Battle Casualties in Korea: Studies of the Surgical Research Team Volume III
Use of an Intra-Aortic Balloon Catheter Tamponade for Controlling lntra-Abdominal Hemorrhage in Man*
Lieutenant Colonel Carl W. Hughes, MC, USA
Everyone is familiar with the practice of manually compressing the exposed aorta for a period of time to control hemorrhage or to combat a hypotensive state during laparotomy. To accomplish this same result in the unexposed aorta, a balloon catheter was tested as an intra-aortic tamponade in two critically injured Korean casualties.
This device (Fig.1) is a number 10, French, non-radio-opaque, Dotter-Lukas 1 balloon catheter, 125 cc. long, with a single lumen communicating with the balloon and equipped with Luer-Lokat the proximal end. The terminal end is occluded and rounded. The balloon begins 1 cm. from the end and is inflated by filling with 20 cc. of sterile normal saline (Fig. 2). It is sterilized by immersion in zephiran solution for 20 minutes.
The catheter was chosen for testing as an intra-aortic tamponade, primarily in those casualties with intra-abdominal hemorrhage whose shock could not be controlled by blood replacement. It was arbitrarily decided that the catheter would be used only in two categories: (1) in moribund patients with evidence of intra-abdominal bleeding in which blood pressure could not be obtained after administration of 10 units of blood; and (2) in moribund patients who were in shock from causes other than blood loss. The assumption was that temporary intra-aortic tamponade would enhance perfusion of the coronary arteries.
Case Reports
Only three patients fitting the first category were observed.
CASE 1. The first patient in this category had a thoraco-abdominal wound. He received approximately 20 units of blood, with progressively increasing distention of the abdomen. The medical officer who was attempting to resuscitate the patient did not think to ask for use of the catheter. Instead, the patient was taken to surgery with an almost unobtainable blood pressure. The bleeding could not be controlled and the patient died on the table. Postmortem examination revealed a laceration of the splenic artery. This case represents the ideal type of case in which use of the catheter might have been lifesaving.
* Previously published in Surgery36: 65, 1954.
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FIGURE1. The catheter with balloon deflated.
FIGURE2. The catheter with balloon inflated with 20 cc. of sterile normal saline solution.
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CASE 2. The second patient was admitted1 hour after injury suffering from grenade wounds of the abdomen, thighs, leg, and foot, and an open comminuted fracture of the right tibia and fibula. He had received 1,000 cc. of plasma prior to admission. His blood pressure on admission was 40 systolic, with a questionable diastolic level; and pulse rate was 120. There was abdominal distention, suggesting uncontrolled intra-abdominal bleeding. In the receiving ward he was given 2,000 cc. of whole blood and 500 cc. of dextran; and his blood pressure was read as 58 systolic, with a questionable diastolic pressure, and pulse was 120. He received 2,500 cc. more of blood without improvement. He was then taken to surgery in a moribund condition; and blood pressure could not be obtained. The level of the diaphragm was estimated by measuring the catheter beside the patient from the common femoral artery to the ninth-rib level in the mid-axillary line. Two umbilical tapes were placed about the common femoral artery and a small transverse slit was made in the artery between the tapes. Through this slit, the catheter was inserted and passed to the level of the diaphragm where the balloon was inflated with 20 cc. of normal saline. His blood pressure was read immediately as 110/70, and his respiration improved. With the catheter in place, the abdomen was opened quickly and from 1,500 to 2,000 cc. of free blood was aspirated. A bleeding, external iliac vein was controlled and a massive laceration of the right lobe of the liver was packed and sutured.
After 15 minutes, the catheter was slowly deflated; then it was moved down to the bifurcation of the aorta and re-inflated to allow oxygenation of the kidneys, liver, and spinal cord. This procedure allowed bleeding at multiple points in the bowel and mesentery and around the celiac axis. Even after bleeding, the patient`s blood pressure was not obtainable and breathing became labored. The catheter was then replaced and inflated at the level of the diaphragm. A blood pressure of 78/50 was obtained; then It rose to 100/54 and respiration improved again. While the catheter at the diaphragmatic level controlled the bleeding and maintained a pressure, It also obscured the bleeding points so that they could no longer be found.
After 10 minutes at this level, the balloon was slowly, partially deflated to expose the bleeding points; but the blood pressure was lost again. Re-inflation of the catheter balloon returned the blood pressure to 96/54; but again it obscured the multiple bleeding points.
As the catheter was repeatedly deflated to demonstrate the bleeding points, the blood pressure continued to fall and the patient`s condition gradually became worse until he died on the operating table. It was feared that prolonged use of the high aortic tamponade might have resulted in liver, renal, or spinal cord damage from anoxia.
During surgery, the patient received 13 additional pints of whole blood, 1 gm. of calcium gluconate and 1,000 cc. of dextran with 4 cc. of norepinephrine.
At autopsy, no damage to the celiac axis was demonstrated. In addition to the damaged liver and iliac vein, however, there were multiple injuries to branches of the splenic artery and mesenteric arteries, as well as a severed spermatic artery.
CASE 3. A third patient, also admitted in coma, was treated without early use of the catheter, but without success. This patient had a gunshot wound through the sternum, abdomen, colon, right internal iliac vein, sacrum, and back, as well as multiple small bowel wounds. He was admitted 2.75 hours before surgery, during which time he received 20 pints of whole blood through three portals, one intra-arterially. His abdomen continued to swell and only at one time during resuscitation was there detectable blood pressure and that was a fleeting beat around 40 systolic.
When taken to the operating
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room, the patient was cyanotic under oxygen, with gasping respiration and unobtainable blood pressure and pulse. The catheter was quickly inserted through a pulseless left common femoral artery and the balloon was inflated at the level of the diaphragm. Blood pressure could not be obtained. Forced respiration was continued and the abdomen was opened almost immediately. Approximately 6,000 cc. of blood were aspirated. A severed internal iliac vein was controlled; but patient died almost simultaneously. He had been given 2,000 cc. additional blood while on the operating table.
Discussion
The catheter was not used in moribund patients of the second category, i. e., those who were in shock from causes other than blood loss. All the patients observed in this group had other complicating factors; and it was felt that these complications would not be overcome by the use of the catheter. While prolonged use of the catheter may result in liver, renal, and cord damage, complications from its use are unknown clinically. Edwards and co-workers found that prolonged experimental use of the balloon for periods of aortic occlusion above the celiac and superior mesenteric arteries resulted in irreversible shock in a high percentage of cases.3 While occlusion of the hepatic vessels has received much attention in the literature recently, conceivably occlusion above the celiac axis may still allow some collateral blood flow to the liver. Twenty minutes has been reported as a maximal time, without showing liver necrosis, for continuous occlusion of the hepatic vessels in normal dogs.4 Other investigations have reported occlusion of the lower thoracic aorta for 45 minutes without complications. This finding, however, was during the resection of an aneurysm.
Probably each of these patients reported would have had a better chance for survival if the catheter had been utilized earlier. Fear of harming a patient, who might have been resuscitated without use of the catheter, caused us to reserve it for only moribund patients in whom there was little hope of recovery. It is believed that at least the first patient, and possibly the other two might have been saved if the intraaortic tamponade had been used earlier. It is felt that, as more experience is gained, the catheter may have a place. in the treatment of patients of the first category. It should be evaluated further for such use.
Summary
An intra-aortic balloon catheter tamponade was utilized in two moribund Korean casualties who had uncontrolled, intra-abdominal hemorrhage. Although both patients expired, the catheter was effective in restoring the blood pressure temporarily in one case. The catheter should be evaluated further, both experimentally and clinically.
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References
1. Dotter, C. T., and Lukas, D. S.: Acutecor pulmonale. Am. J. Physiol. 164: 254, 1951.
2. Sarnoff, S. J.: Personal communication. Harvard School of Public Health, Boston, Massachusetts.
3. Edwards, W. S.; Salter, P. P., Jr., and Carnaggio, V. A.: Intraluminal Aortic Occlusion as a Possible Mechanism for Controlling Massive Intra-Abdominal Hemorrhage. Surgical Forum: 38th Clinical Congress of the American College of Surgeons, 1953,pp. 496-499. W. B. Saunders Company, Philadelphia, 1954.
4. Raffucci, F. L., and Wangensteen, 0. H.: Tolerance of Dogs to Occlusion of the Entire Afferent Vascular Inflow to the Liver. Surgical Forum: 38th Clinical Congress of the American College of Surgeons, 1952, pp. 191-195. W. B. Saunders Company, Philadelphia, 1953.
5. De Bakey, M. E., and Cooley, D. A.: Surgical Treatment of Aneurysm of Abdominal Aorta by Resection and Restoration of Continuity with Hornograft. Surg., Gynec. & Obst. 97:257, 1953.
