Resuscitative endovascular balloon occlusion of the aorta in a pediatric swine model: Is 60 minutes too long?

Abstract

BACKGROUND Resuscitative endovascular balloon occlusion of the aorta (REBOA) is recommended in adults with a noncompressible torso hemorrhage with occlusion times of less than 60 minutes. The tolerable duration in children is unknown. We used a pediatric swine controlled hemorrhage model to evaluate the physiologic effects of 30 minutes and 60 minutes of REBOA. METHODS Pediatric swine weighing 20 kg to 30 kg underwent a splenectomy and a controlled 60% total blood volume hemorrhage over 30 minutes, followed by either zone 1 REBOA for 30 minutes (30R) or 60 minutes (60R). Swine were then resuscitated with shed blood and received critical care for 240 minutes. RESULTS During critical care, the 30R group's (n = 3) pH, bicarbonate, base excess, and lactate were no different than baseline, while at the end of critical care, these variables continued to differ from baseline in the 60R group (n = 5) and were worsening (7.4 vs. 7.2, p < 0.001, 30.4 mmol/L vs. 18.4 mmol/L, p < 0.0001, 5.6 mmol/L vs. −8.5 mmol/L, p < 0.0001, 2.4 mmol/L vs. 5.7 mmol/L, p < 0.001, respectively). Compared with baseline, end creatinine and creatinine kinase were elevated in 60R swine (1.0 mg/dL vs. 1.7 mg/dL, p < 0.01 and 335.4 U/L vs. 961.0 U/L, p < 0.001, respectively), but not 30R swine (0.9 mg/dL vs. 1.2 mg/dL, p = 0.06 and 423.7 U/L vs. 769.5 U/L, p = 0.15, respectively). There was no difference in survival time between the 30R and 60R pediatric swine, p = 0.99. CONCLUSION The physiologic effects of 30 minutes of zone 1 REBOA in pediatric swine mostly resolved during the subsequent 4 hours of critical care, whereas the effects of 60 minutes of REBOA persisted and worsened after 4 hours of critical care. Sixty minutes of zone 1 REBOA may create an irreversible physiologic insult in a pediatric population.

Pediatric emergency resuscitative thoracotomy: A Western Trauma Association, Pediatric Trauma Society, and Eastern Association for the Surgery of Trauma collaborative critical decisions algorithm

“…50 Although there is a relatively robust and growing body of literature in the adult trauma population, the published experience with REBOA in the pediatric population is primarily limited to animal models, radiologic mapping/measuring for theoretical deployment, and case reports. [50][51][52][53][54] Several larger case series using national databases or registries have been published, but the analysis of pediatric REBOA use and outcomes have been almost exclusively in the adolescent/young adult age range of 16 to 18 years. 50,54,55 Given the lack of data and experience with REBOA in the true pediatric age range the group consensus was to not include it as a recommended option or pathway in this algorithm.…”

“…One approach that has been proposed as a safer and less invasive alternative to ERT is REBOA 50 . Although there is a relatively robust and growing body of literature in the adult trauma population, the published experience with REBOA in the pediatric population is primarily limited to animal models, radiologic mapping/measuring for theoretical deployment, and case reports 50–54 . Several larger case series using national databases or registries have been published, but the analysis of pediatric REBOA use and outcomes have been almost exclusively in the adolescent/young adult age range of 16 to 18 years 50,54,55 .…”

A clinical study of the hemodynamic and metabolic effects of Zone 3 REBOA for sacral and pelvic tumor resections

“…Another study [ 2 ] showed that a single continuous occlusion duration longer than 90 min caused significant complications, while the overall damage was minor when the occlusion time was less than 90 min. In some animal studies of hemorrhagic shock, occlusion times of 60 or 90 min were associated with substantial ischemia and reperfusion injury (IRI), which increases late mortality [ 8 – 12 ].

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Nationwide use of REBOA in adolescent trauma patients: An analysis of the AAST AORTA registry

“…The literature suggests that REBOA catheters are being used in pediatric patients, particularly adolescents. In pre-clinical studies, REBOA has been shown to decrease blood loss in a pediatric swine model [7], and pediatric swine have been found to tolerate 30 minutes, but not 60 minutes, of complete aortic occlusion [8]. However, there is no consensus on indications for REBOA use in pediatric patients at this time and more data is needed on the outcomes of pediatric patients undergoing REBOA placement to guide future use.…”