REBOA increases bleeding and mortality
- related: ICU intensive care unit
- tags: #literature #icu
The optimal care of patients with exsanguinating hemorrhage remains an important research priority. Aortic occlusion with a peripherally inserted catheter has been proposed to limit flow of blood to the pelvis and distal extremities temporarily, to allow time to accomplish definitive hemostasis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was proposed to accomplish this task. However, the UK-REBOA trial randomly assigned 90 patients with exsanguinating hemorrhage due to torso trauma to REBOA or standard care. Patients had a median injury severity score of 41, consistent with severe trauma. The trial was closed early for concerning safety signals observed by the Data and Safety Monitoring Board. Contrary to expectations, REBOA did not improve survival or other important end points, and, notably, it led to an increase in mortality due to bleeding (32% vs 17%). REBOA use does not increase pelvic perfusion.
Notably, the time to definitive hemorrhage control was longer with REBOA, suggesting the possibility that REBOA delayed definitive treatment, which contributed to worse outcomes. Although there are valid questions regarding technical aspects of REBOA implementation in the trial, UK-REBOA featured multiple pragmatic elements in support of generalizability (including a nontrivial proportion of patients in whom REBOA was not performed despite attempts to do so) and provides the only randomized evidence about REBOA. In the absence of a substantial change in patient population, device characteristics, or operator techniques, clinical trial evidence does not support REBOA for patients with exsanguinating hemorrhage.12
A 25-year-old man is brought to the emergency department after being struck by an automobile while riding his bicycle. He has severe torso trauma with bleeding and has abject shock despite use of blood products according to the local massive transfusion protocol by the treating team. Heart ultrasonography shows no evidence of pericardial effusion. Bilateral tube thoracostomy has been performed, with ongoing bleeding from both chest tubes. The focused assessment with sonography in trauma (FAST) examination is positive, suggesting intraperitoneal hemorrhage. The team is preparing to perform resuscitative endovascular balloon occlusion of the aorta (REBOA).
On the basis of best evidence, what can be said about this planned action?