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

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.