Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm

Abstract

BackgroundNon-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use.MethodsA multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA.ResultsOf the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination.DiscussionThis algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time.Level of evidenceLevel III.

REBOA for the Treatment of Blast Polytrauma: Zone 3 Provides Cerebral Perfusion, Attenuates Organ Dysfunction and Reperfusion Coagulopathy Compared to Zone 1 in a Swine Model

“…27 In addition, the Emergent Truncal Hemorrhage Control study investigators evaluated a commonly accepted REBOA algorithm to determine adherence to optimal zone placement, 28 and the investigators found that, of the 36 Zone 1 REBOAs placed, 4 (11.1%) should have been Zone 3 and, of those patients, 3 ultimately died because of MOF. 29 To our knowledge, our swine experiment is the first to comprehensively characterize the significant coagulopathic disparities between Zone 1 and Zone 3 occlusion. Compared with AO Zone 3, Zone 1 was associated with significant TEG-measured coagulation abnormalities, including prolonged time to clot formation, poor clot strength, and increased occult fibrinolysis.…”

FAST exam for the anesthesiologist

“…In addition, abdominal ultrasound can be used for procedural guidance. For example, studies demonstrate its usefulness in ensuring proper Foley catheter placement, intrauterine placement of catheters to tamponade hemorrhage, and as part of an algorithm to ensure appropriate placement of resuscitative endovascular balloon occlusion of the aorta (REBOA) devices following trauma 50–52. See Table 1 for a summary of the indications for the FAST exam in the trauma, critical care, and perioperative setting.…”

Principles of pelvic fracture treatment in polytrauma patients

“…multiple organ dysfunction principi lečenja preloma karlice kod politraumatizovanih pacijenata principles of pelvic fracture treatment in polytrauma patients to ischemia-reperfusion injury. This problem is prevented by applying short REBOA, intermittent REBOA (iREBOA), Zone 3 REBOA, and partial REBOA [22,23].…”

“…syndrome -MODS) usled ishemijsko -reperfuzijske reakcije. Ovaj problem se prevenira kratkotrajnom REBOA procedurom, intermitentnom REBOA procedurom (iREBOA), Zona 3 REBOA procedurom i parcijalnom REBOA procedurom [22,23].…”