Balloons for kids: Anatomic candidacy and optimal catheter size for pediatric resuscitative endovascular balloon occlusion of the aorta

Abstract

BACKGROUND:Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential adjunct in pediatric trauma patients with noncompressible truncal and pelvic hemorrhage; however, there are little data evaluating the anatomic considerations of REBOA in children. We evaluated the vascular dimensions and anatomic limitations of using REBOA in children. METHODS:Computed tomography scans of pediatric patients performed between February 2016 and October 2019 were retrospectively reviewed by two investigators. Vascular measurements included diameters of aorta zones I and III, common iliac arteries, external iliac arteries, and common femoral arteries (CFAs), and distances between access site (CFA) and aorta zones I and III. Measurements were grouped within Broselow categories, based upon patient height. Interrater reliability for measurements was determined using intraclass correlation coefficients. Vascular dimensions were correlated with the patient's height, weight, and body mass index using linear regression analysis. RESULTS:A total of 557 computed tomography scans met the inclusion criteria and were reviewed. Measurements of vessel diameter and distance from the CFA to aorta zones I and III were determined and grouped by Broselow category. Patient age ranged from 0 to 18 years, with a male to female ratio of 1:1. Overall interrater reliability of vessel measurements was good (average intraclass correlation coefficient, 0.90). Vessel diameter had greatest correlation with height (R 2 = 0.665, aorta zone I; R 2 = 0.611, aorta zone III) and poorly correlated with body mass index (R 2 = 0.318 and R 2 = 0.290, respectively). CONCLUSION:This study represents the largest compilation of REBOA-related pediatric vessel diameter measurements and the first to provide data on distance between access site and balloon deployment zones. Based on our findings, the 7-Fr REBOA catheter would be appropriate for the Black, Green, and Orange Broselow categories, and a 4-Fr REBOA catheter would be warranted for Yellow, White, and Blue Broselow categories.

Cushioned on the way up, controlled on the way down during resuscitative endovascular balloon occlusion of the aorta (REBOA): investigating a novel compliant balloon design for optimizing safe overinflation combined with partial REBOA ability

“…Although infrequent with most current generation REBOA devices, there are a variety of circumstances whereby additional overinflation ability might prove useful. REBOA in pediatric trauma is currently being investigated,7 and since pediatric aortic sizes are smaller and more variable depending on age, balloon overinflation may occur, predisposing patients to aortic injury. The issue of variable blood vessel sizes also occurs when performing balloon occlusion for proximal control in arteries other than the aorta, such as in the axillary/subclavian artery or iliac artery, before vascular repair 8.…”

A contemporary assessment of resuscitative endovascular balloon occlusion of the aorta

“…In other featured studies, Sykes and colleagues 30 describe the use of computed tomography data to characterize arterial morphometry in a pediatric cohort in anticipation of the potential for REBOA in children, and a group from Madigan Army Medical Center presents findings of study with a handheld pressure transducer and occlusion controller for partial REBOA. 31 In a similar preclinical study in this issue, Lauria and colleagues 32 from Walter Reed National Military Medical Center and the Uniformed Services University provide a glimpse at nextgeneration REBOA devices that will include on-board, real-time pressure sensors and automated balloon controllers.…”

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

“…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).…”