When to REBOA – What’s the Right SBP Range?

May 6, 2024

Written by Shannon Markus

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REBOA has emerged as a critical intervention for managing hemorrhagic shock, but current guidelines are non-specific. Employing REBOA in unstable trauma patients with SBPs 60-80 mmHg is ideal, before further decompensation and increased mortality.

Is it too late now to REBO-AAAA
Noncompressible torso hemorrhage (NCTH) is the leading cause of preventable death in trauma. Hemorrhage control is traditionally attempted via a resuscitative left thoracotomy; however, NCTH mortality remains high. REBOA has emerged as a critical intervention for managing severe hemorrhagic shock, but current guidelines are non-specific. It is known that mortality increases when pre-REBOA SBP decreases, but what is not known is the optimal threshold for REBOA deployment to improve mortality.

Using data from 2 registries, this study aimed to determine the optimal SBP threshold for REBOA placement by analyzing the association between SBP pre-REBOA and 24-hour mortality in 848 patients. The authors performed a retrospective analysis on the registries, which include data on penetrating and blunt trauma patients from 14 countries worldwide.

The patients who died in the first 24 hours had a higher injury severity score, a higher proportion of prehospital cardiac arrest, lower SBP pre-REBOA and lower pupillary response compared with survivors. The authors demonstrated that predicted mortality increased at both extremes of the SBP spectrum (U-shaped association) and that SBP 60 mmHg is an inflection point for an increasing probability of death. Instead of the classic <90 mmhg threshold that is commonly used, the authors suggest that in patients who do not respond to initial resuscitation, the use of REBOA in SBPs between 60 mmHg and 80 mmHg is ideal, before further decompensation or complete cardiovascular collapse.

How will this change my practice?
These authors attempt to fill the”black hole” of knowledge regarding the management of trauma patients with SBP 40-90 mmHg who don’t respond to initial resuscitation. Their proposed cutoff may be a useful tool in encouraging use of REBOA in a crashing patient before it’s too late (before complete cardiovascular collapse). However, use of this is limited to trauma centers with stocked REBOA catheters, ongoing REBOA skills training, and a well-trained operator–which may be hard to come by.

Source
Critical systolic blood pressure threshold for endovascular aortic occlusion-A multinational analysis to determine when to place a REBOA. J Trauma Acute Care Surg. 2024 Feb 1;96(2):247-255. doi: 10.1097/TA.0000000000004160. Epub 2023 Oct 19. PMID: 37853558