A Practical Approach to Introducing Pre-Hospital Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA), the Problems Encountered and Lessons Learned

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is an endovascular procedure which utilises a catheter based balloon device to achieve aortic occlusion. The aim of this resuscitative measure is to improve blood pressure proximal to the occlusion site and therefore preserve cardiac and cerebral perfusion in order to prevent cardiac arrest; additionally there is a relative reduction in arterial inflow to the site of injury. Endovascular techniques are gaining acceptance for the in-hospital management of haemorrhage, however their use in pre-hospital care is still limited. This is due to a number of factors including the technical challenges, training and skill sets of pre-hospital care teams and the potential for harm of REBOA, particularly with extended balloon occlusion times. However, non compressible torso haemorrhage is associated with a mortality of approximately 50% and a significant proportion of these deaths occur in the pre-hospital phase of care. In the exsanguinating patient, resuscitative thoracotomy (RT) with direct aortic compression is often the only means to control haemorrhage. This resuscitative measure is now an established pre-hospital intervention which has significantly improved outcomes in the context of penetrating trauma, particularly thoracic injury. In the context of blunt injury and subdiaphragmatic haemorrhage, however, the outcomes from pre-hospital resuscitative thoracotomy remain poor. We present our initial technique for successfully introducing REBOA for the pre-hospital management of exsanguinating pelvic or groin heamorrhage following trauma, our indications for REBOA and comment on the problems and limitations encountered as well the lessons learned.

Maternal and Neonatal Effects of Remifentanil in Women Undergoing Cesarean Section in Relation to ABCB1 and OPRM1 Polymorphisms

The aim of our study was to evaluate possible effect of ABCB1, and OPRM1 polymorphisms on the efficacy and safety of remifentanil in women undergoing elective cesarean section under general anesthesia. Women received remifentanil (1 µg/kg i.v.) 30 s prior to the induction to standardized general anesthesia. The ABCB1 (rs2032582, rs1045642) and OPRM1 (rs1799971) polymorphisms were analyzed from maternal peripheral blood. The basal hemodynamic and demographic parameters in the study population (n=54) were similar in all the subgroups. The median ± SD increase of systolic blood pressure at 5 min from the baseline was practically completely abolished in homozygous carriers of ABCB1 variants in comparison with wild-type subjects -2.67±25.0 vs. 16.57±15.7 mm Hg, p<0.05 for rs2032582, and 2.00±23.9 vs. 22.13±16.8 mm Hg, p<0.05, for rs1045642, respectively. While no neonate belonging to ABCB1 wild-type homozygous or OPRM1 variant carrying mothers needed any resuscitative measure, 10.5 % of the neonates belonging to OPRM1 wild-type homozygous mothers received resuscitative support similarly as 11.1 %, and 12.5 % of neonates of mothers carrying variants of rs2032582, and rs1045642, respectively. Decreased stabilizing effects of remifentanil on maternal hemodynamics has been observed in ABCB1 wild type mothers, while the adaptation of the neonates was clinically worse in OPRM1 wild type, and ABCB1 variant allele carriers.