Strategies for successful implementation of resuscitative endovascular balloon occlusion of the aorta in an urban Level I trauma center

Abstract

BACKGROUND:The rationale for resuscitative endovascular balloon occlusion of the aorta (REBOA) is to control life-threatening subdiaphragmatic bleeding and facilitate resuscitation; however, incorporating this into the resuscitative practices of a trauma service remains challenging. The objective of this study is to describe the process of successful implementation of REBOA use in an academic urban Level I trauma center. All REBOA procedures from April 2014 through December 2019 were evaluated; REBOA was implemented after surgical faculty attended a required and internally developed Advanced Endovascular Strategies for Trauma Surgeons course. Success was defined by sustained early adoption rates. METHODS:An institutional protocol was published, and a REBOA supply cart was placed in the emergency department with posters attached to depict technical and procedural details. A focused professional practice evaluation was utilized for the first three REBOA procedures performed by each faculty member, leading to internal privileging. RESULTS:Resuscitative endovascular balloon occlusion of the aorta was performed in 97 patients by nine trauma surgeons, which is 1% of the total trauma admissions during this time. Each surgeon performed a median of 12 REBOAs (interquartile range, 5-14). Blunt (77/97, 81%) or penetrating abdominopelvic injuries (15/97, 15%) comprised the main injury mechanisms; 4% were placed for other reasons (4/97), including ruptured abdominal aortic aneurysms (n = 3) and preoperatively for a surgical oncologic resection (n = 1). Overall survival was 65% (63/97) with a steady early adoption trend that resulted in participation in a Department of Defense multicenter trial. CONCLUSION:Strategies for how departments adopt new procedures require clinical guidelines, a training program focused on competence, and a hospital education and privileging process for those acquiring new skills.

Systematic review to evaluate algorithms for REBOA use in trauma and identify a consensus for patient selection

“…Algorithms differed in defining REBOA patient selection criteria based on hemorrhage location, limiting to “below the diaphragm”(1), “abdominopelvic” (1), “abdominal, pelvic or junctional” (1), “torso” (2), or without anatomic qualifications (3). The Hadley et al 15 algorithm (Denver Health) includes a graded approach to REBOA patient selection depending on hemorrhage location.…”

“…Table 2 summarizes the seven algorithms used by the level 1 trauma centers involved in the ongoing rollout of the partial REBOA catheter, with the Denver Health algorithm also previously referenced in table 1 . 15 Patient selection for partial REBOA deployment is similar across institutions, although Denver Health and Vanderbilt University Medical Center use a lower trigger of SBP <80 mm Hg, and St Michael’s Hospital reserves REBOA for patients with a positive abdominal focused assessment with sonography in trauma or pelvic fracture. Resuscitation is not specifically defined as blood product resuscitation, and “non-response” is not specifically defined except in the Grady algorithm.…”

Resuscitative Endovascular Balloon Occlusion of the Aorta as a Bridge to Organ Donation after Blunt Trauma

“…Thus, it is an integral step during resuscitative thoracotomy for injured patients in extremis. Initial investigations of REBOA have indicated a survival benefit in selected patients [17,18]. It is less invasive than resuscitative thoracotomy, which can also lead to organ donation [19].…”

A Guide to Femoral Arterial Access for Resuscitative Endovascular Balloon Occlusion of the Aorta

“…After the decision to use REBOA has been made, it still takes at least several minutes to occlude the aorta because procedures such as obtaining an arterial access, inserting the REBOA catheter, and inflating the balloon are to be performed. Therefore, if you recognize any possibility that the patient might require the use of REBOA (which should happen much earlier than the actual decision to use REBOA), you must start the preparation for the procedure as early as possible [1][2][3]23,24].…”