REBOA

Under Reboa (ger .: resuscitative endovascular balloon occlusion of the aorta ) one is an emergency measure for the supply of multiple trauma, heavily bleeding patients referred, in a endovascular a balloon into the access abdominal aorta ( abdominal aorta is introduced), and by dilation of the balloon the blood supply is interrupted under the balloon to at massive accidental injuries to the abdomen or pelvic region of a temporary hemostasis be achieved by increasing the afterload a hemodynamic to achieve stabilization and exsanguination to prevent.

Indications

Because of the considerable dangers and difficulties of the intensive medical care associated with it, this procedure of interventional radiology is only reserved for trauma centers of maximum care with appropriate equipment. The procedure is comparable to an open thoracotomy or laparotomy clamping of the aorta (super- / infradiaphragmal), but minimally invasive.

The indication consists in polytrauma -patients with uncontrolled massive blood loss ( "bleeding to death") in the abdomen or pelvic region, often by complex pelvic fractures initiated and often with hemorrhage into the retroperitoneal space connected, such as by the demolition of large arteries. The goal is to stabilize the patient hemodynamically and to get time for the definitive treatment of the bleeding, which is usually done by emergency surgery, as a laparotomy or by paraperitoneal access to the retroperitoneal space.

Before a REBOA is used, life-threatening bleeding above the planned REBOA site must be ruled out, especially above the diaphragm: bleeding in the chest cavity ( hemothorax ), pericardium ( hemopericardium ), in the mediastinum or intracranial bleeding. There are three possible locations in the area of ​​the abdominal aorta:

• Zone I: above the celiac trunk
• Zone II: between the celiac trunk and the exit of the renal arteries
• Zone III: between the exit of the renal arteries and the aortic bifurcation.

If the REBOA is inserted deeper into the abdominal aorta, e.g. in zone III, it must also be ensured that there is no life-threatening bleeding into the abdominal cavity ( hemoperitoneum ), as otherwise a higher placement would be indicated. This can be done in the emergency room diagnostics using the FAST ultrasound.

In addition to life-threatening bleeding above the REBOA deployment site, contraindications are also penetrating thoracic wounds that require an immediate anterolateral thoracotomy and, if necessary, an aortic clamp.

execution

The balloon is usually introduced into the femoral artery via an arterial access in the groin - where an arterial access has usually already been introduced as part of the emergency room treatment. First a metal wire is pushed into the abdominal aorta, this is checked by fluoroscopy . If the position of the balloon is correct according to the previously defined zone, the balloon can be dilated. If contrast media is used for this , the position and size can be better controlled.

A REBOA can only last for a maximum of thirty minutes, as the ischemia of the lower half of the body creates considerable dangers. During this time, the multiple trauma patient has to be hemodynamically stabilized by mass transfusions of red cell concentrates , frozen fresh plasma , infusion therapy and the aggressive use of vasoconstrictive drugs such as norepinephrine and vasopressin . At the same time, he must be prepared for the surgical procedure, with intubation anesthesia . However, this must not be too deep, otherwise it slows down the sympathetic vasoconstrictive activity and can also contribute to hypovolemia. Therefore, in addition to intra-arterial blood pressure measurement, a transesophageal heart ultrasound and electroencephalography are often used for monotioing to control the depth of anesthesia.

Since the time is limited, the abdominal or retroperitoneal space is usually "packaged" in the emergency operation after the bleeding has been suctioned off and rinsed out, and the final wound closure is postponed to a "second look" operation a few days later.

For safe treatment of retroperitoneal bleeding from complex pelvic fractures, external stabilization of the pelvis must also be carried out with the help of an external fixator, which is used under fluoroscopic control.

When the bleeding has stopped, the balloon must be removed. The reopening of the lower half of the body leads to a sudden massive drop in blood pressure due to the lack of afterload, for which appropriate anesthesiological measures must be prepared. Hyperkalaemia and a "washout" lactate acidosis also occur due to ischemia and must also be treated immediately, faster than updated laboratory values ​​could be available. In addition to hypovolemic shock , hypothermia and coagulopathy can occur, which can lead to diffuse bleeding and disseminated intravascular coagulation (DIC) as well as multiple organ failure and a systemic inflammatory response syndrome (SIRS).

Complications

In addition to the numerous trauma-related and wound problems caused by REBOA, ischemia can lead to special, serious problems:

• Compartment syndrome : massive swellings in the muscle boxes, especially on the lower leg, can lead to necrosis of the muscles and compress the arteries, which is why early fasciotomies and close pressure monitoring are necessary.
• Crush kidneys : The ischemia of the lower extremities can cause muscle tissue to die off ( rhabdomyolysis ) and lead to acute kidney failure, which can lead to end-stage renal insufficiency with dialysis or a kidney transplant.
• Amputation : after a compartment syndrome or if the vascular supply to the lower extremities has not been adequately restored, especially in the case of wound infection after a compartment has been split, distal amputations are sometimes called v. a. of the foot or lower leg necessary.
• Small intestine necrosis: due to ischemia of the abdominal cavity, surgically ligating the supplying arteries as part of emergency hemostasis, or as part of shock complications (e.g. DIC, sepsis), intestinal sections die. Then a partial removal of the necrotic intestinal sections must be carried out, possibly with temporary or permanent placement of a colostomy or ileostomy .

Results

In a survey of American Level I trauma centers, 42% (15 of 36) of the responding centers (36 of 158) stated that they used REBOA. Of these, REBOA was the drug of choice for hemodynamically unstable pelvic fractures in 40% (6 of 15).

So far, there are numerous individual case descriptions, only a few animal experiments and retrospective studies , which, if correctly indicated, point to an improvement in hemodynamics, positive physiological effects and reduced mortality .

swell

• David R. King, Jerome C. Crowley, Nathan E. Frenk, Haytham MA Kaafarani: Case 39-2019: A 57-Year-Old Woman with Hypotension and Trauma after a Motorcycle Accident , New England Journal of Medicine 2019, Volume 381, Issue 25 from December 19, 2019, pages 2462–2469, DOI: 10.1056 / NEJMcpc1909619
• M. Kulla, M. Engelhardt, T. Holsträter, D. Bieler, Rolf Lefering, K. Elias: REBOA as an additive concept for emergency thoracotomy in the severely injured - necessary or dispensable? Anästh Intensivmed 2018, Volume 59, Pages 562-573, abstract
• K. Elias: Resuscitative balloon occlusion of the aorta (REBOA) - current state of research and indications in Germany , Bundeswehrkrankenhaus Westerstede 2018, as a lecture on December 6, 2018 at the annual congress 2018 of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) in Leipzig, lecture

Individual evidence

1. ^ S. Jarvis, M. Kelly, C. Mains, C. Corrigan, N. Patel, M. Carrick, M. Lieser, K. Banton, D. Bar-Or: A descriptive survey on the use of resuscitative endovascular balloon occlusion of the aorta (REBOA) for pelvic fractures at US level I trauma centers . Patient Saf Surg 2019, edition 13 of December 13, 2019, page 43, doi: 10.1186 / s13037-019-0223-3
2. ↑ M. Sambor: Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhage Control in Trauma Patients: An Evidence-Based Review . J Trauma Nurs 2018, Volume 25, Issue 1 from January 2018, pages 33 - 37, doi: 10.1097 / JTN.0000000000000339

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