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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
Örebro University, School of Medical Sciences. Department of Vascular Surgery, Västmanlands Hospital, Västerås, Sweden.
Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.ORCID iD: 0000-0003-3912-4732
Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery.ORCID iD: 0000-0001-8466-1786
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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. Vol. 49, no 12, p. 2132-2141
Keywords [en]
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: urn:nbn:se:oru:diva-70857DOI: 10.1016/j.injury.2018.09.052ISI: 000452313500005PubMedID: 30301556Scopus ID: 2-s2.0-85054438400OAI: oai:DiVA.org:oru-70857DiVA, id: diva2:1276007
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: 2022-08-24Bibliographically approved
In thesis
1. Resuscitative endovascular balloon occlusion of the aorta: Physiology and clinical aspects of an emerging technique
Open this publication in new window or tab >>Resuscitative endovascular balloon occlusion of the aorta: Physiology and clinical aspects of an emerging technique
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
REBOA, trauma, hemorrhage, partial REBOA, Ischemia reperfusion injury, blood pressure titration, endtidal cabondioxide, traumatic inflammatory response
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-75821 (URN)978-91-7529-304-2 (ISBN)
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: 2021-08-19Bibliographically approved

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Sadeghi, MitraHörer, Tal M.Dogan, Emanuel M.Nilsson, Kristofer F.

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