Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible?
Intraoperative combination of resuscitative endovascular balloon occlusion of the aorta and a median sternotomy in hemodynamically unstable patients with penetrating chest trauma: Is this feasible?
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DOI：
10.1097/ta.0000000000001807
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发表时间：
2018-05-01
影响因子：
3.4
通讯作者：
Rodriguez, Fernando
中科院分区：
文献类型：
--
作者：
Ordonez, Carlos A.;Parra, Michael W.;Rodriguez, Fernando
最近的证据表明，复苏血管内球囊阻断主动脉（REBOA）是一种有效的挽救严重躯干创伤患者生命的干预措施。然而，REBOA在孤立性穿透性胸内损伤患者中的应用仍存在争议。我们建议胸骨正中切开术联合REBOA作为一种可行和有效的方法来控制出血的穿透性胸外伤患者的血流动力学不稳定。我们研究的目的是展示我们使用这种方法的初步经验。方法前瞻性收集2015年1月至2016年12月在一级创伤中心使用REBOA （10fr）联合中位胸骨切开术的病例系列。我们纳入了血流动力学不稳定的不可压缩性躯干出血患者，这些患者伴有穿透性胸部创伤，术中进行REBOA部署和正中胸骨切开术。结果在研究期间，我院共完成68例创伤相关急诊胸外科手术。其中7例胸部穿透性创伤和不可压缩性躯干出血，行REBOA加胸骨正中切开术。7例患者中有6例发生胸内血管损伤：2例锁骨下动脉、2例乳腺内动脉、2例主动脉弓和5例主要中心静脉损伤。4例患者伴AIS >3肺损伤，其中2例肺门血管破裂。reboa相关并发症包括1例上消化道出血。在30天的随访中，7名患者中有6名存活。在幸存者中没有观察到不良的神经系统结果或缺陷。结论REBOA联合胸骨正中切开术是胸外伤致不可压缩性躯干出血患者出血控制的一种可行有效的方法。这些发现挑战了反对在穿透性胸内损伤中使用REBOA的建议。未来的研究需要更强的设计和更大的样本量来证实我们的结果。证据水平：治疗性，V级。
BACKGROUND Recent evidence suggests that resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective life-saving intervention in patients with severe torso trauma. However, the deployment of REBOA in patients with isolated penetrating intrathoracic injuries remains controversial. We propose that a median sternotomy be performed in conjunction with REBOA as a feasible and effective means of hemorrhage control in patients suffering from penetrating chest trauma who present hemodynamically unstable. The objective of our study was to present our initial experience with this approach.METHODS A prospectively collected case series of the use of REBOA (10 Fr) in conjunction with a median sternotomy from January 2015 to December 2016 at a Level I Trauma Center. We included hemodynamically unstable non-compressible torso hemorrhage patients with penetrating chest trauma who underwent intraoperative REBOA deployment plus median sternotomy.RESULTS A total of 68 trauma-related emergent thoracic surgeries were performed at our institution during the study period. Of these, seven suffered from penetrating chest trauma and non-compressible torso hemorrhage and underwent REBOA plus median sternotomy. Six out of the seven patients suffered intrathoracic vascular injuries: two subclavian arteries, two internal mammary arteries, two aortic arch, and five major central venous injuries. Four patients had an associated lung injury with AIS >3, of which two suffered a pulmonary hilar vessel disruption. REBOA-related complications included one case of upper gastrointestinal bleeding. Six out of the seven patients survived the 30-day follow-up. No adverse neurologic outcomes or deficits were observed in survivors.CONCLUSION The combined use of REBOA and median sternotomy could be a feasible and effective alternative to hemorrhage control in patients with non-compressible torso hemorrhage secondary to penetrating chest trauma. These findings challenge the recommendation against the use of REBOA in penetrating intrathoracic injuries. Future studies with stronger designs and larger sample sizes are required to confirm our results.LEVEL OF EVIDENCE Therapeutic, level V.