Patient selection for resuscitative endovascular balloon occlusion of the aorta (REBOA) has evolved during the last decade. A recent multicenter collaboration to implement the newest generation REBOA ...balloon catheter identified variability in patient selection criteria. The aims of this systematic review were to compare recent REBOA patient selection guidelines and to identify current areas of consensus and variability.
In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a systematic review of clinical practice guidelines for REBOA patient selection in trauma. Published algorithms from 2015 to 2022 and institutional guidelines from a seven-center REBOA collaboration were compiled and synthesized.
Ten published algorithms and seven institutional guidelines on REBOA patient selection were included. Broad consensus exists on REBOA deployment for blunt and penetrating trauma patients with non-compressible torso hemorrhage refractory to blood product resuscitation. Algorithms diverge on precise systolic blood pressure triggers for early common femoral artery access and REBOA deployment, as well as the use of REBOA for traumatic arrest and chest or extremity hemorrhage control.
Although our convenience sample of institutional guidelines likely underestimates patient selection variability, broad consensus exists in the published literature regarding REBOA deployment for blunt and penetrating trauma patients with hypotension not responsive to resuscitation. Several areas of patient selection variability reflect individual practice environments.
Level 5, systematic review.
Congenital anomalies of the inferior vena cava (IVC) are rare, but recognized, causing deep venous thrombosis. We present a case of a 50-year-old patient with trauma who suffered an intracranial ...hemorrhage secondary to a fall while on anticoagulation for deep vein thromboses. Venous return from the lower extremities was determined to be through dilated lumbar venous collaterals into the azygous and hemiazygous systems. A second interesting anatomic finding was a hypoplastic left kidney.
Infectious complications impart increased morbidity and mortality following surgery and are common in patients undergoing pancreatectomy. 1 Most infections following pancreatectomy are polymicrobial ...in nature, with the most common organisms cultured from intra-abdominal abscesses being gram-negative bacteria. 1 Gram-negative Burkholderia cepacia, on the other hand, is extremely rare. A CT scan obtained for continued fevers and leukocytoses revealed multiple complex fluid collections in the intra-abdominal space which communicated with a fluid collection within the surgical wound, between the anterior and posterior layers of fascia (Figure 2). Multiple antibiotic regimens have been used to treat B. cepacia infection. 2 β-lactamases, efflux pump proteins, a unique lipopolysaccharide structure, and drug target modification are some of the mechanisms by which B. cepacia imparts antibiotic resistance. 2 Much of the experience with antibiotic therapy come from the treatment of B. cepacia in the CF population, as this is the group that is most well studied with this infection.
OBJECTIVE:We sought to describe contemporary presentation, treatment, and outcomes of patients presenting with acute (A), perforated (P), and gangrenous (G) appendicitis in the United States.
SUMMARY ...BACKGROUND DATA:Recent European trials have reported that medical (antibiotics only) treatment of acute appendicitis is an acceptable alternative to surgical appendectomy. However, the type of operation (open appendectomy) and average duration of stay are not consistent with current American practice and therefore their conclusions do not apply to modern American surgeons.
METHODS:This multicenter prospective observational study enrolled adults with appendicitis from January 2017 to June 2018. Descriptive statistics were performed. P and G were combined into a “complicated” outcome variable and risk factors were assessed using multivariable logistic regression.
RESULTS:A total 3597 subjects were enrolled across 28 sitesmedian age was 37 (27–52) years, 1918 (53%) were male, 90% underwent computed tomography (CT) imaging, 91% were initially treated by appendectomy (98% laparoscopic), and median hospital stay was 1 (1–2) day. The 30-day rates of Emergency Department (ED) visit and readmission were 10% and 6%. Of 219 initially treated with antibiotics, 35 (16%) required appendectomy during index hospitalization and 12 (5%) underwent appendectomy within 30 days, for a cumulative failure rate of 21%. Overall, 2403 (77%) patients had A, whereas 487 (16%) and 218 (7%) patients had P and G, respectively. On regression analysis, age, symptoms >48 hours, temperature, WBC, Alvarado score, and appendicolith were predictive of “complicated” appendicitis, whereas co-morbidities, smoking, and ED triage to appendectomy >6 hours or >12 hours were not.
CONCLUSION:In the United States, the majority of patients presenting with appendicitis receive CT imaging, undergo laparoscopic appendectomy, and stay in the hospital for 1 day. One in five patients selected for initial non-operative management required appendectomy within 30 days. In-hospital delay to appendectomy is not a risk factor for “complicated” appendicitis.
Partial occlusion of the aorta is a resuscitation technique designed to maximize proximal perfusion while allowing a graduated amount of distal flow to reduce the ischemic sequelae associated with ...complete aortic occlusion. The pREBOA catheter affords the ability to titrate perfusion as hemodynamics allows, however, the impact of this new technology for REBOA on blood use and other resuscitative requirements is currently unknown. We hypothesize pREBOA's ability to provide partial occlusion, when appropriate, decreases overall resuscitative requirements when compared to ER-REBOA.
The entire AAST AORTA Registry was used to compare resuscitation requirements between all ER-REBOA and pREBOA. Unpaired t-tests were used to compare resuscitation strategies including packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, cryoprecipitate, crystalloids, and need for pressors.
When comparing ER-REBOA (n=800) use to pREBOA (n=155), initial patient presentations were similar except for age (44 vs 40 p=0.026) and rates of blunt injury (78.4% vs 78.7% p<0.010). Zone-1 occlusion was used less often in ER-REBOA (65.8 vs 71.7 p=0.046). Partial occlusion was performed in 85% of pREBOA compared to 11% in ER-REBOA (p<0.050). Vitals at the time of REBOA were worse in ER-REBOA, and received significantly more units of PRBCs, FFP, platelets, and liters of crystalloids than pREBOA (p<0.05). Rates of ARDS and septic shock were lower in pREBOA (p<0.05).
When comparing pREBOA to ER-REBOA, there has been a rise in Zone-1 and partial occlusion. In our pilot analysis of the AORTA Registry, there was a reduction in administration of pRBC, FFP, platelets, and crystalloids. Though further prospective studies are required, this is the first to demonstrate an association between pREBOA, partial occlusion, and reduced blood use and resuscitative requirements.
Extending the time to definitive hemorrhage control in noncompressible torso hemorrhage (NCTH) is of particular importance in the battlefield where transfer times are prolonged and NCTH remains the ...leading cause of death. While resuscitative endovascular balloon occlusion of the aorta is widely practiced as an initial adjunct for the management of NCTH, concerns for ischemic complications after 30 minutes of compete aortic occlusion deters many from zone 1 deployment. We hypothesize that extended zone 1 occlusion times will be enabled by novel purpose-built devices that allow for titratable partial aortic occlusion.
This is a cross-sectional analysis describing pREBOA-PRO zone 1 deployment characteristics at seven level 1 trauma centers in the United States and Canada (March 30, 2021, and June 30, 2022). To compare patterns of zone 1 aortic occlusion, the AORTA registry was used. Data were limited to adult patients who underwent successful occlusion in zone 1 (2013-2022).
One hundred twenty-two patients pREBOA-PRO patients were included. Most catheters were deployed in zone 1 (n = 89 73%) with a median zone 1 total occlusion time of 40 minutes (interquartile range, 25-74). A sequence of complete followed by partial occlusion was used in 42% (n = 37) of zone 1 occlusion patients; a median of 76% (interquartile range, 60-87%) of total occlusion time was partial occlusion in this group. As was seen in the prospectively collected data, longer median total occlusion times were observed in the titratable occlusion group in AORTA compared with the complete occlusion group.
Longer zone 1 aortic occlusion times seen with titratable aortic occlusion catheters appear to be driven by the feasibility of controlled partial occlusion. The ability to extend safe aortic occlusion times may have significant impact to combat casualty care where exsanguination from NCTH is the leading source of potentially preventable deaths.
Therapeutic/Care Management; Level IV.
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