Re: Indication and survival bias Threats to Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) outcomes research

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We thank Nunez et al. for their interest in our study. However, we disagree with their comment that our study may comprise the presence of indication bias and survival bias. We excluded patients who were diagnosed with penetrating thoracic injuries, such as cardiovascular injury or hemothorax, for the purpose of removing indication bias. Furthermore, we adjusted for patient characteristics, including the presence of cardiopulmonary arrest on admission, using a propensity score analysis. In regard to survival bias, we performed a sensitivity analysis excluding patients with cardiopulmonary arrest on admission, and the results were similar to those of the main analysis where these patients were included.We agree with the comment by Nunez et al. that the most powerful strategy to mitigate the risk of selection bias is to design and conduct a randomized controlled trial, and we hope that they will do this themselves.Their quotation from Frank Butler is not useful here. We believe that doctors should always reconsider their practice and update their knowledge based on evidence for best practice.

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