Extending the golden hour

Russo, Rachel M.; Williams, Timothy K.; Grayson, J.; Lamb, Christopher; Cannon, Jeremy W.; Clement, Nathan F.; Galante, Joseph M.; Neff, Lucas P.

doi:10.1097/ta.0000000000000940

Cited by 127 publications

(69 citation statements)

References 20 publications

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“…Some studies reported that small introducer sheaths for REBOA may be associated with fewer complications [27, 29] and that ultrasound should be optimized for REBOA [30]. Moreover, partial or intermittent REBOA should be considered in some cases [31, 32]. However, their effect remains unclear.…”

Section: Discussionmentioning

confidence: 99%

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study

et al. 2018

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BackgroundAlthough resuscitative endovascular balloon occlusion of the aorta (REBOA) may be effective in trauma management, its effect in patients with severe multiple torso trauma remains unclear.MethodsWe performed a retrospective study to evaluate trauma management with REBOA in hemodynamically unstable patients with severe multiple trauma. Of 5899 severe trauma patients admitted to our hospital between January 2011 and January 2018, we selected 107 patients with severe torso trauma (Injury Severity Score > 16) who displayed persistent hypotension [≥ 2 systolic blood pressure (SBP) values ≤ 90 mmHg] regardless of primary resuscitation. Patients were divided into two groups: trauma management with REBOA (n = 15) and without REBOA (n = 92). The primary endpoint was the effectiveness of trauma management with REBOA with respect to in-hospital mortality. Secondary endpoints included time from arrival to the start of hemostasis. Multivariable logistic regression analysis, adjusted for clinically important variables, was performed to evaluate clinical outcomes.ResultsTrauma management with REBOA was significantly associated with decreased mortality (adjusted odds ratio of survival, 7.430; 95% confidence interval, 1.081–51.062; p = 0.041). The median time (interquartile range) from admission to initiation of hemostasis was not significantly different between the two groups [with REBOA 53.0 (40.0–80.3) min vs. without REBOA 57.0 (35.0–100.0) min ]. The time from arrival to the start of balloon occlusion was 55.7 ± 34.2 min. SBP before insertion of REBOA was 48.2 ± 10.5 mmHg. Total balloon occlusion time was 32.5 ± 18.2 min.ConclusionsThe use of REBOA without a delay in initiating resuscitative hemostasis may improve the outcomes in patients with multiple severe torso trauma. However, optimal use may be essential for success.

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Section: Discussionmentioning

confidence: 99%

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study

et al. 2018

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“…14–18 However, the techniques of partial REBOA (P-REBOA) and intermittent REBOA (I-REBOA) using existing technology pose a risk of ongoing hemorrhage. 17, 19 Studies with large animal injury models have demonstrated that P-REBOA can lead to increased blood loss when compared to complete REBOA. 17 Furthermore, hemodynamic instability during attempts at partial flow restoration has been observed in early clinical experience.…”

Section: Introductionmentioning

confidence: 99%

“…17, 19 Studies with large animal injury models have demonstrated that P-REBOA can lead to increased blood loss when compared to complete REBOA. 17 Furthermore, hemodynamic instability during attempts at partial flow restoration has been observed in early clinical experience. 20 While this approach to aortic flow reintroduction is rational in resource-rich environments with access to blood products and operating rooms, it will be limited in scenarios in which a prolonged time period exists between injury and hemorrhage control.…”

Section: Introductionmentioning

confidence: 99%

Automated variable aortic control versus complete aortic occlusion in a swine model of hemorrhage

Williams

Neff

Johnson

et al. 2017

Journal of Trauma and Acute Care Surgery

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Background Future endovascular hemorrhage control devices will require features that mitigate the adverse effects of vessel occlusion. Permissive regional hypoperfusion (PRH) with variable aortic control (VAC) is a novel strategy to minimize hemorrhage and reduce the ischemic burden of complete aortic occlusion (AO). The objective of this study was to compare PRH with VAC to AO in a lethal model of hemorrhage. Methods Twenty-five swine underwent cannulation of the supraceliac aorta, with diversion of aortic flow through an automated extracorporeal circuit. After creation of uncontrolled liver hemorrhage, animals were randomized to 90 minutes of treatment: Control (full, unregulated flow; n=5) AO (no flow; n=10), and PRH with VAC (dynamic distal flow initiated after 20 minutes of AO; n=10). In the PRH group, distal flow rates were regulated between 100–300mL/min based on a desired, preset range of proximal mean arterial pressure (MAP). At 90 minutes, damage control surgery, resuscitation, and restoration of full flow ensued. Critical care continued for 4.5 hours or until death. Hemodynamic parameters and markers of ischemia were recorded. Results Study survival was 0%, 50%, and 90% for control, AO, and VAC respectively (p<0.01) (Figure). During intervention, VAC resulted in more physiologic proximal MAP (84mmHg±18 vs. 105±9mmHg, p<0.01) and higher renal blood flow than AO animals (p=0.02). During critical care, VAC resulted in higher proximal MAP (73 mmHg±8 vs. 50 mmHg±6, p<0.01), carotid and renal blood flow (p<0.01), lactate clearance (p<0.01), and urine output (p<0.01) than AO despite requiring half the volume of crystalloids to maintain proximal MAP ≥50 mmHg (p<0.01). Conclusion Permissive regional hypoperfusion with variable aortic control minimizes the adverse effects of distal ischemia, optimizes proximal pressure to the brain and heart, and prevents exsanguination in this model of lethal hemorrhage. These findings provide foundational knowledge for the continued development of this novel paradigm and inform next generation endovascular designs.

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“…Utilizing a rapidly fatal porcine liver injury model, P-REBOA was able to extend survival nearly 3.5-fold over no intervention, but was unable to achieve satisfactory hemostasis over complete REBOA. Further translational investigation suggests that (15). P-REBOA may best be implemented following a brief period of complete aortic occlusion to achieve initial hemostasis prior to the re-introduction of distal blood flow.…”

Section: Endovascular Methods For Achieving Aortic Occlusionmentioning

confidence: 99%

“…The dysregulation of the immune response in animal models of aortic occlusion leads to migration of leukocytes into ischemic distal tissue beds, principally the intestines, and profound leukopenia (9, 15). Similar leukocyte sequestration in the intestines of humans is associated with mesenteric ischemia, intestinal dysfunction, and an increased risk of sepsis (16).…”

Section: Effects Of Aortic Occlusionmentioning

confidence: 99%

Emerging Endovascular Therapies for Non-Compressible Torso Hemorrhage

Russo

Neff

Johnson

et al. 2016

Shock

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Management of non-compressible torso hemorrhage (NCTH) remains a challenge despite continued advancements in trauma resuscitation. Resuscitative thoracotomy with aortic cross-clamping and recent advances in endovascular aortic occlusion, including resuscitative endovascular occlusion of the aorta (REBOA), have finite durations of therapy due to the inherent physiologic stressors that accompany complete occlusion. Here we attempt to illuminate the current state of aortic occlusion for trauma resuscitation including: 1) explanation of the deleterious consequences of complete occlusion, 2) potential methods and limitations of existing technology to overcome these consequences, 3) a description of innovative methods to improve the resuscitation of NCTH. By explaining the complexity and potential deleterious effects of resuscitation augmented with aortic occlusion, our goal is to provide practitioners with a real-world perspective on current endovascular technology and to encourage the continued innovation required to overcome existing obstacles.

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Extending the golden hour

Abstract: In the setting of severe ongoing hemorrhage, P-REBOA increased survival time beyond the golden hour while maintaining cMAP and carotid flow at physiologic levels.

Cited by 127 publications

References 20 publications

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study

Effect of resuscitative endovascular balloon occlusion of the aorta in hemodynamically unstable patients with multiple severe torso trauma: a retrospective study

Automated variable aortic control versus complete aortic occlusion in a swine model of hemorrhage

Emerging Endovascular Therapies for Non-Compressible Torso Hemorrhage

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