American Journal of Emergency Medicine 33 (2015) 473.e1-473.e2

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American Journal of Emergency Medicine

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Case Report

Intra-aortic balloon occlusion catheter for treating hemorrhagic shock after massive Duodenal ulcer bleeding?,??

Abstract

Clamping the descending aorta by emergency thoracotomy is a well-known effective procedure to stop bleeding from lesions under the diaphragm. We successfully treated a case of cardiopulmonary arrest resulting from a massive duodenal ulcer hemorrhage using an intra aortic balloon occlusion (IABO) catheter instead of the conventional technique. Our experience suggests that IABO catheters can be used to treat patients with hemorrhagic shock regardless of the presence of cardiopulmonary arrest. This can be a life-saving procedure, which prevents ischemic brain injury. This article describes the advantages of using IABO catheters and our experience with this case.

A 79-year-old woman was transferred to our hospital from another hospital in shock after receiving massive Fluid replacement therapy as part of the treatment of massive duodenal ulcer hemorrhage. Fig. illustrates her treatment course. Although her systolic blood pressure (SBP) was 135 mm Hg at admission, it suddenly dropped to 40 mm Hg. She had cardiopulmonary arrest (CPA) despite rapid resuscitation with blood transfusion. She recovered after cardiopulmonary-cerebral resuscitation for 20 minutes. We immediately inserted a 9F sheath (Terumo, Gifu, Japan) into the right femoral artery using the Seldinger technique. Then, as an intra-aortic balloon occlusion (IABO) catheter, an 8F Fogarty occlusion catheter (Edwards Lifescience, Irvine, CA) was introduced up to 50 cm into the sheath into the descending aorta. The patient’s SBP recovered to 240 mm Hg without IABO catheter balloon inflation. However, the balloon was inflated later because her SBP gradually decreased before upper gastrointestinal endoscopy. Then, the patient’s SBP increased to 130 mm Hg, and upper gastrointestinal endoscopy was performed soon afterward. It revealed heavy bleeding and massive clots. However, we had difficulty identifying the bleeding point and stopping the bleeding. During this procedure, the patient’s SBP gradually decreased despite the inflated balloon. She experienced again CPA for 10 minutes. After another successful resuscitation, the patient was immediately transferred to the operating room for surgical control of the bleeding. The patient underwent hemostasis by electrocoagulation and ligation after incision of the duodenal bulb exposed the culprit vessels. The balloon was left inflated during the operation because the patient’s SBP did not stabilize after temporary

? Conflict of interest: The authors declare that they have no conflict of interest.

?? Shintaro Shigesato conceived the study concept and design, was involved with patient care, drafted the manuscript, and conducted the literature review. Tetsunosuke Shimizu, Tadahiro Kittaka, and Hiroshi Akimoto were involved with framing of the study concept and design, patient care, manuscript drafting, and literature review. Shintaro Shigesato and Tetsunosuke Shimizu were the main contributors in the drafting of the manuscript. All authors have read and approved the final version of the manuscript.

E-mail address: [email protected] (H. Akimoto).

deflation. However, the balloon was deflated soon after achieving hemostasis. The balloon inflation time was approximately 150 minutes. The total amount of blood transfusion until surgery completion was 24 units of Packed red blood cells, 16 units of fresh-frozen plasma, and 35 units of platelet concentrate. The patient postoperatively underwent capillary hydrodynamic fractionation to correct electrolyte abnormalities and to remove increased levels of muscle and Liver enzymes, caused by massive blood transfusions and reperfusion injury due to continuous and prolonged inflation of the balloon. However, she developed acute multiple-organ failure, that is, acute liver, renal failure, and respiratory failures, necessitating positive end-expiratory pressure with high oxygen concentration and tracheostomy. Fortunately, all laboratory data almost normalized after 3 weeks. No ischemic brain injury symptoms were observed during her admission. The patient was discharged without significant complications on postoperative day 31. Rapid fluid resuscitation has gained popularity as an initial treatment of hemorrhagic shock. The “deadly triad” is initiated if even temporary hemostasis is not achieved rapidly in patients showing no Hemodynamic improvement with rapid fluid resuscita- tion, to avoid fatality. Descending aorta clamping by emergency thoracotomy is an effective procedure to stop bleeding under the diaphragm [1,2]; however, IABO catheters are recently becoming

increasingly recognized as a simple alternative [3-7].

Intra-aortic balloon occlusion catheters are advantageous because they are easy to insert and use, increase cerebral blood flow, allow for quick response in patients with secondary worsening of circulatory dynamics, and provide doctors with additional time to select more effective treatments. The present patient was able to return home without any risk of ischemic brain injury, especially Hypoxic-ischemic encephalopathy, despite 2 cardiac arrests. We believe that balloon inflation of the IABO catheter, which was already inserted at the time of the second cardiac arrest as well as during the operation, brought about desirable effects such as increased cerebral blood flow. Lylyk et al [8] reported a 15% increase in mean flow velocity during balloon inflation in both middle cerebral arteries. There are no reports that balloon inflation use during cardiopulmonary-cerebral resuscitation results in increased cerebral blood flow and decreased frequency of hypoxic-ischemic encephalopathy. However, balloon inflation can easily increase cerebral blood flow during resuscitation.

Our standard protocol for IABO catheter alternates between 15 minutes of inflation and 5 minutes of deflation, and we restrict continuous balloon inflation to 60 minutes to prevent visceral Ischemic injury. The present patient developed multiple organ failure, associated with reperfusion injury, because the maintenance of stable hemodynamics was difficult and we could not deflate the balloon for

150 minutes. The primary roles of the IABO catheter are to stop bleeding, increase cerebral blood flow, and provide visceral blood flow.

0735-6757/(C) 2014

473.e2 S. Shigesato et al. / American Journal of Emergency Medicine 33 (2015) 473.e1-473.e2

250

(U)

20

0

FFP 16U PC 35U

Adrenaline

Adrenaline Calcium gluconate

Calcium gluconate Sodium hydrogen carbonate

UGE

0

1

60

CPCR

CPCR

120

180

Dopamine

Total amount of blood transfusion: PRBC 24U

200

Blood pressure (mmHg)

150

100

50

0 (min)

Emergency admission

Insertion of the sheath for IABO catheter

IABO

inflation

Operation (131 min)

IABO

deflation

Fig. Time course from admission to the completion of operation. Time course change of the SBP is shown. The length of the first CPA was 20 minutes, whereas the second one was 10 minutes. The balloon of the IABO catheter was slowly inflated with 10 mL saline solution. The operative time was 131 minutes. Total inflation time of the balloon of the IABO catheter was 150 minutes.

To the best of our knowledge, IABO catheter use has been previously described in patients with hemorrhagic shock after trauma, but that in patients with CPA during hemorrhagic shock due to visceral bleeding, similar to that in our case, has not been reported. In conclusion, IABO catheters should be increasingly applied in patients with hemorrhagic shock with or without CPA due to internal diseases, with the aim of increasing cerebral blood flow.

Shintaro Shigesato Tetsunosuke Shimizu Tadahiro Kittaka Hiroshi Akimoto

Osaka Mishima Emergency Medical Critical Care Center

Takatsuki City, Osaka 569-1124 Japan E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2014.01.024

References

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4. Sovik E, Strokkeland P, Strom BS, et al. The use of Aortic occlusion balloon catheter without fluoroscopy for life-threatening post-partum hemorrhage. Acta Anaesthesiol Scand 2012;56:388-93.
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8. Lylyk P, Vila JF, Miranda C, et al. Partial aortic obstruction improves cerebral perfusion and clinical symptoms in patients with symptomatic. Neurol Res 2005;27:S129-35.