Survival outcomes and predictors of mortality,re-bleeding and complications for acute severe variceal bleeding requiring balloon tamponade

BACKGROUND Acute severe variceal bleeding(AVB)refractory to medical and endoscopic therapy is infrequent but associated with high mortality.Historical cohort studies from 1970-1980s no longer represent the current population as balloon tamponade is no longer first-line therapy for variceal bleeding;treatments including vasoactive therapies,intravenous antibiotics,endoscopic variceal band ligation are routinely used,and there is improved access to definitive treatments including transjugular intrahepatic portosystemic shunts.However,only a few studies from the current era exist to describe the practice of balloon tamponade,its outcomes,and predictors with a requirement for further updated information.AIM To describe current management of AVB requiring balloon tamponade and identify the outcomes and predictors of mortality,re-bleeding and complications.METHODS A retrospective multi-centre cohort study of 80 adult patients across two large tertiary health networks from 2008 to 2019 in Australia who underwent balloon tamponade using a Sengstaken-Blakemore tube(SBT)were included for analysis.Patients were identified using coding for balloon tamponade.The primary outcome of this study was all-cause mortality at 6 wk after the index AVB.Secondary outcomes included re-bleeding during hospitalisation and complications of balloon tamponade.Predictors of these outcomes were determined using univariate and multivariate binomial regression.RESULTS The all-cause mortality rates during admission and at 6-,26-and 52 wk were 48.8%,51.2%and 53.8%,respectively.Primary haemostasis was achieved in 91.3%and re-bleeding during hospitalisation occurred in 34.2%.Independent predictors of 6 wk mortality on multivariate analysis included the Model for Endstage Liver disease(MELD)score(OR 1.21,95%CI 1.06-1.41,P=0.006),advanced hepatocellular carcinoma(OR 11.51,95%CI 1.61-82.20,P=0.015)and re-bleeding(OR 13.06,95%CI 3.06-55.71,P<0.001).There were no relevant predictors of re-bleeding but a large proportion in which this occurred did not survive 6 wk(76.0%vs 24%).Although mucosal trauma was the most common documented complication after SBT insertion(89.5%),serious complications from SBT insertion were uncommon(6.3%)and included 1 patient who died from oesophageal perforation.CONCLUSION In refractory AVB,balloon tamponade salvage therapy is associated with high rates of primary haemostasis with low rates of serious complications.Re-bleeding and mortality however,remain high.

Control of Postpartum Haemorrhage with Uterine Balloon Tamponade Using Foley Catheter in a Rural Mission Hospital in Ebonyi State, Southeast Nigeria

Background: Postpartum haemorrhage is the leading cause of maternal deaths worldwide, the majority of which occur in low resource settings. Uterine atony is the commonest cause of postpartum haemorrhage. Uterine balloon tamponade (UBT) is an effective method of treating refractory postpartum haemorrhage. Aim: Commercial UBT devices are often not affordable and not readily available in rural settings. The aim of this paper is to report on three cases of postpartum haemorrhage successfully managed with uterine balloon tamponade using Foley catheters. Case Reports: We report on three patients with major obstetric haemorrhage from uterine atony who were successfully managed with uterine balloon tamponade using Foley’s urethral catheter. The first two patients had primary postpartum haemorrhage while the third patient had significant bleeding during the surgical evacuation of the uterus for a molar pregnancy. In each case, uterine bleeding was refractory to pharmacologic uterotonics. They all had uterine tamponade with a Foley catheter with the dramatic resolution of their bleeding. Conclusion: In well-selected patients, uterine balloon tamponade with Foley catheter is cheap, arrests bleeding and prevents clinical deterioration among women with refractory postpartum haemorrhage, especially in low resource settings where commercial balloon tamponade may not be available or affordable.

Implementing uterine balloon tamponade(UBT)device for immediate postpartum hemorrhage management:Leveraging resource allocation and highlighting noteworthy experiences

Background The use of uterine balloon tamponade(UBT)devices for intrauterine packing and management of vaginal bleeding by uterine atony has shown promising results in improving the quality of care and reducing maternal mortality.Objective This report aims to provide an overview of progress made in implementing UBT devices in northern Cote d'Ivoire.Material and methods A four-year retrospective study was conducted in the North-East(163,645),North-Center(351,909),and North-West(57,983).In 2017,UBT was adopted by members of the healthcare system.Subsequently,5 national and 32 regional trainers have been trained.The training session was a theoretical and practical program with a low simulator.UBT is a male condom tied to a urinary catheter,filled with liquid.Positive outcomes included stopping bleeding,avoiding the need for surgery,and preventing maternal deaths(MD).In 2018,3,515 UBT devices were distributed.In 2019,monitoring tools and transmission circuits of the data were validated.In 2020,the collection of data and local manufacturing was launched.Results During the process,978 health workers,mainly midwife(52.0%)and nurses(32.2%)out of the 1,295 assigned were trained.The number of trained individuals decreased from 209 in 2019 to 160 in 2020.A total of 1,715 UBT devices were locally manufactured,adding to the existing gift of 5,080 devices,with total availability of 6,795.The distribution of devices increased from 2017 to 2019 but decreased in 2020.Success rates increased from 87.3%in 2017(365/418)to 95.0%in 2019(556/585)and slightly decreased in 2020 to 98.0%(681/695).Adverse outcomes(144/2,193),included MD(35/2,193)and medical evacuation to the surgical center(109/2,193).Conclusion The implementation of UBT in northern Cote d'Ivoire successfully reduced maternal death rates caused by immediate post-partum hemorrhage(IPPH).However,to ensure sustainability,further improvements are needed,including increased monitoring,ongoing training,and device availability.