Here’s a continuation from yesterday’s post!
Step 4: Run to the OR!
Remember, REBOA is a technique for temporarily controlling hemorrhage. The entire point is to allow the surgical team an opportunity to permanently control it. So package the patient safely, and run to the OR as fast as you can.
Step 5: Deflate the balloon
Assuming the surgical team has been successful, what goes up must come down. Deflating the balloon is a team sport as well. There are two things to think about here.
First, has the hemorrhage really been controlled? Everyone will find out when the balloon comes down. The surgical team needs to be ready with laparotomy pads, hemostatic agents, and must be ready to attack the problem area(s) again if significant bleeding recurs. If it does, the surgeons should quickly assess to see if the old problem hasn’t been dealt with completely, or if another unsuspected one is present. The balloon can be re-inflated if needed.
Second, there will be consequences. Metabolic consequences. There will be a significant reperfusion effect, with washout of lots of metabolic products. Make sure your anesthesia team is prepared for a significant acid load in short order, with wild fluctuations in vital signs. It may be wise to intermittently deflate and re-inflate for intervals to allow the team at the head of the bed to maintain order.
Step 6. Repair the damage.
Remember, the sheath used to introduce the REBOA is large. Older and larger sheathes virtually guaranteed the need for surgical repair. Some of the newer and smaller may be closable using various percutaneous systems, but don’t count on it yet.
If it hasn’t already been done, cut down on the sheath and inspect the entry point in the CFA. Perform a sound vascular repair after it’s been removed, including inspection for good back bleeding distally. Then, aside from the usual critical care that this patient will need, be sure to monitor the lower extremity closely for any changes in the pulse exam.
Tomorrow: The results
Direct links to the REBOA series: