Challenges and learning curve in adopting resuscitative endovascular balloon occlusion of the aorta for trauma patients: A retrospective multicenter study

초록

Background: This study aimed to assess the learning curve of REBOA from the first case in trauma centers using cumulative sum (CUSUM) analysis. Materials and Methods: This study enrolled consecutive trauma patients who visited five trauma centers from December 2015 to December 2021. To monitor the effectiveness of REBOA, we performed risk-adjusted cumulative sum (RA-CUSUM) analysis for mortality due to exsanguination. For individual risk adjustment, we implemented the least absolute shrinkage and selection operator (LASSO) logistic regression model. We then calculated the CUSUM for: (1) the time from common femoral artery (CFA) access to confirmation of REBOA placement (RP-CUSUM), (2) the total occlusion time (OT-CUSUM), (3) door-to-balloon time (DB-CUSUM), and (4) the time from injury to admission (IA-CUSUM). To determine whether observed deviations were statistically significant, a V-mask was superimposed on the CUSUM curve. Results: A total of 251 patients were enrolled. The overall mortality rate was 67.7% (170/251), and the mortality rate due to exsanguination was 49.0% (123/251). The RA-CUSUM model was developed using a LASSO logistic regression approach. In three hospitals, the RA-CUSUM showed an improvement after 5-34 procedures. However, the RA-CUSUM showed fluctuations with deterioration in the other two hospitals. The RA-CUSUM fluctuations exceeded the V-mask control limits. RA-CUSUM charts for five hospitals deviated beyond the V-mask boundaries, indicating that the processes were out of control. Other CUSUM charts-such as RP-, OT-, DB-, and IA-CUSUM-exhibited fluctuations limited within V-mask boundaries, which suggests no significant change. Conclusion: CUSUM analysis demonstrated that a reduction in risk-adjusted mortality may be achieved with experience. Nevertheless, trauma surgeons should exercise caution due to a potential decline in the performance of REBOA, particularly the rate of mortality due to exsanguination.

키워드