Page 41 - JSOM Fall 2024

TABLE 1 Experts’ Demographic Data, Specialties, and Experiences fluids, and pressor amines. Since REBOA has potentially se-
with REBOA rious complications, 16–18 it is important to identify the cases
Years of No. of that, after receiving medical care, are deemed too serious and
practice as REBOA non-responsive to conventional treatments. These would be
Country Specialty senior inflated the patients unlikely to get to the hospital alive and for whom
Italy General surgery 21 30 REBOA would be the only therapeutic tool allowing survival.
USA Trauma surgery 10 15 The proposed protocol does not encourage systematic use
Israel Trauma surgery 20 15 of REBOA in patients who could be saved by conventional
Turkey Emergency medicine 5 8 therapeutics that are less invasive and have fewer potential
USA Trauma surgery 1 15 complications.
Switzerland Vascular surgery 20 25 Responses and Credibility of the Experts
Sweden Vascular surgery 5 4 It is assumed that the experts predominantly answered based
Israel General surgery 27 21 on their personal opinions and experiences. The majority
Israel Vascular surgery 21 12 of our experts have sound experience in REBOA use, with
Sweden Intensive care 1 4 REBOA being performed a median of 12 times per year, giving
Sweden Vascular surgery 8 100 legitimacy to our study.
Russia trauma surgeon 10 25
Sweden Vascular surgery 4 8 Suggested Protocol
Israel General surgery 21 15 Based on the answers to the questions posed in our study,
England Emergency medicine 9 5 compiled along with the existing recommendations regarding
USA Pediatric surgery 7 2 REBOA, we propose a protocol for REBOA use in a civilian
prehospital setting. The specificity of our system in France,
USA Trauma surgery 6 20 where a surgeon is not available in the prehospital setting,
France Intensive care 2 3 made it unnecessary to compare REBOA with resuscitative
Sweden Vascular surgery 1 2 thoracotomy, a procedure which would be relevant in a hospi-
REBOA = resuscitative endovascular balloon occlusion of the aorta. tal setting. 6,19 Figure 1 synthesizes our protocol as a decisional
algorithm.
have the legal possibility to use all medical therapies. Paramed-
ics can only use medications for which a protocol has been Indications and Contraindications
authorized. Indeed, in a medicalized prehospital system, be- REBOA is used for patients in hemorrhagic shock of an ab-
fore reaching the need for REBOA, the physician has other dominal, pelvic, or junctional origin or in the postpartum con-
therapeutic means to resuscitate the patient and stabilize their text. We consider supra-aortic trunk trauma to be an absolute
hemodynamics—including blood, blood plasma, intravenous contraindication to REBOA. Additionally, REBOA use can

TABLE 2 Ten Questions Submitted to the Experts and Their Answers
Answer, %
Round No. of
Question Yes No number answers
In your opinion, is there an indication of REBOA for a patient in cardiac arrest due to 76 24 1 17
hemorrhagic shock, whose lesions can be reached by REBOA?
In your opinion, is there an indication of REBOA for a patient in uncontrolled hemorrhagic 94 6 1 17
shock after a post-partum hemorrhage?
In your opinion, in a hemorrhagic patient, vascularly well-filled and whose hemodynamics 94 6 2 18
remain unstable with 3 mg/h of norepinephrine, should we inflate a REBOA to prevent the
patient’s death and get them to the operating room alive?
Would you agree that it might be useful to place a desilet upstream of the common femoral 94 6 2 18
artery (CFA) (without setting up the REBOA), in a hemorrhagic shock state patient, cared
for in the prehospital setting, in the situation where their medical condition would be
declining and it would be necessary to set up and inflate a REBOA during transport?
Would you say that REBOA is useful for a patient in cardiorespiratory arrest (CRA) due to 26 74 2 19
a hemorrhagic shock with lesions reachable by the REBOA, and with a no-flow time of over
5 minutes?
In the case of REBOA placement (zone I) in the prehospital setting, would you agree that 74 26 2 19
the maximum occlusion duration is approximately 30 minutes, with a partial or intermittent
occlusion when possible?
Would you agree that the best approach to the use of REBOA in the prehospital setting 89 11 2 19
would be a 10- or 20-minute complete occlusion, followed by a partial and gradual
deflation, depending on the patient’s systolic blood pressure?
In your opinion, to place a REBOA in the prehospital setting, and to respect minimal aseptic 84 16 2 19
technique, would it be sufficient to wear sterile gloves and eventually use a sterile field?
Do you agree that out-of-hospital REBOA should be used after notifying the trauma center 85 15 3 20
doctor, when possible?
Do you agree that if REBOA is indicated, the physician on the field must be limited to two 90 10 3 20
attempts or 5 minutes to place the introducer?
REBOA = resuscitative endovascular balloon occlusion of the aorta.

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