Indications, timing and coagulation management for tracheostomy during extracorporeal membrane oxygenation support

Abstract

Extracorporeal membrane oxygenation (ECMO) is used as a short-term life support in patients with cardiac or lung failure refractory to conventional treatment, as a bridge to recovery, to a long-term care system or as a bridge to transplant. Tracheostomy in these patients can be helpful, both as a respiratory weaning strategy, as well as for the cases where it is necessary to keep the mechanical support for a longer period of time. It improves lung function by reducing the dead space, it allows a faster swallowing rehabilitation and oral feeding and a more effective bronchial toilet. Furthermore, the patient can be alert and cooperative with a decrease in analgesic drug consumption and a less haemodynamic impact. Early tracheostomy appears to be associated with shorter weaning times in ECMO patients. The percutaneous technique has been proven to be superior to the surgical one in terms of reduced complications. Management of anticoagulants before performing invasive procedures in patients on ECMO is crucial. However, there are no standardised protocols. It has been shown that tracheostomised patients on ECMO require a higher amount of concentrated red blood cells. Given the link between a worse outcome and an increased blood transfusion rate it may be reasonable to conclude that bleeding in ECMO patients with tracheostomy results in a worse prognosis. However, this finding has not been confirmed in all studies.

Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: a single-center retrospective observational study

“…Tracheostomy is one of the most widely used procedures in ICUs and may be performed at the bedside; however, complications such as bleeding and tracheal or bronchial injury can occur [ 36 ]. As ECMO circuits generally require systemic heparinization and may cause consumptive coagulopathy associated with blood–biomaterial interaction, bleeding complications are the predominant concern and may require temporary removal of the tracheostomy and oral reintubation for hemostasis [ 37 , 38 ]. In the present study, we found that bleeding was the most common complication of tracheostomy, occurring in 13.3% of all patients.…”