Resuscitative Endovascular Balloon Occlusion of the Aorta: A New Weapon to Combat Exsanguinating Hemorrhage

Hemorrhage is a leading cause of death from trauma, as well as from obstetrical emergencies and misadventures in elective surgery. While visible bleeding is easily managed by compression and vessel ligation even under battlefield conditions, noncompressible torso hemorrhage remains a lethal problem. Noncompressible torso hemorrhage can result from pelvic or retroperitoneal trauma, uterine disease or injury, or misplaced hardware in orthopedic procedures. Surgical visualization of injuries in the deep pelvis is difficult, and profuse bleeding can occur from a network of veins that offers no easy site for vascular control. Angiographic embolization is possible in modern facilities, but even in the best-equipped centers it can take time to mobilize the necessary resources. Too often the patient bleeds to death or sustains a lethal dose of shock before hemorrhage can be controlled.

During active bleeding, time is the enemy. Two review articles in this issue of Anesthesia & Analgesia describe a new technique for temporizing lethal hemorrhage, one that can minimize critical hypoperfusion during the time needed to definitively address the source of bleeding through surgery or invasive radiology.^1,2 Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged in recent years as an adjunctive therapy in major trauma cases and has been supported by development of new technology and protocols.

Briefly, REBOA consists of rapid access to the femoral artery, with placement of a balloon-tipped catheter in the descending aorta. Inflation of the balloon leads to partial or complete obstruction of the aorta, with significant reduction in lower body arterial pressure. The resulting low-flow state facilitates native hemostatic mechanisms and prevents washout of fragile early blood clots. The aortic level at which the balloon is inflated can be estimated initially, then fine-tuned by ultrasound or fluoroscopy as time and patient condition allow. Unlike the all-or-none thoracic aortic cross-clamp of the open chest cardiac arrest, often as physiologically damaging as the trauma itself, the REBOA balloon can be adjusted in both location and inflation to minimize bleeding while preserving some perfusion.

The review articles on REBOA in this issue of Anesthesia & Analgesia, from 2 of America’s busiest trauma centers, provide more details on indications for REBOA, technical considerations in placement and maintenance, physiologic changes induced by balloon inflation and deflation, and early clinical evidence of effectiveness. A parallel article in this month’s Anesthesia & Analgesia Case Reports illustrates the use of REBOA as part of damage control resuscitation in the first minutes after a severe injury.³ Each of these articles emphasizes the importance of close communication among the members of the trauma team during use of REBOA—the anesthesiologist is integral to good management. Physiologic changes with balloon inflation and deflation can be dramatic—if the team is not coordinating then wide swings in vital signs are likely, with the potential for cardiac arrest on the one hand and pressure-induced rebleeding on the other. As a properly integrated component of hemostatic (“damage control”) resuscitation, REBOA will save lives that are being lost today. Future studies will determine the best indications, further improve available devices, and compare the endovascular technique to the traditional open approach to aortic occlusion.

Use in the trauma population may be just the beginning. With equipment on hand and experience in our heads, REBOA could be applied to patients with abdominal or pelvic bleeding from many different causes, including unanticipated obstetrical hemorrhage, vascular surgery catastrophes, and inaccessible spinal tumors. As such, every anesthesiologist should be aware of the principles and physiology of REBOA, and every large hospital should have the necessary equipment on hand.

Perhaps more notable than the technique itself is what these articles represent: the increasing recognition in the United States of the subspecialty of trauma anesthesiology. While all anesthesiologists must have familiarity with the basics of resuscitation and life support, trauma specialists bring added value through their deeper understanding of mechanisms of injury, trauma patient physiology and the logistics of team-based care during both the golden hour of early resuscitation and the subsequent days or weeks of critical care. In European countries, of course, anesthesiologists have always been involved in prehospital and emergency care, but this tradition has only just been rediscovered in America. The Trauma Anesthesiology Society (www.tashq.org) was founded in 2011, and now boasts an international membership of several hundred enthusiastic clinician scientists, including the authors of these reviews. The Society has been instrumental in establishing and supporting a Trauma Section in Anesthesia & Analgesia, and we are proud to have served as the Executive Section Editor and Senior Editor for its inaugural year. We hope to bring to light many more examples of emerging science in trauma care, with particular emphasis on the role that anesthesiologists can play in delivering good outcomes for our patients.

DISCLOSURES

Name: Richard P. Dutton, MD, MBA.

Contribution: This author helped review the literature and write the editorial.

Name: Frank Herbstreit, DrMed.

Contribution: This author helped review the literature and write the editorial.

This manuscript was handled by: Jean-Francois Pittet, MD.