Management of the Unstable Patient During EVTM and REBOA

Abstract

Most trauma patients who require Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) will be cardiovascularly “unstable”—whatever that means. The term is typically used to describe a physiological state characterized by hypotension, hypoperfusion, and tachycardia, often—but not invariably—brought on by blood loss. REBOA is used as part of a damage control resuscitation approach, when blood loss has reached critical levels, to obtain temporary hemorrhage control, while hemostatic resuscitation is instituted. Understanding the physiological consequences of REBOA, and the relationship between anesthesia and aortic occlusion, is therefore critically important. Experience with the intra-operative and anesthetic management of REBOA patients is still limited. Nevertheless, there are a number of key principles which, if adhered to, will help anesthesiologists and surgeons manage these complex and demanding patients. This chapter discusses a number of issues, including communication, crew resource management, timing of REBOA, circulatory access, induction and maintenance of anesthesia, analgesia, hemostatic resuscitation, afterload reduction, monitoring, electrolyte management, and balloon deflation.

Experts’ Comments by Luca Ansaloni and Federico Coccolini

Traumatic torso hemorrhage (TTH) is an important cause of morbidity and mortality in the field of trauma and emergency medicine and surgery [11, 12]. In recent times, there has been a renewed interest in the adoption of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in association with the Endovascular resuscitation and Trauma Management (EVTM) approach for patients who present with TTH [13]. Like all medical interventions and procedures, there are not only benefits, but even risks associated with the REBOA technique. However, in the case of REBOA, these complications are not unanimously agreed upon with varying viewpoints and studies. This chapter aims to indicate the correct management of REBOA placement in hemodynamically unstable patients with TTH, in order to reduce the well-known complications of the REBOA technique at each step of its application. Although REBOA is an emergent and increasingly accepted technique used as a less invasive alternative (than surgical interventions) for controlling bleeding in patients with TTH, in order to allow for this procedure to be used in widespread practice, a better understanding of the potential complications that can arise in all stages (arterial access, balloon positioning, inflation, during occlusion, deflation, and removal of the sheath) must be well recognized. The understanding of the physiology of temporary aortic occlusion, an excellent grade of communication between trauma team members, an integrated management of anesthesia, hemostatic resuscitation and fluid balance during REBOA application (especially during balloon deflation times), and finally an appropriate monitoring of the patients with TTH, can allow identification of specific complications and adequate measures to be taken to avoid these complications and reduce potential morbidity and mortality associated with REBOA.