Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in a Pediatric Swine Model: Is 60 Minutes Too Long?

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is recommended in adults with a non-compressible torso hemorrhage with occlusion times of less than 60 minutes. The tolerable duration in children is unknown. We used a pediatric swine controlled hemorrhage model to evaluate the physiologic effects of 30 and 60 minutes of REBOA. METHODS: Pediatric swine weighing 20-30kg underwent a splenectomy and a controlled 60% total blood volume hemorrhage over 30 minutes, followed by either Zone 1 REBOA for 30 minutes (30R) or 60 minutes (60R). Swine were then resuscitated with shed blood and received critical care for 240 minutes. RESULTS: During critical care, the 30R group's (n=3) pH, bicarbonate, base excess and lactate were no different than baseline, while at the end of critical care, these variables continued to differ from baseline in the 60R group (n=5) and were worsening (7.4 vs 7.2, p<0.001, 30.4 vs 18.4mmol/L, p<0.0001, 5.6 vs -8.5mmol/L, p<0.0001, 2.4 vs 5.7mmol/L, p<0.001, respectively). Compared to baseline, end creatinine and creatinine kinase were elevated in 60R swine (1.0 vs 1.7mg/dL, p<0.01 and 335.4 vs 961.0U/L, p<0.001, respectively), but not 30R swine (0.9 vs 1.2 mg/dL, p=0.06 and 423.7 vs 769.5U/L, p=0.15, respectively). There was no difference in survival time between the 30R and 60R pediatric swine, p=0.99. CONCLUSION: The physiologic effects of 30 minutes of Zone 1 REBOA in pediatric swine mostly resolved during the subsequent 4 hours of critical care, whereas the effects of 60 minutes of REBOA persisted and worsened after 4 hours of critical care. Sixty minutes of Zone 1 REBOA may create an irreversible physiologic insult in a pediatric population. LEVEL OF EVIDENCE: Not applicable, translational animal scienceOriginal article.