below the renal arteries) [ 34 , 35 ].…”

Toracotomia de reanimação e novas alternativas invasivas para reanimação do paciente politraumatizado grave

“…As hemorragias traumáticas não compressíveis de tronco (abdome, pelve e retroperitônio), acometendo o compartimento subdiafragmático, são a principal indicação para uso do REBOA (38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48). Entretanto, mesmo para essa indicação, os trabalhos ainda são conflitantes, inclusive com estudos mostrando aumento de mortalidade, lesão renal aguda e amputação de membros inferiores com o uso do dispositivo.…”

“…Alguns estudos em paradas cardiorrespiratórias não traumáticas, antes uma contraindicação ao método, estão em andamento, e mostram resultados promissores em relação a desfecho neurológico, tempo de interrupção da massagem e menor uso de noradrenalina. (45)(46)(47)(48)(49) Contraindicações relativas, como os extremos de idade que não foram abrangidos em estudos iniciais, incluindo menores de 18 anos e maiores de 70 anos, começam a ser revistas (49)(50)(51).…”

“…Em relação aos aspectos técnicos da utilização do REBOA, as dúvidas giram ao entorno não da técnica em si, tendo em vista a experiência de múltiplas especialidades na manipulação do acesso arterial femoral, como cirurgiões gerais e do trauma, cirurgiões vasculares, cardiologistas para realização de cateterismo cardíaco, anestesiologistas, emergencistas e intensivistas para coleta de exames e monitorização invasiva do paciente; as principais dúvidas se encontram em qual paciente utilizar a oclusão ressuscitativa por balão endovascular da aorta, quais parâmetros clínicos utilizar como limiar e a que especialidade compete o domínio da técnica para manipulação do REBOA (43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54)(55).…”