Optimal timing of tracheostomy in patients on veno‐venous extracorporeal membrane oxygenation for coronavirus 2019: a case series

Abstract

An early tracheostomy is often considered for patients with veno-venous extracorporeal membrane oxygenation (VV-ECMO).However, there is no consensus on the timing of a tracheostomy in patients on VV-ECMO for coronavirus disease 2019 (COVID-19). The present report described the optimal timing of tracheostomy for these patients. Method:The present study was a single-center case series. We retrospectively reviewed the medical records of nine consecutive patients who underwent tracheostomy either during or after VV-ECMO treatment in our center between January 1, 2020 and December 31, 2020.Results: All the patients received a percutaneous dilatational tracheostomy, which was performed during VV-ECMO in four patients.Three of these patients experienced hemorrhagic complications, and the remaining patient required a circuit change on the day after the operation. Heparin was discontinued 8 h preoperatively and resumed 1-14 h later. The platelet count was below normal in two patients, but no transfusion was performed. APTT was almost normal, and D-dimer was elevated postoperatively. The remaining five patients received a tracheostomy after weaning off VV-ECMO, and no complication was observed. Eight patients were deeply sedated during VV-ECMO to prioritize lung rest and prevent infecting the healthcare workers. Conclusion:In the present study, patients who underwent a tracheostomy during VV-ECMO tended to have more hemorrhagic complications. Because an early tracheostomy during ECMO has little benefit for patients with COVID-19, it should be performed after weaning off VV-ECMO to protect the safety of the healthcare workers concerned.

Extracorporeal Membrane Oxygenation for COVID-19: Collaborative Experience From the Texas Medical Center in Houston With 2 Years Follow-Up

“…Subsequent studies have found higher rates of bleeding complications in patients who underwent tracheostomy while on VV-ECMO. 12 Such bleeding complications were not common in this cohort. Additionally, these patients needed more intensive ICU management for critical illness myopathy, and survivors needed aggressive physical and occupational therapy after ICU discharge.…”

Early Tracheostomy During Extracorporeal Membrane Oxygenation: The Question Is Not When But Who

“…Multiple studies have shown small increases in bleeding but no procedural mortality or need for surgical reintervention. 10,11 Boudreaux et al 1 found similar results.…”

Safety of tracheostomy during extracorporeal membrane oxygenation support: A single‐center experience

“…Kohne et al, in a large study of 2259 COVID‐19 patients on ECMO, suggested that tracheostomy may be a safe procedure in most cases, although bleeding complications may occur 21 . Matsuyoshi et al 27 reported that in a series of 9 patients with COVID‐19, there was a higher bleeding risk in those who underwent a percutaneous tracheostomy (only 4 patients) during V‐V ECMO and suggested performing the procedure after ECMO explantation. In our experience, the majority of patients with COVID‐19 underwent surgical tracheostomy due to a departmental choice to reduce the risk of viral spread, since percutaneous tracheostomy is considered an aerosol‐generating procedure 28,29 .…”