Three cases of resuscitative endovascular balloon occlusion of the aorta (REBOA) in austere pre-hospital environment-technical and methodological aspects

Abstract

Background: The present paper describes three cases where ER-REBOA® was used with partial aorta occlusion (AO), by performing a partial resuscitative endovascular balloon occlusion of the aorta or pREBOA, in an austere pre-hospital military environment.In addition, because no specific REBOA algorithm for pre-hospital environment exists yet, this paper seeks to fill this gap, proposing a new pragmatic REBOA algorithm.

Methods: Belgian Special Operations Surgical Team applied REBOA in three patients according to a decisional algorithm, based on the MIST acronym used for trauma patients. Only 3 ml, in the first instance, was inflated in the balloon to get AO. The balloon was then progressively deflated, and reperfusion was tracked through changes of end-tidal carbon dioxide (EtCO₂).

Results: Systolic blood pressure (SBP) before ER-REBOA® placement was not higher than 60 mmHg. However, within the first 5 min after AO, SBP improved in all three cases. Due to the aortic compliance, a self-made pREBOA was progressively achieved while proximal SBP was raising with intravenous fluid infusion. Afterwards, during deflation, a steep inflection point was observed in SBP and EtCO₂.

Conclusions: ER-REBOA® is suitable for use in an austere pre-hospital environment. The MIST acronym can be helpful to select the patients for which it could be beneficial. REBOA can also be performed with pREBOA in a dynamic approach, inflating only 3 mL in the balloon and using the aortic compliance. Furthermore, while proximal SBP can be convenient to follow the occlusion, EtCO₂ can be seen as an easy and interesting marker to follow the reperfusion.

Keywords: Austere surgery; Partial REBOA; Pre-hospital; REBOA; Resuscitative endovascular balloon occlusion of the aorta; Shock; Trauma.

Fig. 1

Proposed algorithm for the placement of REBOA catheters in pre-hospital. Due to a lack of diagnostic devices in pre-hospital settings, in-hospital algorithms [45] are impossible to implement. Nevertheless, a pragmatic approach is required to use REBOA in the right patient. Therefore, REBOA catheters can be placed according to this algorithm based on the MIST acronym, widely accepted in pre-hospital care, and quickly useable by any medical provider, regardless of his training level

Fig. 2

Abbreviated Injury Scale, Injury Severity Score, New Injury Severity Score, and Trauma Injury Severity Score (% of survival) of the three patients. Due to a lack of diagnostic devices, some lesions were missed. The calculated scores are therefore most probably underestimated

Fig. 3

Heart rate during REBOA procedure. 1—at admission, 2—before REBOA, 3—within the first 5 min after AO, 4—after deflation of 1 cc (2 cc were directly deflated for patient 3), 5—after deflation of 2 cc, 6—after full deflation, and 7—at the end of the surgery

Fig. 4

Systolic blood pressure during REBOA procedure. 1—at admission, 2—before REBOA (NM = not measurable for patients 1 and 3), 3—within the first 5 min after AO, 4—after deflation of 1 cc (2 cc were directly deflated for patient 3), 5—after deflation of 2 cc, 6—after full deflation, and 7—at the end of the surgery

Fig. 5

End-tidal carbon dioxide during REBOA procedure. Values at admission and before REBOA were not measured. 3—within the first 5 min after AO, 4—after deflation of 1 cc (2 cc were directly deflated for patient 3), 5—after deflation of 2 cc, 6—after full deflation, 7—at the end of the surgery. A steep inflection point can be observed in 4 for patient 1 and in 6 for the other patients