Increased crystalloid fluid requirements during zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) versus Abdominal Aortic and Junctional Tourniquet (AAJT) after class II hemorrhage in swine

Abstract

Purpose Pelvic and lower junctional hemorrhage result in a significant amount of trauma related deaths in military and rural civilian environments. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infra-renal (zone 3) Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are two options for resuscitation of patients with life threatening blood loss from and distal to the pelvis. Evidence suggest differences in the hemodynamic response between AAJT and zone 3 REBOA, but fluid management during resuscitation with the devices has not been fully elucidated. We compared crystalloid fluid requirements (Ringer’s acetate) between these devices to maintain a carotid mean arterial pressure (MAP) > 60 mmHg. Methods 60 kg anesthetized and mechanically ventilated male pigs were subjected to a mean 1030 (range 900–1246) mL (25% of estimated total blood volume, class II) haemorrhage. AAJT (n = 6) or zone 3 REBOA (n = 6) were then applied for 240 min. Crystalloid fluids were administered to maintain carotid MAP. The animals were monitored for 30 min after reperfusion. Results Cumulative resuscitative fluid requirements increased 7.2 times (mean difference 2079 mL; 95% CI 627–3530 mL) in zone 3 REBOA (mean 2412; range 800–4871 mL) compared to AAJT (mean 333; range 0–1000 mL) to maintain target carotid MAP. Release of the AAJT required vasopressor support with norepinephrine infusion for a mean 9.6 min (0.1 µg/kg/min), while REBOA release required no vasopressor support. Conclusion Zone 3 REBOA required 7.2 times more crystalloids to maintain the targeted MAP. The AAJT may therefore be considered in a situation of hemorrhagic shock to limit the need for crystalloid infusions, although removal of the AAJT caused more severe hemodynamic and metabolic effects which required vasopressor support.

Intermittent thoracic resuscitative endovascular balloon occlusion of the aorta improves renal function compared to 60 min continuous application after porcine class III hemorrhage

“…The increased need for vasopressor support on release of cREBOA may also be connected to a cardiac ischemic reperfusion injury and a decrease in central blood volume. We detected a similar effect when comparing zone 3 REBOA and an Abdominal Aortic and Junctional Tourniquet [29].…”

Comparison of emergency surgical cricothyroidotomy and percutaneous cricothyroidotomy by experienced airway providers in an obese, in vivo porcine hemorrhage airway model

“…In this animal study, eFONA by surgical cricothyroidotomy was faster and had improved proxy survival and oxygenation compared to percutaneous cricothyroidotomy. The study was designed to follow hemorrhage control studies according to our previous works [ 32 , 33 ], which was ethically beneficial by honoring the 3R of animal welfare in research by “reducing the number of animals used to a minimum and to obtain information from fewer animals or more information from the same number of animals”. We considered the model relevant to simulate a CICO situation.…”

“…Fifth, we used a size 20 scalpel which we believe optimized the methodology in the pig, still it’s a limitation as size 10 is standard in humans. Sixth, there are many percutaneous techniques described [ 32 , 33 ]. This study may therefore not draw conclusions of the performance of other techniques, although the difficulties of cricothyroid membrane perforation suggest that other percutaneous techniques would perform similarly.…”

“…Twelve crossbred male pigs with a mean weight (standard deviation, SD) (60.3 ± 4.1) kg were anesthetized as part of a protocol of hemorrhage control, as earlier described [ 32 , 33 ]. Premedication consisted of 150 mg tiletamine/zolazepam (Zoletil 100 Vet) and 6 mg medetomidine (Domitor) after which anesthesia was induced with fentanyl 2.5 µg/kg and pentobarbitalnatrium 6 mg/kg.…”

“…Hemorrhage was achieved through surgical exposure and then transection of the common femoral artery or the carotid artery. It took approximately 20 min to reach the estimated blood loss in both groups [ 32 , 33 ]. At completion of the primary studies, the animals were stabilized for 30 min in the ventilator.…”