Page 111 - 2022 Spring JSOM

clean and dry. A drain in the right upper quadrant had dark measures, and ideally prior to the onset of traumatic cardiac
blood present in it. His lab measurements were notable for arrest. Multicenter observational US civilian data reviewed by
5
a hemoglobin value of 9.4g/dL and a lactic acidosis level of Brenner et al demonstrated that when REBOA was compared
5
4.4mmol/L. Computed tomography revealed a moderate-size with thoracotomy and aortic cross-clamping for torso hemor-
hematoma adjacent to the transplanted liver but no active con- rhage, there was a statistically significant survival advantage
trast extravasation. He was transfused with 2 units of packed from the trauma bay to the OR (93% vs 48%) and to dis-
red blood cells, started on low-dose phenylephrine via a pe- charge (22.2% vs 3.4%) in patients who had NCTH but did
ripheral intravenous line, and transferred to the ICU approxi- not arrest and require cardiopulmonary resuscitation. Specific
5
mately 2 hours after his arrival at the ED. complications include vascular access difficulties (inability to
access the femoral artery, intimal tears, development of retro-
On arrival at the ICU, he was noted to be markedly dia- peritoneal hematoma), limb ischemic complications (including
phoretic and acutely hypotensive, with a blood pressure of thromboembolism and the need for amputation), multiorgan
62/41mmHg despite blood transfusion. His heart rate was failure (primarily the result of prolonged ischemia of multiple
within the range of 130 bpm. On identifying these physiologic organs, especially with Zone 1 insertion), and postdeflation
changes, the telemedicine intensivist initiated contact with the physiologic derangement (because of rapid washout of toxic
primary team at bedside. The telemedicine intensivist directed inflammatory mediators). As with other procedures, super-
8,9
the bedside team in aggressive resuscitation measures, includ- vision by a more experienced clinician is a crucial component
ing requesting continued blood product resuscitation and of safe utilization and stepwise training of less experienced
obtaining large-bore central access via the subclavian vein. A colleagues in real-world clinical application, and may go some
massive transfusion protocol was initiated within minutes of way toward reducing complications. The bedside procedural-
intensivist contact. Non–cross-matched blood was obtained ist in our case had undertaken both local and regional training
initially and initiated through the subclavian line. The patient courses but had not placed a REBOA into an actual patient.
continued to deteriorate and suffered cardiopulmonary arrest Real-time telemedicine supervision and procedural guidance
within 17 minutes of arrival at the ICU. as an alternative to in-person supervision could allow this
and has, to our knowledge, not been described previously. If
During closed chest compressions, bright blood was expelled the opportunity to obtain imaging arises to confirm position,
from the patient’s surgical incision. Lab measurements drawn this could also be reviewed in real time by the telemedicine
on his arrival at the ICU revealed an acute 2.7g/dL drop in the physician.
patient’s hemoglobin level compared with the lab results on his
arrival at the ED. Both data points suggested exsanguinating At our multihospital civilian health system, not every ICU (at
nontraumatic NCTH from the abdomen as the source of the both the major academic center as well as regional commu-
patient’s rapid decline. Given the witnessed arrest and knowing nity hospitals) has an attending intensivist physically present
that an OR and the on-call surgeon could be available within at all times. Therefore, we utilize a critical care telemedicine
the next 20 to 30 minutes, the telemedicine intensivist directed system that provides an additional layer of expert medical and
a REBOA be placed to assist resuscitation. Because the bedside nursing support for critically ill patients across our health sys-
proceduralist had not placed a REBOA other than in a training tem, including the ED, ICU, and trauma bay. The telemedicine
course, the individual steps were directed by the telemedicine intensivist, by using audiovisual tools (typically hard-wired
intensivist. The proceduralist utilized ultrasound-guidance to cameras and microphones in each patient room but also mo-
obtain vascular access with a 7-cm French introducer sheath bile audiovisual carts in a minority of locations, both allowing
in the right common femoral artery. The REBOA catheter two-way audiovisual communication over a secure intranet),
was measured against external landmarks (mid-sternum and can provide real-time guidance and support to house staff in
sternal notch) to determine the length of insertion for Zone the management of both routine and critical scenarios. In
10
1 placement and was successfully deployed within 5 minutes. particular, the telemedicine intensivist can serve as a resuscita-
The balloon was inflated with 8mL of sterile water to allow tion team leader, cognitively off-loading the personnel physi-
complete aortic occlusion. The clinical situation did not allow cally present in the room to perform hands-on interventions.
for confirmation with radiograph. However, no further blood Previous simulation-based studies have shown the benefit of
was visibly exiting the wound with compressions. having the telemedicine physician in this team leader role. 11
The patient did not respond to maximal resuscitative efforts, When a HALO procedure such as REBOA is required, an ex-
and his resuscitation was aborted after approximately 30 min- perienced telemedicine physician can play a crucial supervisory
utes. An autopsy was obtained, which revealed 1L of intra- role for the less-experienced proceduralist, as we demonstrate
abdominal hematoma but without large-vessel disruption. The in this case. The challenge we faced here was that the proce-
REBOA catheter was identified as being appropriately placed duralist had not performed a REBOA procedure other than
in the descending thoracic aorta. in a training course, and the time-critical nature of the pro-
cedure precluded the arrival of the on-call faculty intensivist
or surgeon. Thus, the telemedicine intensivist was best placed
Discussion
to directly supervise the procedure. We demonstrated that the
Because of the notable mortality associated with hemorrhagic telemedicine support to the proceduralist allowed him to suc-
shock, it is critical that any viable technique be used to ad- cessfully place the catheter in a timely fashion without imme-
dress the bleeding. The use of REBOA presents a conundrum diate complications.
because it has the potential to benefit when used correctly, but
conversely can cause significant harm if performed incorrectly. Peer Review
Evolving data appear to support its use in profound hemor- This case presented an opportunity to improve care and was
rhagic shock refractory to usual damage-control resuscitation discussed at our internal morbidity and mortality review. Key

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