复苏性主动脉球囊阻断术在严峻情况下应用的可行性及拟议培训路径

Ross Elliot M, Redman Theodore T

J Spec Oper Med. 2018 Spring;18(1):37-43. doi: 10.55460/QB5T-9JAQ.

BACKGROUND

Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment.

METHODS

This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure.

RESULTS

There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625).

CONCLUSION

This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds.

背景

不可压缩的交界区和躯干出血仍然是战斗伤亡死亡的一个重要原因。复苏性血管内主动脉球囊阻断术（REBOA）是治疗许多交界区和不可压缩性出血的有效方法。目前医院放置REBOA的时间标准约为6分钟。本研究考察了非外科医生在严峻野外环境中应用REBOA治疗的培训过程和能力。

方法

这是一项技能获取和可行性研究。本实验的参与者是两名获得委员会认证的军事急诊医学医生，他们之前没有血管内手术经验。两位医生都参加了两个全国认可的REBOA培训课程。为该研究开发了一个灌注尸体模型。然后，每位医生在院前护理的不同阶段进行REBOA操作。记录每个操作的时间点。

结果

在非医院环境中，对14个灌注尸体模型进行了28次REBOA导管置入尝试：8次在野外环境中置入，8次在静态救护车中置入，4次在移动救护车中置入，8次在UH - 60飞机上飞行过程中置入。在两位医生、导管置入侧或单个尸体模型之间，未发现球囊充气时间有统计学显著差异。85.7%的模型成功置入。经皮穿刺成功的时间占53.6%。REBOA置入的总体平均时间为543秒（即约9分钟；中位数为439秒；95%置信区间[CI]，429 - 657），经皮导管的平均置入时间为376秒（即6.3分钟；95%CI，311 - 44），而需要血管切开的情况为821秒（95%CI，655 - 986）。重要的是，从决定转为开放切开直至REBOA置入的时间为455秒（95%CI，285 - 625）。