Page 26 - Journal of Special Operations Medicine - Spring 2017

Figure 3 Establishment of arterial access and sheath Figure 4 Out-of-hospital REBOA to facilitate patient
placement for out-of-hospital REBOA. salvage via resuscitation and damage control surgery. Arrow
highlights ER-REBOA catheter and 7F sheath in the right
common femoral artery.

Total blood required after REBOA inflation was a mean
the calibrated marking on the device to determine opti- of 3.75 units of whole blood (range, 2–6 units); three
mal positioning in each case. 14,20 patients also received packed red blood cells (mean, 4.3
units; range, 1–8 units). Fresh frozen plasma (FFP) was
REBOA insufflation was undertaken in aortic zone 1 for administered to two patients: one received 1 unit of FFP
three patients (average insertion depth, 47cm) and zone 3 and the other received 1 unit of FFP and 3 units of liq-
(depth, 30cm) for the patient with fragmentation burden uid plasma.
to the lower torso. Total time from initiation of REBOA
procedure (skin puncture or incision) to balloon inflation After achieving surgical hemostasis, balloon deflation
ranged from 5 to 8 minutes (Table 1). REBOA placement was performed in a stepwise fashion over 3–5 minutes.
and inflation were conducted by a general surgeon (two This maneuver was tolerated without complication in
cases, including the one instance where cut-down access each instance. Balloon inflation time (aortic occlusion
was performed) or an emergency physician (two cases). time) ranged from 20 to 28 minutes for the three zone 1
There were no fellowship-trained vascular or trauma/ deployments, and 65 minutes for the zone 3 placement.
acute care surgeons present during the care. The balloon and femoral artery sheath were removed at
the completion of the procedure in each case before evac-
Response to balloon insufflation was appreciated im- uation to the next echelon of care. In two cases, manual
mediately in all patients. Prior to ER-REBOA inflation, pressure alone was used to facilitate hemostatic removal
SBP was discernable in three patients, with a mean pre- of the 7F sheath from the femoral artery. In each of these
inflation SBP of 70mm Hg (range, 50–90mmHg; Table instances, a handheld ultrasound device was used to ex-
1). In the fourth patient, no measurable BP before infla- amine the arterial access site after holding pressure, and
tion was noted. After inflation, all patients were noted palpable pulses were noted distally after completion.
to have an immediate BP response, with a mean postin- For a third case, there was a question on ultrasound ex-
flation SBP of 118 mmHg (range, 110–120mmHg). amination of femoral sheath hematoma and the decision
was made to explore the area and repair the arteriotomy
REBOA facilitated resuscitation and surgical damage using interrupted polypropylene sutures; this was per-
control of NCTH in all cases (Figure 4). Two patients formed without complication. The patient undergoing
underwent tube thoracostomy placement with minimal initial open cut-down access to the femoral artery also
output and no patient demonstrated evidence of thoracic underwent uncomplicated suture closure of the arteri-
bleeding above potential REBOA zone 1 placement. otomy site. There were no access-related complications.
In one case of zone 1 REBOA, the balloon was noted
All patients underwent exploratory laparotomy, dur- to migrate distally after restoration of proximal BP to a
ing which significant hemoperitoneum was encountered hypertensive state that necessitated deflation, proximal
in each instance (range, 1–3L estimated). Control of repositioning, and reinflation of the balloon, which was
mesenteric hemorrhage was required in three patients, done without complication. After resuscitation and dam-
along with intestinal, colonic, or gastric resection. Hem- age control surgery, all patients were transported to a
orrhage from a bladder source required intervention in local facility for ongoing care. All patients survived the
one patient and another with significant hepatic injury approximate 2-hour transfer without incident and were
required packing and hepatorraphy. The final patient reported to be hemodynamically stable upon delivery to
sustained a fragmentation injury to the external iliac ar- the next level of care. No additional follow-up is avail-
tery, which required direct surgical repair (Table 1). able regarding their clinical course after transfer.

4 Journal of Special Operations Medicine Volume 17, Edition 1/Spring 2017