Melike N Harfouche, Nikolay Bugaev, John J Como, Douglas R Fraser, Allison G McNickle, Guy Golani, Benjamin P Johnson, Horacio Hojman, Hiba Abdel-Aziz, Jaswin S Sawhney, Daniel C Cullinane, Steven Lorch, Elliott R Haut, Nicole Fox, Laurence S Magder, George Kasotakis
{"title":"外科和创伤患者主动脉血管内球囊闭塞的复苏：来自东部创伤外科协会的系统回顾、荟萃分析和实践管理指南。","authors":"Melike N Harfouche, Nikolay Bugaev, John J Como, Douglas R Fraser, Allison G McNickle, Guy Golani, Benjamin P Johnson, Horacio Hojman, Hiba Abdel-Aziz, Jaswin S Sawhney, Daniel C Cullinane, Steven Lorch, Elliott R Haut, Nicole Fox, Laurence S Magder, George Kasotakis","doi":"10.1136/tsaco-2024-001730","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the management of patients with subdiaphragmatic bleeding, as well as its utility in traumatic cardiac arrest (TCA), is unknown.</p><p><strong>Methods: </strong>A working group from the Eastern Association for the Surgery of Trauma (EAST) applied the Grading of Recommendations Assessment, Development and Evaluation methodology (GRADE) to perform a systematic review and meta-analysis, assess the level of evidence, and create recommendations pertaining to the use of REBOA in the management of trauma or non-trauma patients, as well as those in TCA (1946 to 2024).</p><p><strong>Results: </strong>Thirty-one studies were included in the meta-analysis. In unstable trauma patients with subdiaphragmatic bleeding, there was no significant difference in mortality among patients who were treated with REBOA vs no REBOA [OR 0.86, 95% CI 0.37, 2.04]. Subgroup analysis for individuals with pelvic fractures demonstrated higher mortality for REBOA vs no REBOA [OR=2.15, CI 1.35, 3.42]. In patients with TCA, pooled analysis demonstrated decreased mortality with REBOA vs resuscitative thoracotomy (OR 0.32, 95% CI 0.15, 0.69). Compared with no REBOA, prophylactic placement of REBOA prior to cesarean section in placenta accreta syndrome (PAS) had lower intra-operative blood loss [-1.06 L, CI -1.57 to -0.56] and red blood cell transfusion [-2.44 units, CI -4.27 to -0.62]. Overall, the level of evidence was assessed by the working group as very low.</p><p><strong>Conclusion: </strong>Considering the risks associated with its use and lack of discernible benefit, the committee conditionally recommends against the use of REBOA in trauma patients who are hemodynamically unstable due to suspected subdiaphragmatic hemorrhage. Further research is needed to identify specific subpopulations who may benefit. 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In unstable trauma patients with subdiaphragmatic bleeding, there was no significant difference in mortality among patients who were treated with REBOA vs no REBOA [OR 0.86, 95% CI 0.37, 2.04]. Subgroup analysis for individuals with pelvic fractures demonstrated higher mortality for REBOA vs no REBOA [OR=2.15, CI 1.35, 3.42]. In patients with TCA, pooled analysis demonstrated decreased mortality with REBOA vs resuscitative thoracotomy (OR 0.32, 95% CI 0.15, 0.69). Compared with no REBOA, prophylactic placement of REBOA prior to cesarean section in placenta accreta syndrome (PAS) had lower intra-operative blood loss [-1.06 L, CI -1.57 to -0.56] and red blood cell transfusion [-2.44 units, CI -4.27 to -0.62]. Overall, the level of evidence was assessed by the working group as very low.</p><p><strong>Conclusion: </strong>Considering the risks associated with its use and lack of discernible benefit, the committee conditionally recommends against the use of REBOA in trauma patients who are hemodynamically unstable due to suspected subdiaphragmatic hemorrhage. Further research is needed to identify specific subpopulations who may benefit. 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引用次数: 0
摘要
背景：复苏血管内球囊栓塞主动脉（REBOA）在处理膈下出血患者中的作用，以及它在创伤性心脏骤停（TCA）中的应用，目前尚不清楚。方法：来自东部创伤外科协会（EAST）的一个工作组应用建议分级评估、发展和评价方法（GRADE）进行系统回顾和荟萃分析，评估证据水平，并创建有关REBOA在创伤或非创伤患者以及TCA患者管理中的使用的建议（1946年至2024年）。结果：31项研究被纳入meta分析。在伴有膈下出血的不稳定创伤患者中，接受REBOA治疗与未接受REBOA治疗的患者死亡率无显著差异[OR 0.86, 95% CI 0.37, 2.04]。骨盆骨折患者的亚组分析显示，REBOA组死亡率高于未REBOA组[OR=2.15, CI 1.35, 3.42]。在TCA患者中，汇总分析显示REBOA与复苏开胸术相比死亡率降低（OR 0.32, 95% CI 0.15, 0.69）。与无REBOA相比，在胎盘增生综合征（PAS）剖宫产前预防性放置REBOA，术中出血量[-1.06 L, CI -1.57 ~ -0.56]和红细胞输血[-2.44单位，CI -4.27 ~ -0.62]较低。总的来说，工作组评估的证据水平非常低。结论：考虑到使用REBOA的相关风险和缺乏明显的益处，委员会有条件地建议，由于怀疑膈下出血而导致血流动力学不稳定的创伤患者不要使用REBOA。需要进一步的研究来确定可能受益的特定亚群。对于因怀疑膈下出血而发生TCA的患者，以及在PAS中预防性放置TCA的患者，委员会有条件地建议使用REBOA。证据等级：四级。
Resuscitative Endovascular Balloon Occlusion of the Aorta in surgical and trauma patients: a systematic review, meta-analysis and practice management guideline from the Eastern Association for the Surgery of Trauma.
Background: The role of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the management of patients with subdiaphragmatic bleeding, as well as its utility in traumatic cardiac arrest (TCA), is unknown.
Methods: A working group from the Eastern Association for the Surgery of Trauma (EAST) applied the Grading of Recommendations Assessment, Development and Evaluation methodology (GRADE) to perform a systematic review and meta-analysis, assess the level of evidence, and create recommendations pertaining to the use of REBOA in the management of trauma or non-trauma patients, as well as those in TCA (1946 to 2024).
Results: Thirty-one studies were included in the meta-analysis. In unstable trauma patients with subdiaphragmatic bleeding, there was no significant difference in mortality among patients who were treated with REBOA vs no REBOA [OR 0.86, 95% CI 0.37, 2.04]. Subgroup analysis for individuals with pelvic fractures demonstrated higher mortality for REBOA vs no REBOA [OR=2.15, CI 1.35, 3.42]. In patients with TCA, pooled analysis demonstrated decreased mortality with REBOA vs resuscitative thoracotomy (OR 0.32, 95% CI 0.15, 0.69). Compared with no REBOA, prophylactic placement of REBOA prior to cesarean section in placenta accreta syndrome (PAS) had lower intra-operative blood loss [-1.06 L, CI -1.57 to -0.56] and red blood cell transfusion [-2.44 units, CI -4.27 to -0.62]. Overall, the level of evidence was assessed by the working group as very low.
Conclusion: Considering the risks associated with its use and lack of discernible benefit, the committee conditionally recommends against the use of REBOA in trauma patients who are hemodynamically unstable due to suspected subdiaphragmatic hemorrhage. Further research is needed to identify specific subpopulations who may benefit. For individuals with TCA due to suspected subdiaphragmatic bleeding and for prophylactic placement in PAS, the committee conditionally recommends for the use of REBOA.
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