Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane Oxygen Support: A 10-Year Institutional Experience

Tracheostomy Insertion During Venovenous Extracorporeal Membrane Oxygenation: Do the Benefits Outweigh the Risks?

“…1 The recent study by Kruit et al is therefore extremely welcome. 2 They report a high incidence of bleeding (40%) associated with percutaneous tracheostomy insertion during VV-ECMO albeit with a low incidence of significant bleeding (8%). Systemic, procedural, and pathological bleeding is common during VV-ECMO and just as there are risks and benefits associated with therapeutic anticoagulation, so too there are for percutaneous tracheostomy insertion during VV-ECMO ( Table 1).…”

“…The paper is particularly timely in light of the most recent outbreak. 2 In the review, the authors mention that certain immunocompromised patients theoretically may be at increased risk of mycobacteria infection. Although this has not been studied in this particular subset of heater-cooler related infections, at least 1 recent case report has outlined an infection that may have been influenced by the perioperative use of steroids.…”

“…During a 10-year period, Kruit et al report percutaneous tracheostomy insertion in 50/770 (6.5%) patients receiving VV-ECMO with 4 (8%) experiencing significant bleeding (necessitating surgical control and frequent packing or accompanied by a decrease in hemoglobin 420%). 2 It is not clear whether or not such bleeding directly affects outcomes, such as mortality. Due to the potential benefits listed above, we previously trialled its use at our center in patients deemed appropriate for sedation weaning, spontaneous breathing, and mobilization.…”

Percutaneous Tracheostomy On Veno-Venous Extracorporeal Membrane Oxygenation: Balancing the Risk of Bleeding With Thrombosis

“…The authors conclude that "percutaneous tracheostomy insertion in patients supported with veno-venous ECMO appears to be a safe procedure even when anticoagulation is continued." 4 Interestingly, the retrospective analysis by Kruit et al demonstrates that patients in whom heparin infusions were stopped for less than 4 hours did not have a statistically significant increase in percutaneous tracheostomy-related bleeding complications compared with those in whom anticoagulation was stopped for more than 4 hours. Generalizing this conclusion should be approached with some caution, however, because patients in the bleeding and nonbleeding groups had identical median activated partial thromboplastin time (aPTT) ratios before tracheostomy.…”

“…3 In this issue of the journal, Kruit et al retrospectively describe their own institution's 10-year observational experience with bleeding complications in patients undergoing percutaneous tracheostomy while on V-V ECMO support. 4 They also attempt to identify predictors for bleeding in this patient population and assess the safety of this procedure.…”