Postoperative Critical Care Management Considerations

Abstract

Critical care in patients managed by EndoVascular resuscitation and Trauma Management (EVTM) is like standard intensive care in many respects. However, femoral access, Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), and grafts/stents are means that are specific and impose considerations. Femoral access via large-bore sheaths introduces a risk of limb-threatening complications, which motivates additional frequent monitoring, including distal perfusion and possibly noninvasive near-infrared spectroscopy of the lower limb. Aortic occlusion has challenging postreperfusion cardiovascular effects, e.g., a vasodilatory shock, on top of the hemorrhagic shock and postresuscitation physiology, which may warrant advanced cardiovascular monitoring to initiate adequate resuscitation. Due to the ischemia-reperfusion injury of distal (abdominal) organs, use of REBOA possibly increases the risk of postresuscitation distal organ dysfunctions, especially renal failure, mesenteric ischemia, abdominal compartment syndrome, and multiple organ failure. A high level of clinical suspicion is demanded. Implantation of vascular grafts and stents prompts early anticoagulation in patients with an elevated risk of bleeding to avoid thromboembolic events; correct timing, dosing, and individual assessment are critical components. Knowledge from adjacent areas is useful in the creation of guidelines for postoperative critical care in EVTM patients, but future work should aim to explore EVTM-specific critical care considerations.

Expert’s Comments by Andrew Kirkpatrick

Doctors Nilsson and Axelsson have written an excellent and focused review of what is currently known concerning the physiology and pathophysiology of patients surviving EndoVascular resuscitation and Trauma Management (EVTM). As the authors acknowledge, there is much still to be learned as utilizing Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a relatively new practice in most centers. There is more experience with Endovascular aneurysmal repair (EVAR) in which aortic occlusion, coagulopathy, and massive transfusion clearly associate with severe intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) [59]. Survivors of REBOA deployment will be critically ill with all the expected complications of catastrophic trauma and from technical aspects of major arterial access, but also with additional critical visceral concerns related to the unique physiology of aortic occlusion. Specifically, such patients display markedly increased rates of mesenteric ischemia, renal failure, and severe IAH. Further, the effects of IAH/ACS will not be limited to the abdomen but will be systemic due to elaborated biomediators propagating multiorgan dysfunction syndrome/multisystem organ failure and/or through polycompartmental pressure interactions [74, 75]. It is likely that post EVTM, patients will be especially susceptible to what Malbrain has termed the Acute Intestinal Distress Syndrome. This is a postresuscitation syndrome in which a first “hit” such as severe trauma/shock induces bowel ischemia-reperfusion injury, releasing proinflammatory mediators into the peritoneum and systemic circulation, leading to neutrophil priming, increased intestinal permeability, extravasation of fluid into the bowel wall and mesentery, translocation of intestinal bacteria, and absorption of bacterial endotoxin. Subsequently, with massive resuscitation and aortic occlusion as a second severe “hit,” visceral edema leads to severe IAH, compressing intra-abdominal lymphatics, further decreasing visceral perfusion thus escalating the increased permeability and driving further bacterial translocation/endotoxin absorption and generation of proinflammatory mediators [74, 76,77,78,79]. Intra-abdominal pressure monitoring will thus be imperative for post EVTM patients, for whom aggressive IAH management will be required [80], including decompressive laparotomy if necessary. Obviously, a less invasive solution to trauma that ultimately requires a maximally invasive solution to consequences of that first solution is far from ideal. Progress in medicine is rife with challenges that led to innovative solutions as scientific understanding and technique progress, and post EVTM critical care management will hopefully be one of those areas.