St. Michael’s is pioneering the use of a new device that can control bleeding and save lives

St. Michael’s is the first hospital in Ontario to use the new ER-REBOA catheter.

The high-tech manikin known as Orlando lies on a bed in St. Michael’s trauma bay, surrounded by nurses, respiratory therapists, x-ray techs, physicians, surgeons, clericals, educators, simulation centre personnel and observers who are either performing or witnessing the trial of an innovative new device and procedure.

The team has been told that Orlando has been in a motorcycle crash and is experiencing pelvic bleeding. Led by emergency physician Dr. Andrew Petrosoniak, they will be testing the new ER-REBOA catheter, which was recently approved by Health Canada but has not yet been used in Ontario.

Inserted into the patient’s groin, the catheter delivers a balloon to the aorta that, when inflated, will stop blood flow from that point downward in the body, controlling bleeding in patients suffering from blunt force trauma —and saving lives, as pelvic bleeding is a leading cause of death following traumatic injury. Previously, the trauma surgeon would have had to open up the patient’s chest and clamp the aorta, a much more invasive procedure with longer recovery time and greater risk of death.

“All the blood gets diverted north of where the balloon is, to keep the heart and brain going,” Dr. Petrosoniak explains. “If you’re in shock and losing blood, you’re no longer going to bleed, at least temporarily, and we can get you to a place for definitive control of bleeding.”

The in situ simulation test session was designed and executed in collaboration with the Allan Waters Family Simulation Centre team, clinical nurse educator Lee Barratt and operational readiness champion Candis Kokoski to make the situation as realistic as possible. Watched closely by the team, trauma surgeon Dr. Joao Rezende-Neto inserts the catheter in Orlando’s groin, advances it up to the desired position, inflates the balloon to stop the blood flow and then safely deflates and removes it. The whole process takes about 15 minutes, well within the advised 30-minute limit on restricting blood flow to the lower part of the body. Extensive feedback follows, as the trauma team participants and observers analyze every detail of the procedure and work flow to determine if it could be done any faster or more efficiently.

“We thought we should test-pilot it, get feedback and make sure we know what’s needed from an educational perspective,” says Dr. Petrosoniak. “Because it’s not just surgeons or trauma team leaders, it’s a team thing. The nurses need to be just as fast getting the device hooked up so we can get the patients out of the trauma bay as quickly as possible.”

St. Michael’s is the first hospital in Ontario to use the new ER-REBOA catheter (it stands for Resuscitative Endovascular Balloon Occlusion of the Aorta), an advanced version of a catheter first developed during the Korean War. The big difference with the newest version is that it’s thinner, which means it’s easier to insert, gentler on the blood vessel and simpler to use. It’s a step up from the REBOA catheter that St. Michael’s surgeons pioneered the use of in Canada in 2015, which has also been employed successfully in Montreal. “The first use of REBOA in Canada was here in the trauma room,” says Dr. Rezende-Neto. “We have proof, because ‘In the Zone: Lessons from the First Canadian Emergency Department Application of REBOA’ has been accepted for publication in The Canadian Journal of Emergency Medicine.”

While the number one indication for the ER-REBOA catheter is pelvic fracture, Dr. Rezende-Neto is also testing the use of three of the devices together to deal with injury to the retrohepatic vena cava, a large vein that passes behind the liver. “It’s one of the deadliest injuries,” he says, “because the bleeding is rapid and it takes a lot of effort to move the liver out of the way to gain access. The chances of surviving are low. So I came up with a technique using three REBOA catheters to isolate all the blood and then, in a bloodless field, the surgeon can repair the injury.”  Dr. Rezende-Neto says the results of that testing will soon be published in the Panamerican Journal of Trauma, Critical Care and Emergency Surgery.

With the test deemed a success, the ER-REBOA catheter was cleared for use in St. Michael’s trauma bay on Oct. 9. Dr. Petrosoniak estimates that it will probably be used just once or twice a month, but the trauma team is excited by what it could mean for those patients.

“I’m looking forward to using this technology again,” says Dr. Rezende-Neto. “It will make a big difference in the way we control bleeding and stabilize hemorrhaging patients. And it will save lives.”

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