REBOA new snake in the grass?
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1 REBOA new snake in the grass? Does it have a place in South Africa and other LMICs? Tim Hardcastle Trauma Surgeon IALCH/UKZN Controversies in Surgery 2016
2 History nothing new under the sun (Solomon = Ecclesiates) Use of an Intra-Aortic Balloon Catheter Tamponade for Controlling Intra-Abdominal Hemorrhage in Man Lieutenant Colonel Carl W. Hughes (Medical Corps, US Army) Surgery 1954; 36:65 An intra-aortic balloon catheter tamponade was utilized in two moribund Korean War casualties with uncontrolled intra-abdominal hemorrhage. Although both patients expired, the catheter was effective in temporarily restoring the blood pressure in one case. The catheter should be further evaluated both experimentally and clinically. No widespread adoption
3 History nothing new under the sun (Solomon = Ecclesiates) Use of an Intra-Aortic Balloon Catheter Tamponade for Controlling Intra-Abdominal Hemorrhage in Man Lieutenant Colonel Carl W. Hughes (Medical Corps, US Army) Surgery 1954; 36:65 An intra-aortic balloon catheter tamponade was utilized in two moribund Korean War casualties with uncontrolled intra-abdominal hemorrhage. Although both patients expired, the catheter was effective in temporarily restoring the blood pressure in one case. The catheter should be further evaluated both experimentally and clinically. No widespread adoption
4 So what is REBOA actually? Resuscitative balloon-occlusion catheter placed via a femoral sheath access to inflate the balloon in the aorta at either level I or III to enable proximal control of non-compressible bleeding in a patient rapidly deteriorating / in cardiac arrest
5
6 Techniques
7
8
9 Indications for REBOA Non-compressible intraabdominal haemorrhage Solid organs Major vessel injury Major pelvic haemorrhage in combination with EPPP Tamponade Allows imaging in the OR if C-arm / Hybrid suite
10
11 Some caveats: Most of the research on this is from the last 5 years! Still in evolution in centres of excellence Lots of courses and many enthusiasts who have only done this on cadavers or mannicans Watch the developments closely
12 Current literature does it work?
13
14
15 Current literature complications/outcome
16
17 Current literature complications: Japan
18 Current literature outcome USA
19 Current literature outcomes Japan
20 Current literature outcomes?
21 From the ED to the OR to the Field? Is this a new prehospital option? FEASIBLE TRAINABLE DO-ABLE What about complications? What about legalities of scope of practice? What about outcome?
22
23 To date: 1 case report!
24 What about SA and the other LMIC s? Immature systems staffed by non-specialist practitioners Time to definitive care must be under 40 minutes for survival Limited specialists Limited access to fluoroscopy (newer devices don t need this) Minimal prehospital physician-staffed vehicles or helicopters Other medical priorities with the devil of distance Not for the immediate future outside clinical trials and in-hospital
25 Evidence to qualify this opinion? Resuscitative endovascular balloon occlusion of the aorta (REBOA): a population based gap analysis of trauma patients in England and Wales. <400 pts out of would benefit! 1 patient very days in MTC s High mortality group From LMIC perspective not priority Barnard et al. Emerg Med J Dec;32(12):
26 Considerations prior to doing this Availability of resources (OR, equipment) Distance from definitive care Average time to major trauma centre in KZN 8 hours!* Skill set can we allow interns or CMO s to do this? Complication profile (RT vs REBOA) Time & training *Cheddie et al, SAMJ, 2011; 101: 176
27 Considerations prior to doing this Availability of resources (OR, equipment) Distance from definitive care Skill set Complication profile (RT vs REBOA) Time & training
28 A systematic review of the use of resuscitative endovascular balloon occlusion of the aorta in the management of hemorrhagic shock. Overall, the evidence base is weak with no clear reduction in hemorrhage-related mortality demonstrated. Formal, prospective study is warranted to clarify the role of this adjunct in torso hemorrhage. Morrison JJ1, Galgon RE, Jansen JO, Cannon JW, Rasmussen TE, Eliason JL. J Trauma Acute Care Surg Feb;80(2):324-34
29 AORTA Trial 114 patients 46 REBOA vs. 68 RT Equal time to aortic occlusion with both techniques (~12 minutes) Overall survival 21% - no difference between the two techniques No significant difference as to overall survival between groups -?sample-size factor 28 vs 16% survival, but: -OPEN >>> penetrating trauma; >>>CPR in progress; >>>hypotension; >>> survivors to ICU admission -REBOA >>>Deaths in ED/OR Journal of Trauma and Acute Care Surgery, Publish Ahead of Print DOI: /TA
30 Where are we today? More questions!
31 Summary At least for now outside the big centres of excellence
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