REBOA and its effect on hemodynamics and cerebral blood flow as measured by CTP in a large animal model of raised intracranial pressure and hemorrhagic shock.

Abstract

Hemorrhage is among the leading causes of preventable deaths in trauma. Further traumatic brain injury (TBI) often present in a polytrauma patient, and is known to worsen outcomes when present with non compressible torso hemorrhage (NCTH). Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been developed as a means of hemorrhage control and afterload increase during a state of hemorrhagic shock, but its use in patients with both hemorrhagic shock and concomitant TBI is controversial, as the potential for ischemia reperfusion injury and acute hypertension may cause intracranial lesion progression. To date, there is limited data on how REBOA alters hemodynamics in a model of hemorrhagic shock and brain injury resulting in raised intracranial pressure. The goal of the current study is to define how full REBOA and partial REBOA alter systemic and cerebral hemodynamics in a porcine model of TBI with raised ICP with concomitant hemorrhagic shock. This will be examined throughout the intervention and for 3 hours of resuscitation. It will be evaluated with hemodynamic, laboratory, and radiographic assessments.

Class of hemorrhagic shock is associated with progressive diastolic coronary flow reversal and diminished left ventricular function

“… Stonko et al, 2022a ; Cannon et al, 2018 ; Khan and McMonagle, 2019 ; Vella et al, 2019 ; Wasicek et al, 2019 ; Stonko et al, 2022e REBOA, however, is contingent on spontaneous circulation. To achieve spontaneous circulation during ECA, the current practice is to perform CPR with a REBOA in place, but previous studies have shown that the use of CPR is terrible for brain perfusion ( Abdou et al, 2022 ; Patel et al, 2022b ; Edwards et al, 2022 ). Therefore, other methods, such as SAAP and ECMO, may be better alternatives to CPR in the absence of spontaneous circulation.…”

The Underlying Cardiovascular Mechanisms of Resuscitation and Injury of REBOA and Partial REBOA

“…Coronary flows are measured continuously and recorded in microseconds, though extracted in 5 ms increments. The pressure-volume loops are generated with a micromanometer tipped catheter (Transonic Corporation, Ithaca, NY) and computed with the admittance method ( Johnson et al, 2017 ; Edwards et al, 2022 ). PV loop data was recorded in pressure versus volume versus time data with LabChart, and exported to MATLAB (Mathworks, Nantick, MA, United States).…”

“…LabChart analyzes each PV loop, which corresponds to one cardiac cycle, for hemodynamic parameters such as stroke work, heart rate, and measures of preload, afterload and ( Heindl et al, 2020 ; Edwards et al, 2022 ) contractility over time. We have previously described methodology for averaging the PV loop over a time period to determine a single PV loop that is representative of LV function during that time period, and published Matlab code to execute this procedure ( Edwards et al, 2022 ). In summary of the mathematical methodology, we convert raw pressure-volume data to polar coordinates, interpolate numerous cardiac cycle loops, then convert back to cartesian coordinates.…”

“…In this situation, full REBOA increases afterload thereby permitting hemodynamic rescue, but in turn reduces arterial compliance and can produce supra-physiologic arterial pressures in the perfused organs, while depriving distal organs of flow entirely ( Russo et al, 2016 ; Ribeiro Junior et al, 2018 ; Wasicek et al, 2019 ; Nowadly et al, 2020 ). Maintaining occlusive thoracic REBOA after return of spontaneous circulation (ROSC) or to prevent arrest which is then followed by high arterial pressure therefore places strain on the left ventricle (LV) and is thought to contribute to myocardial injury, and to increase intracranial pressures ( Uchino et al, 2016 ; Johnson et al, 2017 ; Bailey et al, 2019 ; Abdou et al, 2021 ; Edwards et al, 2022 ). Indeed, clinical and basic science data have shown that fREBOA may be harmful and, therefore, proceduralists will typically transition to pREBOA when feasible ( Johnson et al, 2016 ; Russo et al, 2016 ; Ribeiro Junior et al, 2018 ; Sadeghi et al, 2018 ; Bailey et al, 2019 ; Wasicek et al, 2019 ; Abdou et al, 2021 ).…”