Goodenough Christopher J, Cobb Tyler A, Holcomb John B
Department of Surgery, University of Texas Health Science Center at Houston, Memorial Hermann Hospital Red Duke Trauma Institute, Houston, Texas, USA.
Trauma Surg Acute Care Open. 2018 Oct 1;3(1):e000165. doi: 10.1136/tsaco-2018-000165. eCollection 2018.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) has become an increasingly popular alternative to emergency thoracotomy and aortic cross-clamping in patients with exsanguinating hemorrhage.1 This new capability is increasingly being used in non-trauma situations.2 3 This report demonstrates another novel use of REBOA for iatrogenic intra-abdominal hemorrhage. An 83-year-old man with multiple medical comorbidities and a history of chronic mesenteric ischemia was admitted to our institution for an elective mesenteric revascularization. Revascularization was unsuccessful, despite attempts to cross the lesion. Postprocedure, the patient developed a right groin hematoma, and CT on postprocedure day 0 demonstrated a femoral artery pseudoaneurysm and subintimal contrast at the level of the celiac artery, representing an iatrogenic dissection. The following day, he complained of dizziness. Physical examination revealed a blood pressure of 68/35 mm Hg, heart rate of 100 beats per minute, and a distended abdomen. Because the surgical intensive care unit (SICU) was full, he was transferred to the neurotrauma intesive care unit (NTICU) and intubated for hemodynamic instability. A chest X-ray revealed a prior thoracic endovascular aortic repair (figure 1), but no intrathoracic hemorrhage or pathology. Bedside ultrasonography revealed intra-abdominal fluid. Laboratory workup showed hemoglobin of 6.1 g/dL, from 10.9 the previous day. The patient was given two units of packed red blood cells, without response. The intensive care unit (ICU) team initiated norepinephrine, with minimal improvement despite increasing doses. Figure 1Chest X-ray with catheter in zone 1. Arrows mark the proximal and distal markers of the resuscitative endovascular balloon occlusion of the aorta.
WHAT WOULD YOU DO?: Transfuse two units of packed red blood cells and observe.Proceed to the operating room (OR) for exploratory laparotomy.Endovascular balloon occlusion of the aorta (zone 1).
对于出现大出血的患者，复苏性血管内主动脉球囊阻断术（REBOA）已越来越成为紧急开胸手术和主动脉交叉钳夹术的常用替代方法。1 这种新方法越来越多地用于非创伤情况。2 3 本报告展示了REBOA在医源性腹腔内出血中的另一种新用途。一名83岁男性，有多种内科合并症及慢性肠系膜缺血病史，因择期肠系膜血管重建术入住我院。尽管尝试通过病变部位，但血管重建未成功。术后，患者出现右腹股沟血肿，术后第0天的CT显示股动脉假性动脉瘤及腹腔干水平的内膜下造影剂，提示医源性夹层。次日，他主诉头晕。体格检查发现血压为68/35 mmHg，心率为每分钟100次，腹部膨隆。由于外科重症监护病房（SICU）已满员，他被转至神经创伤重症监护病房（NTICU），因血流动力学不稳定而插管。胸部X线显示既往有胸段血管内主动脉修复术（图1），但无胸腔内出血或病变。床旁超声检查显示腹腔内有液体。实验室检查显示血红蛋白从之前的10.9 g/dL降至6.1 g/dL。患者输注了两单位浓缩红细胞，但无反应。重症监护病房（ICU）团队开始使用去甲肾上腺素，尽管剂量增加，但改善甚微。图1 第1区带导管的胸部X线片。箭头标记复苏性血管内主动脉球囊阻断术的近端和远端标记。
你会怎么做？：输注两单位浓缩红细胞并观察。前往手术室（OR）进行剖腹探查术。血管内主动脉球囊阻断术（第1区）。
