确定用于治疗膈肌以下不可压缩性出血患者的REBOA最佳部署策略。
Determination of optimal deployment strategy for REBOA in patients with non-compressible hemorrhage below the diaphragm.
作者信息
Johnson Nicholas L, Wade Charles E, Fox Erin E, Meyer David E, Fox Charles J, Moore Ernest E, Morrison Jonathan, Scalea Thomas, Bulger Eileen M, Inaba Kenji, Morse Bryan C, Moore Laura J
机构信息
Department of Surgery, The University of Texas Health Science Center at Houston John P and Katherine G McGovern Medical School, Houston, Texas, USA.
Department of Surgery, University of Colorado Denver Health Medical Center, Denver, Colorado, USA.
出版信息
Trauma Surg Acute Care Open. 2021 Feb 23;6(1):e000660. doi: 10.1136/tsaco-2020-000660. eCollection 2021.
BACKGROUND
Non-compressible truncal hemorrhage (NCTH) is the leading cause of preventable death after trauma. Resuscitative endovascular balloon occlusion of the aorta (REBOA) achieves temporary hemorrhage control, supporting cardiac and cerebral perfusion prior to definitive hemostasis. Aortic zone selection algorithms vary among institutions. We evaluated the efficacy of an algorithm for REBOA use.
METHODS
A multicenter prospective, observational study conducted at six level 1 trauma centers over 12 months. Inclusion criteria were age >15 years with evidence of infradiaphragmatic NCTH needing emergent hemorrhage control within 60 min of ED arrival. An algorithm characterized by the results of focused assessment with sonography in trauma and pelvic X-ray was assessed post hoc for efficacy in a cohort of patients receiving REBOA.
RESULTS
Of the 8166 patients screened, 78 patients had a REBOA placed. 21 patients were excluded, leaving 57 patients for analysis. The algorithm ensures REBOA deployment proximal to hemorrhage source to control bleeding in 98.2% of cases and accurately predicts the optimal REBOA zone in 78.9% of cases. If the algorithm was violated, bleeding was optimally controlled in only 43.8% (p=0.01). Three (75.0%) of the patients that received an inappropriate zone 1 REBOA died, two from multiple organ failure (MOF). All three patients that died with an inappropriate zone 3 REBOA died from exsanguination.
DISCUSSION
This algorithm ensures proximal hemorrhage control and accurately predicts the primary source of hemorrhage. We propose a new algorithm that will be more inclusive. A zone 3 REBOA should not be performed when a zone 1 is indicated by the algorithm as 100% of these patients exsanguinated. MOF, perhaps from visceral ischemia in patients with an inappropriate zone 1 REBOA, may have been prevented with zone 3 placement or limited zone 1 occlusion time.
LEVEL OF EVIDENCE
Level III.
背景
不可压缩性躯干出血（NCTH）是创伤后可预防死亡的主要原因。复苏性血管内主动脉球囊阻断术（REBOA）可实现暂时性出血控制，在确定性止血之前维持心脏和脑灌注。各机构的主动脉区域选择算法各不相同。我们评估了一种REBOA使用算法的疗效。
方法
在6个一级创伤中心进行了为期12个月的多中心前瞻性观察研究。纳入标准为年龄>15岁，有膈下NCTH证据，且在急诊科就诊后60分钟内需紧急控制出血。对一组接受REBOA治疗的患者事后评估了一种以创伤超声重点评估结果和骨盆X线为特征的算法的疗效。
结果
在8166例筛查患者中，78例患者接受了REBOA治疗。排除21例患者，剩余57例患者进行分析。该算法可确保在98.2%的病例中，将REBOA放置在出血源近端以控制出血，并在78.9%的病例中准确预测最佳REBOA区域。如果违反该算法，仅43.8%的病例出血得到最佳控制（p=0.01）。接受不适当的1区REBOA治疗的患者中有3例（75.0%）死亡，2例死于多器官功能衰竭（MOF）。接受不适当的3区REBOA治疗的所有3例患者均死于失血。
讨论
该算法可确保近端出血得到控制，并准确预测出血的主要来源。我们提出一种更具包容性的新算法。当算法显示为1区时，不应进行3区REBOA，因为这些患者中有100%死于失血。对于接受不适当的1区REBOA治疗的患者，MOF可能源于内脏缺血，通过放置3区或限制1区阻断时间或许可以预防。
证据级别
三级。
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