Elsevier

Injury

Volume 50, Issue 6, June 2019, Pages 1186-1191
Injury

Consensus on resuscitative endovascular balloon occlusion of the Aorta: A first consensus paper using a Delphi method

https://doi.org/10.1016/j.injury.2019.04.024Get rights and content

Highlights

  • This is the first Delphi Consensus on the use of REBOA.

  • Our panel reached consensus on (contra)indications, physiological parameters for patient selection and early femoral access.

  • There was no consensus on the use of REBOA in the pre-hospital setting, patients in extremis and in patients with 2 or more major bleeding sites.

  • Further research should focus on REBOA in pre hospital and military setting, patients in (near) cardiac arrest and inflation times.

Abstract

Background

To further strengthen the evidence base on the use of Resuscitative Endovascular Balloon occlusion of the Aorta (REBOA) we performed a Delphi consensus. The aim of this paper is to establish consensus on the indications and contraindications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.

Study Design

A literature review facilitated the design of a three-round Delphi questionnaire. Delphi panelists were identified by the investigators. Consensus was reached when at least 70% of the panelists responded to the survey and more than 70% of respondents reached agreement or disagreement.

Results

Panel members reached consensus on potential indications, contra-indications and settings for use of REBOA (excluding the pre hospital environment), physiological parameters for patient selection and indications for early femoral access. Panel members failed to reach consensus on the use of REBOA in patients in extremis (no pulse, no blood pressure) and the use of REBOA in patients with two major bleeding sites.

Conclusions

Consensus was reached on indications, contra indications, physiological parameters for patient selection for REBOA and early femoral access. The panel did not reach consensus on the use of REBOA in patients in pre-hospital settings, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings, patients in near cardiac arrest and REBOA inflation times.

Introduction

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an adjunct to sustain the circulation until definitive surgical or endovascular repair [1]. Three recent systematic analysis have helped to consolidate a disparate evidence base in patients with severe traumatic or non-traumatic haemorrhage [[2], [3], [4]]. A large cohort study on the use of REBOA at a single tertiary care facility in these patients report that REBOA is a minimally invasive alternative to emergency department thoracotomy with aortic cross-clamp to temporize non-compressible torso haemorrhage and obtain proximal control in both traumatic and non traumatic causes of haemorrhage [5]. But since optimal patient selection and a clear mortality benefit has yet to be demonstrated, the REBOA concept is still not fully embedded in most hospitals. Furthermore, the pioneering use of this haemorrhage control adjunct in the prehospital phase, despite early promising results [6,7], has not been widely adopted. Recent terrorist threats in western countries have contributed to an increased awareness of the value for advanced bleeding control in the earliest phase after injury, suggesting that the potential utilization of REBOA in this setting warrants examination [8]. In particular, there is a need to focus research on the differences between the main indications for REBOA; trauma and non-trauma related major haemorrhage, including ruptured abdominal aortic aneurysm (rAAA). The outcome of this study contributes to the clinical practice guidelines and reviews [[2], [3], [4]] that have been recently published by Pasley et al (the Joint Trauma System Clinical Practice Guideline 38 (JTS CPG 38) [9], Cannon et al [10] and Brenner et al (Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of REBOA [11].

The primary aim of this paper is to establish consensus on the indications and contra indications for the use of REBOA in trauma and non-trauma patients based on the existing evidence and expertise.

Section snippets

Methods

The Delphi technique is well suited for consensus-building by using a series of questionnaires to collect data from a panel of selected subjects [12]. An international three-round Delphi consultation was conducted.

Results

In the first round 38 panel members (38/52, 73.1%), responded to the questionnaire, with 36 (36/38, 94.7%) panel members completing the survey in full. The panel members consisted of 2 emergency physicians (2/38, 5.3%), 3 interventional radiologists (3/38, 7.9%), 12 vascular surgeons (12/38, 31.6%) and 21 trauma surgeons (21/38, 55.3%). The region of their practice was in 1 case from the UK (1/36, 2.8%), 2 from Asia (2/36, 5.6%), 3 from South America (3/36, 8.3%), 3 panel members practice in

Location of procedure

The expert panel reached consensus that REBOA can be used in austere military setting, emergency departments, operating rooms and intensive care units, but disagrees with the statement that REBOA is feasible in the pre hospital setting (20/36, 55.6%).

Location of bleeding site

Panel members reached consensus that REBOA is indicated in the following patient populations: traumatic abdominopelvic hemorrhage, hemorrhage arising from a ruptured aneurysm, patients with severe post partum hemorrhage (PPH), exsanguination

Vascular access

Femoral artery access is a precursor for potential REBOA use, but does not mandate subsequent REBOA use (Table 3). In case of early femoral artery access a 5 Fr (15/36; 41.7%) or 7 Fr (15/36; 44.4%) introducer sheath was recommended. Panel members stated that trauma surgeons (26/36; 72.2%) or vascular surgeons (24/36; 66.7%) should perform the REBOA procedure, but agreed that REBOA can be safely and effectively performed in a variety of settings and by providers of various clinical background,

Zone 1 REBOA

Regarding inflation times for aortic occlusion in Zone 1 of the aorta, it is not recommended that inflation time (full REBOA) exceeds more than 30 min with 87.5% (35/40) of panel members agreeing. Panel members were divided on whether the inflation times for aortic occlusion in Zone 1 of the aorta should be limited (15/40; 37.5%) or not (25/40; 62.5%) if the patients remained unstable despite aggressive efforts.

Zone 3 REBOA

Regarding inflation times for aortic occlusion in Zone 3 of the aorta, it is not

Discussion

Panel members reached consensus that REBOA is potentially indicated in patient populations that are consistent with the beneficial effect of REBOA found in the recently published review and meta analyses by Borger van der Burg et al [4] and patients described in the joint statement from the ACS COT and ACEP and JTS CPG 38. Our panel considered that patients in extremis (no pulse, no blood pressure) are no candidates for REBOA, but should undergo early femoral access. This is in contradiction to

Conclusions

Our expert panel reached consensus on indications, contra indications, physiological parameters for patient selection for the use of REBOA and early femoral access. There was no consensus on the use of REBOA in patients in the pre-hospital setting, patients in extremis (no pulse, no blood pressure) and in patients with 2 or more major bleeding sites. Further research should focus on the indications of REBOA in pre hospital settings and use of REBOA in austere military setting, patients in

Disclaimer

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense, Dutch or United States government. Several authors are employees of the Dutch or United States government.

Conflict of interest statement

B.L.S. Borger van der Burg, B. Kessel, J.J. DuBose, T.M. Hörer and R. Hoencamp report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

Contribution of the authors

B.L.S. Borger van der Burg, B. Kessel and R. Hoencamp prepared the study set-up. B.L.S. Borger van der Burg, B. Kessel, T.M. Hörer, J.J. DuBose and R. Hoencamp selected the panelists and constructed the questionnaires, B.L.S. Borger van der Burg performed the study and collected the data. Borger van der Burg, B. Kessel, T.M. Hörer, J.J. DuBose and R. Hoencamp prepared the manuscript. B.L.S. Borger van der Burg the tables. Borger van der Burg, B. Kessel, T.M. Hörer, J.J. DuBose and R. Hoencamp

Acknowledgements

Ken Boffard, Jeremy Cannon, Federico Coccolini, Martin Delle, Daniel Eefting, Charles Fox, Jaap Hamming, Lauri Handolin, John Holcomb, Joseph Ibrahim, Kenji Inaba, Michael Johnson, Christos Karkos, David King, Lars Lonn, Joseph Love, Martin Malina, Vassil Manchev, Junichi Matsumoto, Ofer Merin, Ernest Moore, Laura Moore, Jonathan Morrison, George Oost, Tomohiko Orita, Artai Pirouzram, Bruno Pereira, Frank Plani, Victor Reva, Samy Sadek, Joao Sahagoff, Thomas Scalea, Gad Shaked, Edmund Sovik,

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