血管内主动脉闭塞术的关键收缩压阈值——多国分析以确定何时放置 REBOA。
Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA.
机构信息
From the Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O., F.R.-H., A.F.G., J.J.S., C.S., M.J.F., A.S., H.P.), Fundación Valle del Lili; Universidad Icesi (C.A.O., Y.C., A.F.G., J.J.S., C.S., A.S., L.S.), Cali, Colombia; Division of Trauma and Acute Care Surgery, Department of Surgery (C.A.O., A.F.G., J.J.S.), Universidad del Valle, Cali, Colombia; Department of Trauma Critical Care (M.W.P.), Broward General Level I Trauma Center, Fort Lauderdale, Florida; Centro de Investigaciones Clínicas (CIC) (Y.C., N.P.-L.), Fundación Valle del Lili, Cali, Colombia; Center for Surgery and Public Health, Department of Surgery, Brigham & Women's Hospital (J.P.H.-E., C.P.O.), Harvard Medical School & Harvard T.H. Chan School of Public Health; Center for Surgery and Public Health (C.Z.), Boston, Massachusetts; Yale School of Medicine (C.Z.), New Haven, Connecticut; Department of Intensive Care (M.G.), Fundación Valle del Lili, Cali, Colombia; R Adams Cowley Shock Trauma Center (T.S.), University of Maryland Medical Center, Baltimore, Maryland; Faculty of Medicine and Health, Department of Cardiothoracic and Vascular Surgery and Department of Surgery (D.T.M.G., T.M.H.), Örebro University, Örebro, Sweden; Surgical Division (B.K.), Hillel Yaffe Medical Center, Hadera, Israel; Dell School of Medicine (J.D.), University of Texas, Austin, Texas; and Department of Surgery (M.B.), UCLA David Geffen School of Medicine, Los Angeles, California.
出版信息
J Trauma Acute Care Surg. 2024 Feb 1;96(2):247-255. doi: 10.1097/TA.0000000000004160. Epub 2023 Oct 19.
BACKGROUND
Systolic blood pressure (SBP) is a potential indicator that could guide when to use a resuscitative endovascular balloon occlusion of the aorta (REBOA) in trauma patients with life-threatening injuries. This study aims to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in severely injured hemodynamically unstable trauma patients.
METHODS
We performed a pooled analysis of the aortic balloon occlusion (ABO) trauma and AORTA registries. These databases record the details related to the use of REBOA and include data from 14 countries worldwide. We included patients who had suffered penetrating and/or blunt trauma. Patients who arrived at the hospital with a SBP pre-REBOA of 0 mm Hg and remained at 0 mm Hg after balloon inflation were excluded. We evaluated the impact that SBP pre-REBOA had on the probability of death in the first 24 hours.
RESULTS
A total of 1,107 patients underwent endovascular aortic occlusion, of these, 848 met inclusion criteria. The median age was 44 years (interquartile range [IQR], 27-59 years) and 643 (76%) were male. The median injury severity score was 34 (IQR, 25-45). The median SBP pre-REBOA was 65 mm Hg (IQR, 49-88 mm Hg). Mortality at 24 hours was reported in 279 (32%) patients. Math modeling shows that predicted probabilities of the primary outcome increased steadily in SBP pre-REBOA below 100 mm Hg. Multivariable mixed-effects analysis shows that when SBP pre-REBOA was lower than 60 mm Hg, the risk of death was more than 50% (relative risk, 1.5; 95% confidence interval, 1.17-1.92; p = 0.001).
DISCUSSION
In patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mm Hg and 80 mm Hg may be a useful tool in resuscitation efforts before further decompensation or complete cardiovascular collapse. The findings from our study are clinically important as a first step in identifying candidates for REBOA.
LEVEL OF EVIDENCE
Prognostic and Epidemiological; Level IV.
背景
收缩压（SBP）是一种潜在的指标，可以指导在有生命威胁的创伤患者中何时使用主动脉球囊阻断复苏（REBOA）。本研究旨在通过分析 REBOA 前 SBP 与严重创伤性血流动力学不稳定患者 24 小时死亡率之间的关系，确定放置 REBOA 的最佳 SBP 阈值。
方法
我们对主动脉球囊闭塞（ABO）创伤和 AORTA 登记处进行了汇总分析。这些数据库记录了与 REBOA 使用相关的详细信息，包括来自全球 14 个国家的数据。我们纳入了有穿透性和/或钝性创伤的患者。排除了在 REBOA 前 SBP 为 0mmHg 且球囊充气后仍保持在 0mmHg 的患者。我们评估了 REBOA 前 SBP 对 24 小时内死亡概率的影响。
结果
共有 1107 名患者接受了血管内主动脉闭塞治疗，其中 848 名符合纳入标准。中位年龄为 44 岁（四分位距 [IQR]，27-59 岁），643 名（76%）为男性。损伤严重程度评分中位数为 34（IQR，25-45）。REBOA 前 SBP 中位数为 65mmHg（IQR，49-88mmHg）。24 小时报告死亡率为 279 例（32%）。数学建模显示，在 SBP 低于 100mmHg 时，主要结局的预测概率稳步增加。多变量混合效应分析表明，当 REBOA 前 SBP 低于 60mmHg 时，死亡风险超过 50%（相对风险，1.5；95%置信区间，1.17-1.92；p=0.001）。
讨论
在对初始复苏无反应的患者中，在 SBP 为 60mmHg 至 80mmHg 之间使用 REBOA 可能是在进一步失代偿或完全心血管崩溃之前复苏努力中的有用工具。我们的研究结果具有重要的临床意义，因为这是确定 REBOA 候选者的第一步。
证据水平
预后和流行病学；IV 级。
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