区域 3 血管内球囊阻断在严重骨盆骨折治疗中的应用模式和结果：来自创伤和急性护理外科学协会主动脉阻塞复苏创伤数据库的结果。
Patterns and outcomes of zone 3 REBOA use in the management of severe pelvic fractures: Results from the AAST Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery database.
机构信息
From the R Adams Cowley Shock Trauma Center (M.H., T.S., J.D.), University of Maryland School of Medicine, Baltimore, Maryland; Division of Trauma and Critical Care (K.I.), University of Southern California, Los Angeles, California; Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery (J.C., M.S.), University of Pennsylvania, Philadelphia, Pennsylvania; and Department of Surgery (E.M.), University of Colorado, Denver Health Medical Center, Denver, Colorado.
出版信息
J Trauma Acute Care Surg. 2021 Apr 1;90(4):659-665. doi: 10.1097/TA.0000000000003053.
BACKGROUND
Knowledge on practice patterns for aortic occlusion (AO) in the setting of severe pelvic fractures is limited. This study aimed to describe clinical outcomes based on number and types of interventions after zone 3 resuscitative endovascular balloon occlusion of the aorta (REBOA) deployment.
METHODS
A retrospective review of the American Association for the Surgery of Trauma Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery multicenter registry was performed for patients who underwent zone 3 AO from 2013 to 2020. Patients with a blunt mechanism who survived beyond the emergency department were included. Interventions evaluated were preperitoneal pelvic packing (PP), angioembolization (AE), and external fixation (EF) of the pelvis. Management approaches were compared against the primary outcome of mortality. Secondary outcomes included transfusion requirements, overall complications and acute kidney injury (AKI).
RESULTS
Of 207 patients who underwent zone 3 AO, 160 (77.3%) fit the inclusion criteria. Sixty (37.5%) underwent AO alone, 50 (31.3%) underwent a second hemostatic intervention, and 49 (30.6%) underwent a third hemostatic intervention. Overall mortality was 37.7% (n = 60). There were no differences in mortality based on any number or combination of interventions. On multivariable regression, only EF was associated with a mortality reduction (odds ratio, 0.22; p = 0.011). Increasing number of interventions were associated with higher transfusion and complication rates. Pelvic packing + AE was associated with increased AKI than PP or AE alone (73.3% vs. 29.5% and 28.6%, p = 0.005), and AE was associated with increased AKI resulting in dialysis than PP alone (17.9% vs. 6.8%, p = 0.036).
CONCLUSION
Zone 3 REBOA can be used as a standalone hemorrhage control technique and as an adjunct in the management of severe pelvic fractures. The only additional intervention associated with a mortality reduction was EF. The benefit of increasing number of interventions must be weighed against more harm. Heterogeneity in practice patterns for REBOA use in pelvic fracture management underscores the need for an evidence base to standardize care.
LEVEL OF EVIDENCE
Therapeutic, Level IV.
背景
关于严重骨盆骨折患者使用主动脉阻断（AO）的实践模式的知识有限。本研究旨在根据区域 3 复苏性血管内球囊阻断主动脉（REBOA）放置后的干预次数和类型描述临床结果。
方法
对 2013 年至 2020 年期间接受区域 3 AO 的美国创伤外科协会主动脉阻断复苏和急性护理手术多中心登记处进行了回顾性审查。纳入了钝性机制且在急诊科存活下来的患者。评估的干预措施包括腹膜前骨盆填塞（PP）、血管栓塞（AE）和骨盆外固定（EF）。管理方法与主要结局死亡率进行了比较。次要结局包括输血需求、总体并发症和急性肾损伤（AKI）。
结果
在 207 例接受区域 3 AO 的患者中，有 160 例（77.3%）符合纳入标准。60 例（37.5%）仅行 AO，50 例（31.3%）行第二次止血干预，49 例（30.6%）行第三次止血干预。总体死亡率为 37.7%（n=60）。任何数量或组合的干预措施均未导致死亡率差异。多变量回归分析显示，仅 EF 与死亡率降低相关（比值比，0.22；p=0.011）。干预次数的增加与更高的输血和并发症发生率相关。骨盆填塞+AE 与增加的 AKI 相关，高于 PP 或 AE 单独治疗（73.3%比 29.5%和 28.6%，p=0.005），AE 与增加的 AKI 导致透析相关，高于 PP 单独治疗（17.9%比 6.8%，p=0.036）。
结论
区域 3 REBOA 可单独用作出血控制技术，并作为严重骨盆骨折治疗的辅助手段。唯一与死亡率降低相关的额外干预措施是 EF。必须权衡增加干预次数的好处与更多的危害。REBOA 在骨盆骨折管理中的应用实践模式的异质性突显了制定标准化治疗方案的必要性。
证据水平
治疗，IV 级。
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