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Resuscitative endovascular balloon occlusion of the aorta: Physiology and clinical aspects of an emerging technique
Örebro University, School of Medical Sciences.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Traumatic hemorrhagic shock is a major cause of death worldwide. Patients enter the fatal triad of hypothermia, acidosis and coagulopathy and die quickly due to cardiovascular collapse. Ideally, procedures should be performed at the injury scene to prevent this fatal event. Unfortunately, intervention cannot be performed as soon as is needed and time to intervention becomes the enemy of survival. Hemorrhage control until definitive repair can possibly save lives. Hemorrhage from the extremities can be controlled by external pressure but severe hemorrhage from thoracic, abdominal or pelvic cavities, called non-compressible torso hemorrhage, requires internal hemorrhage control. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) uses an endovascular balloon that is inserted into the aorta using minimally invasive methods and is inflated to increase perfusion pressure and avoid cardiovascular collapse, providing a bridge to intervention. REBOA is hypothetised to increase central blood pressure but cause ischemia reperfusion injury below the occlusion level. The purpose of this thesis was to investigate the general impact of REBOA on physiology, metabolism, inflammatory response in normovolemia and hemorrhage. Investigation was conducted through clinical and experimental models.

Study I was a multicentre cohort study of patients with traumatic hemorrhagic shock who received REBOA. Ninety-six patients were included, with an overall mortality of 56% and with no major complications from REBOA use. REBOA was used in a continuous and non-continuous fashion depending on the patients’ level of hypovolemia.

Study II and the following three studies were animal experimental studies. Study II was a randomized control study in pigs to evaluate physiological, metabolic, inflammatory and end-organ function in a normovolemic state. It was demonstrated that REBOA increased central blood pressure but caused ischemic insult.

Study III, a randomised controlled experimental model in pigs. Investigation was made to examine the possibility of titrating blood pressure with partial occlusion and investigate if partial occlusion reduced the ischemic insult. Partial REBOA could be achieved in this study and the ischemia reperfusion injury was less pronounced in partial occlusion than total. However, the difficulty regarding how to determine partial occlusion in a clinical setting remained.

Study IV was therefore an experimental study conducted to compare the different methods of determining partial occlusion and detect the best correlation to organ perfusion. The following variables were compared to oxygen consumption: end-tidal carbon dioxide, aortic blood flow, superior mesenteric blood flow and femoral mean pressure. The study revealed that end-tidal carbon dioxide correlates best to organ perfusion.

Place, publisher, year, edition, pages
Örebro: Örebro University , 2019. , p. 66
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 199
Keywords [en]
REBOA, trauma, hemorrhage, partial REBOA, Ischemia reperfusion injury, blood pressure titration, endtidal cabondioxide, traumatic inflammatory response
National Category
Surgery
Identifiers
URN: urn:nbn:se:oru:diva-75821ISBN: 978-91-7529-304-2 (print)OAI: oai:DiVA.org:oru-75821DiVA, id: diva2:1343676
Public defence
2019-11-08, Örebro universitet, Campus USÖ, hörsal C3, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-08-19 Created: 2019-08-19 Last updated: 2019-10-17Bibliographically approved
List of papers
1. The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry
Open this publication in new window or tab >>The use of aortic balloon occlusion in traumatic shock: first report from the ABO trauma registry
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2018 (English)In: European Journal of Trauma and Emergency Surgery, ISSN 1863-9933, E-ISSN 1863-9941, Vol. 44, no 4, p. 491-501Article in journal (Refereed) Published
Abstract [en]

PURPOSE: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a technique for temporary stabilization of patients with non-compressible torso hemorrhage. This technique has been increasingly used worldwide during the past decade. Despite the good outcomes of translational studies, clinical studies are divided. The aim of this multicenter-international study was to capture REBOA-specific data and outcomes.

METHODS: REBOA practicing centers were invited to join this online register, which was established in September 2014. REBOA cases were reported, both retrospective and prospective. Demographics, injury patterns, hemodynamic variables, REBOA-specific data, complications and 30-days mortality were reported.

RESULTS: Ninety-six cases from 6 different countries were reported between 2011 and 2016. Mean age was 52 ± 22 years and 88% of the cases were blunt trauma with a median injury severity score (ISS) of 41 (IQR 29-50). In the majority of the cases, Zone I REBOA was used. Median systolic blood pressure before balloon inflation was 60 mmHg (IQR 40-80), which increased to 100 mmHg (IQR 80-128) after inflation. Continuous occlusion was applied in 52% of the patients, and 48% received non-continuous occlusion. Occlusion time longer than 60 min was reported as 38 and 14% in the non-continuous and continuous groups, respectively. Complications, such as extremity compartment syndrome (n = 3), were only noted in the continuous occlusion group. The 30-day mortality for non-continuous REBOA was 48%, and 64% for continuous occlusion.

CONCLUSIONS: This observational multicenter study presents results regarding continuous and non-continuous REBOA with favorable outcomes. However, further prospective studies are needed to be able to draw conclusions on morbidity and mortality.

Place, publisher, year, edition, pages
Springer Berlin/Heidelberg, 2018
Keywords
Aortic occlusion, Hemorrhage, IABO, REBOA, Trauma
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-61724 (URN)10.1007/s00068-017-0813-7 (DOI)000440981100002 ()28801841 (PubMedID)2-s2.0-85027305588 (Scopus ID)
Funder
Swedish Society for Medical Research (SSMF)
Note

Funding Agencies:

Research Committee of Region Örebro County  

Nyckelfonden at Örebro University Hospital  

ALF Grants (Agreement concerning research and education of doctors)  

Region Örebro County 

Available from: 2017-11-07 Created: 2017-11-07 Last updated: 2019-10-15Bibliographically approved
2. Total resuscitative endovascular balloon occlusion of the aorta causes inflammatory activation and organ damage within 30 minutes of occlusion in normovolemic pigs
Open this publication in new window or tab >>Total resuscitative endovascular balloon occlusion of the aorta causes inflammatory activation and organ damage within 30 minutes of occlusion in normovolemic pigs
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(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-77389 (URN)
Available from: 2019-10-15 Created: 2019-10-15 Last updated: 2019-10-15Bibliographically approved
3. Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA
Open this publication in new window or tab >>Blood pressure targeting by partial REBOA is possible in severe hemorrhagic shock in pigs and produces less circulatory, metabolic and inflammatory sequelae than total REBOA
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2018 (English)In: Injury, ISSN 0020-1383, E-ISSN 1879-0267, Vol. 49, no 12, p. 2132-2141Article in journal (Refereed) Published
Abstract [en]

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective adjunct in exsanguinating torso hemorrhage, but causes ischemic injury to distal organs. The aim was to investigate whether blood pressure targeting by partial REBOA (pREBOA) is possible in porcine severe hemorrhagic shock and to compare pREBOA and total REBOA (tREBOA) regarding hemodynamic, metabolic and inflammatory effects.

Methods: Eighteen anesthetized pigs were exposed to induced controlled hemorrhage to a systolic blood pressure (SBP) of 50 mmHg and randomized into three groups of thoracic REBOA: 30 min of pREBOA (target SBP 80-100 mmHg), tREBOA, and control. They were then resuscitated by autologous transfusion and monitored for 3 h. Hemodynamics, blood gases, mesenteric blood flow, intraperitoneal metabolites, organ damage markers, histopathology from the small bowel, and inflammatory markers were analyzed.

Results: Severe hemorrhagic shock was induced in all groups. In pREBOA the targeted blood pressure was reached. The mesenteric blood flow was sustained in pREBOA, while it was completely obstructed in tREBOA. Arterial pH was lower, and lactate and troponin levels were significantly higher in tREBOA than in pREBOA and controls during the reperfusion period. Intraperitoneal metabolites, the cytokine response and histological analyses from the small bowel were most affected in the tREBOA compared to the pREBOA and control groups.

Conclusion: Partial REBOA allows blood pressure titration while maintaining perfusion to distal organs, and reduces the ischemic burden in a state of severe hemorrhagic shock. Partial REBOA may lower the risks of post-resuscitation metabolic and inflammatory impacts, and organ dysfunction. (C) 2018 Published by Elsevier Ltd.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Hemorrhage, REBOA, Trauma, Injury, Anaerobic metabolism, Aortic balloon occlusion, Shock, Partial REBOA, Ischemia reperfusion injury, Inflammatory response
National Category
Anesthesiology and Intensive Care Surgery
Identifiers
urn:nbn:se:oru:diva-70857 (URN)10.1016/j.injury.2018.09.052 (DOI)000452313500005 ()30301556 (PubMedID)2-s2.0-85054438400 (Scopus ID)
Funder
Swedish Society of MedicineSwedish Society for Medical Research (SSMF)
Note

Funding Agencies:

Research Committee of Region Örebro County  

Nyckelfonden at Örebro University Hospital  

Region Örebro County  

ALF 

Available from: 2019-01-07 Created: 2019-01-07 Last updated: 2019-10-15Bibliographically approved
4. End-tidal carbon dioxide as an indicator of partial REBOA and distal organ metabolism in normovolemia and hemorrhagic shock in anesthetized pigs
Open this publication in new window or tab >>End-tidal carbon dioxide as an indicator of partial REBOA and distal organ metabolism in normovolemia and hemorrhagic shock in anesthetized pigs
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(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-77391 (URN)
Available from: 2019-10-15 Created: 2019-10-15 Last updated: 2019-10-15Bibliographically approved

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