The Implementation of a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Program at a Level One New England Trauma Center: Feasibility and Early Outcomes
Elizabeth Roderick, Daniel Ricaurte, Alfred Croteau, Jonathan D. Gates, Stacey Bass, Akhilesh Jain, Jane Keating
Hartford Hospital, Simsbury, Connecticut, United States
Objective(s): We evaluated the feasibility of implementing a Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) program at our level one trauma center and evaluated early outcomes.
Design: We formed a multidisciplinary committee including physicians (trauma surgery, emergency medicine, vascular surgery, and interventional radiology) and nurses (emergency medicine (EM) and intensive care (ICU)), in order to create and review clinical practice guidelines for the placement of REBOA at our institution. Next, with permission from an outside institution, we adapted a previously validated educational course, and all trauma surgeons and critical care board certified emergency medicine physicians were trained in the placement of REBOA for patients with non-compressible torso hemorrhage over the course of two weeks. Additionally, all EM and ICU nurses received training regarding femoral arterial lines and sheath management. Next, we implemented a formal process in order to review each REBOA placement to identify areas for improvement and/or complications. Finally, we instituted a plan for refresher training and continuing medical education to maintain REBOA competency and privileges.
Setting: The study took place at our urban, level one, academic, trauma center in New England.
Patients: Trauma patients greater than or equal to 18 years of age were included. Patients with non-compressible torso hemorrhage suffering either blunt or penetrating injuries were considered for REBOA if they were partial or non-responders to blood product resuscitation. Pregnant patients, children, or patients with significant hemothorax or suspected aortic or cardiac injury were excluded.
Interventions: Placement of REBOA (zone 1 or Zone 3)
Main Outcome Measure(s): The main outcome measured was the success of REBOA placement, as well as patient outcomes including hospital mortality, length of stay, extremity complications, and blood product utilization.
Results: In the 6 months following our REBOA program implementation, 6 REBOA catheters were attempted. All REBOA catheters were successfully placed on the first attempt utilizing ultrasound guidance by a trauma surgeon. Four Zone 3 catheters and two Zone 1 catheters were placed. All Zone 3 catheters were placed for pelvic fracture-related bleeding that was successfully embolized following REBOA. The Zone 1 catheters were placed immediately preoperatively for intraabdominal bleeding. Upon committee review, only one critique was made regarding Zone selection, and this feedback was provided to the attending surgeon. There were no complications related to catheter placement or removal. All patients survived to discharge.
Conclusions: A REBOA program is feasible and safe following a comprehensive multi-disciplinary effort. The efforts described here can be utilized by similar trauma programs for adaptation of this endovascular approach to bleeding control.
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