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Efficacy of intermittent versus standard resuscitative endovascular balloon occlusion of the aorta in a lethal solid organ injury model

Kuckelman, John DO; Derickson, Michael MD; Barron, Morgan MD; Phillips, Cody J. DO; Moe, Donald MD; Levine, Tiffany MD; Kononchik, Joseph P. PhD; Marko, Shannon T. DVM; Eckert, Matthew MD; Martin, Matthew J. MD

Journal of Trauma and Acute Care Surgery: July 2019 - Volume 87 - Issue 1 - p 9–17
doi: 10.1097/TA.0000000000002307
2019 EAST PODIUM PAPER
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BACKGROUND High-grade solid organ injury is a major cause of mortality in trauma. Use of resuscitative endovascular balloon occlusion of the aorta (REBOA) can be effective but is limited by ischemia-reperfusion injury. Intermittent balloon inflation/deflation has been proposed as an alternative, but the safety and efficacy prior to operative hemorrhage control is unknown.

METHODS Twenty male swine underwent standardized high-grade liver injury, then randomization to controls (N = 5), 60-min continuous REBOA (cR, n = 5), and either a time-based (10-minute inflation/3-minute deflation, iRT = 5) or pressure-based (mean arterial pressure<40 during deflation, iRP = 5) intermittent schedule. Experiments were concluded after 120 minutes or death.

RESULTS Improved overall survival was seen in the iRT group when compared to cR (p < 0.01). Bleeding rate in iRT (5.9 mL/min) was significantly lower versus cR and iRP (p = 0.02). Both iR groups had higher final hematocrit (26% vs. 21%) compared to cR (p = 0.03). Although overall survival was lower in the iRP group, animals surviving to 120 minutes with iRP had decreased end organ injury (Alanine aminotransferase [ALT] 33 vs. 40 in the iRT group, p = 0.03) and lower lactate levels (13 vs. 17) compared with the iRT group (p = 0.03). No differences were seen between groups in terms of coagulopathy based on rotational thromboelastometry.

CONCLUSION Intermittent REBOA is a potential viable adjunct to improve survival in lethal solid organ injury while minimizing the ischemia-reperfusion seen with full REBOA. The time-based intermittent schedule had the best survival and prolonged duration of tolerable zone 1 placement. Although the pressure-based schedule was less reliable in terms of survival, when effective, it was associated with decreased acidosis and end-organ injury.

From the Department of Surgery (J.K., M.D., M.B., C.P., D.M., J.K., M.E., M.J.M.), Department of Clinical Investigations (T.L., S.M.), Madigan Army Medical Center, Tacoma, Washington; and Trauma and Emergency Surgery Service (M.J.M.), Legacy Emanuel Medical Center, Portland, Oregon.

This article was given at the 32nd Annual Meeting of the Eastern Association for the Surgery of Trauma, on January 15, 2019 in Austin, Texas.

Address for reprints: Matthew J. Martin, MD, Department of Surgery, ATTN: MCHJ-SGY-G, Madigan Army Medical Center, 9040-A Fitzsimmons Avenue, Tacoma, WA 98431; email: traumadoc22@gmail.com.

Online date: April 25, 2019

© 2019 Lippincott Williams & Wilkins, Inc.