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Artigo em Inglês | MEDLINE | ID: mdl-32068720


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.

J Pediatr Surg ; 55(2): 346-352, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31787320


BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has not been studied in children. We hypothesized that REBOA was feasible and would improve hemorrhage control and survival time, compared to no aortic occlusion, in a pediatric swine liver injury model. METHODS: Pediatric swine were randomized to Zone 1 REBOA or no intervention (control). Piglets underwent a partial liver amputation and free hemorrhage followed by either REBOA or no intervention for 30 min, then a damage control laparotomy and critical care for 4 h. RESULTS: Compared to control piglets (n = 5), REBOA piglets (n = 6) had less blood loss (34.0 ±â€¯1.6 vs 61.3 ±â€¯2.5 mL/kg, p < 0.01), higher end hematocrit (28.1 ±â€¯2.1 vs 17.1 ±â€¯4.1%, p = 0.03), higher end creatinine (1.4 ±â€¯0.1 vs 1.2 ±â€¯0.1 mg/dL, p = 0.05), higher end ALT and AST (56 ±â€¯4 vs 32 ±â€¯6 U/L, p = 0.01 and 155 ±â€¯26 vs 69 ±â€¯25 U/L, p = 0.05) and required more norepinephrine during critical care (1.4 ±â€¯0.3 vs 0.3 ±â€¯0.3 mg/kg, p = 0.04). All REBOA piglets survived, whereas 2 control piglets died, p = 0.10. CONCLUSION: In pediatric swine, 30 min of REBOA is feasible, decreases blood loss after liver injury and may improve survival. LEVEL OF EVIDENCE: Level 1.

Artigo em Inglês | MEDLINE | ID: mdl-31576422


PURPOSE: While resuscitative endovascular balloon occlusion of the aorta (REBOA) is contraindicated in patients with aortic injuries, this technique may benefit poly-trauma patients with less extreme thoracic injuries. The purpose of this study was to characterize the effects of thoracic injury on hemodynamics during REBOA and the changes in pulmonary contusion over time in a swine model. METHODS: Twelve swine were anesthetized, instrumented, and randomized to receive either a thoracic injury with 5 impacts to the chest or no injury. All animals underwent controlled hemorrhage of 25% blood volume followed by 45 min of Zone 1 REBOA. Animals were then resuscitated with shed blood, observed during a critical care period, and euthanized after 6 h of total experimental time. RESULTS: There were no differences between the groups at baseline. The only difference after 6 h was a lower hemoglobin in the thoracic trauma group (8.4 ± 0.8 versus 9.4 ± 0.6 g/dL, P = 0.04). The average proximal mean arterial pressures were significantly lower in the thoracic trauma group during aortic occlusion [103 (98-108) versus 117 (115-124) mmHg, P = 0.04]. There were no differences between the pulmonary contusion before REBOA and at the end of the experiment in size (402 ± 263 versus 356 ± 291 mL, P = 0.782) or density (- 406 ± 127 versus - 299 ± 175 HFU, P = 0.256). CONCLUSIONS: Thoracic trauma blunted the proximal arterial pressure augmentation during REBOA but had minimal impacts on resuscitative outcomes. This initial study indicates that REBOA does not seem to exacerbate pulmonary contusion in swine, but blunt thoracic injuries may attenuate the expected rises in proximal blood pressure during REBOA.

Adv Skin Wound Care ; 31(1): 596-600, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29240587


BACKGROUND: Diabetes mellitus is a worldwide pandemic that impacts more than 387 million people, with 29 million individuals affected in the United States alone. Diabetic patients have a 25% lifetime risk of developing a diabetic foot ulcer (DFU). Having a DFU is associated with a risk of recurrence approaching 70%. In addition, 1 in 6 patients with DFU will have a lower-limb amputation, with an associated increase in mortality ranging from 47% to 70%. Therefore, limb salvage is critical in patients with DFU. CASE STUDY: This article describes the case of a 70-year-old man with diabetes mellitus, end-stage renal disease, and peripheral arterial occlusive disease who presented with a 1.5% total-body-surface-area, third-degree burn to the left hallux with dry gangrene extending to the midfoot. Ankle brachial indexes were 0.66 on the left and 0.64 on the right. Toe pressures on the left were absent because of extensive dry gangrene. His right foot had a prior transmetatarsal amputation. Using a retrograde pedal approach, a chronic total occlusion of the left posterior tibial artery was recanalized with balloon angioplasty. He then underwent a transmetatarsal amputation with closure, except that the plantar medial side could not be closed without tension. Therefore, an autologous full-thickness skin graft, from the amputation specimen, was used to bridge the defect. DISCUSSION: At 32-week follow-up, the wound was healed, the graft had fully incorporated, and the patient was ambulating well using custom orthotic footwear. The creative use of amputated tissue to assist with wound coverage has not been well described in the literature.

Queimaduras/cirurgia , Pé Diabético/cirurgia , Salvamento de Membro/métodos , Doença Arterial Periférica/cirurgia , Retalhos Cirúrgicos/transplante , Idoso , Cotos de Amputação/cirurgia , Queimaduras/diagnóstico , Pé Diabético/fisiopatologia , Sobrevivência de Enxerto , Humanos , Isquemia/complicações , Isquemia/diagnóstico , Isquemia/cirurgia , Masculino , Doença Arterial Periférica/diagnóstico , Índice de Gravidade de Doença , Transplante Autólogo , Resultado do Tratamento , Cicatrização/fisiologia