Abstract
PurposePelvic and lower junctional hemorrhage result in a significant amount of trauma related deaths in military and rural civilian environments. The Abdominal Aortic and Junctional Tourniquet (AAJT) and infra-renal (zone 3) Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) are two options for resuscitation of patients with life threatening blood loss from and distal to the pelvis. Evidence suggest differences in the hemodynamic response between AAJT and zone 3 REBOA, but fluid management during resuscitation with the devices has not been fully elucidated. We compared crystalloid fluid requirements (Ringer’s acetate) between these devices to maintain a carotid mean arterial pressure (MAP) > 60 mmHg.Methods60 kg anesthetized and mechanically ventilated male pigs were subjected to a mean 1030 (range 900–1246) mL (25% of estimated total blood volume, class II) haemorrhage. AAJT (n = 6) or zone 3 REBOA (n = 6) were then applied for 240 min. Crystalloid fluids were administered to maintain carotid MAP. The animals were monitored for 30 min after reperfusion.ResultsCumulative resuscitative fluid requirements increased 7.2 times (mean difference 2079 mL; 95% CI 627–3530 mL) in zone 3 REBOA (mean 2412; range 800–4871 mL) compared to AAJT (mean 333; range 0–1000 mL) to maintain target carotid MAP. Release of the AAJT required vasopressor support with norepinephrine infusion for a mean 9.6 min (0.1 µg/kg/min), while REBOA release required no vasopressor support.ConclusionZone 3 REBOA required 7.2 times more crystalloids to maintain the targeted MAP. The AAJT may therefore be considered in a situation of hemorrhagic shock to limit the need for crystalloid infusions, although removal of the AAJT caused more severe hemodynamic and metabolic effects which required vasopressor support.
Highlights
Trauma is a major global health issue contributing to about 10% of overall mortality and an annual worldwide death of more than 5.8 million people [1, 2]
We have shown that a transition from the Aortic and Junctional Tourniquet (AAJT) to zone 3 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may be safely performed with hemodynamic support, in a report where we suggested hemodynamic differences between the interventions [14]
Baseline characteristics displayed differences for mean arterial pressure (MAP) which was higher in the AAJT group and heart rate which was higher in the REBOA group (Table 1)
Summary
Trauma is a major global health issue contributing to about 10% of overall mortality and an annual worldwide death of more than 5.8 million people [1, 2]. Resuscitative endovascular balloon occlusion of the aorta (REBOA) and the Abdominal Aortic and Junctional Tourniquet (AAJT) are devices with the potential to control hemorrhage from the lower body including the pelvis by closing off arterial inflow [8,9,10]. For patients with traumatic hemorrhage, current guidelines in the US recommend a zone 3 location of the REBOA balloon for isolated injuries including and distal to the pelvis [12]. Both devices constitute potential prehospital and battlefield interventions to decrease mortality from non-compressible torso hemorrhage. Causing less severe ischemia and being better tolerated after reperfusion, zone 3 REBOA has limited resuscitative hemodynamic effects compared to a zone 1 location [15]
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