Safety and Putative Benefits of Tracheostomy Tube Placement in Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience

Abstract

Purpose: Patients supported with extracorporeal membrane oxygenation (ECMO) have been reported to have increased sedation requirements. Tracheostomies are performed in intensive care to facilitate longer term mechanical ventilation, reduce sedation, improve patient comfort, secretion clearance, and ability to speak and swallow. We aimed to investigate the safety of tracheostomy (TT) placement on ECMO, its impact on fluid intake, and the use of sedative, analgesic, and vasoactive drugs. Methods: Prospective data were collated for all ECMO patients over a 5.5-year period. Data included the cumulative dose of sedatives and analgesics, fluid balance, inotrope and vasopressor requirements, and number of packed red cell (PRC) units transfused. Data were analyzed to determine the differences in the aforementioned between 5 days pre-TT and post-TT insertion. Results: Thirty-one (22.1%) of 140 patients underwent TT while on ECMO in the study period. Inotrope and vasopressor use was significantly less in the post-TT period compared to pre-TT dose (P value ¼ .01). This was in the setting of Sequential Organ Failure Assessment scores the day before TT placement being significantly greater than those on days 2, 3, and 4. There was a trend toward reduction in analgesic usage in the post-TT period. No major complications of TT were reported. There was no significant difference (P value ¼ .46) in the amount of PRC used post-TT. Conclusions: These data indicate that TT may result in a reduction in vasopressor and inotropic requirement. Data do not suggest increased major bleeding with placement of TT in patients on ECMO. The potential risk and benefits of inserting a TT in ECMO patients need further validation in prospective clinical studies.

Safety and outcomes of percutaneous tracheostomy in coronavirus disease 2019 pneumonitis patients requiring prolonged mechanical ventilation

“…In noncoronavirus disease populations receiving extracorporeal membrane oxygenation, consideration of tracheostomy is recommended for patients deemed to be on a trajectory to recovery, as it has the same perceived benefits of reduced sedation requirements and a lower incidence of ventilatorassociated pneumonia. [22][23][24] In this study, patients receiving extracorporeal membrane oxygenation were selected for tracheostomy according to the same principles as nonextracorporeal membrane oxygenation patients. This pragmatic approach was taken given the current lack of literature surrounding extracorporeal membrane oxygenation in Covid-19 patients.…”

“…Sixty-five patients (86.7 per cent) had been liberated from invasive mechanical ventilation, with a median (interquartile range) post-tracheostomy duration of ventilation of 12 (7-16) days. Moreover, 59 (86.7 per cent) of patients had been successfully decannulated and 44 (68.7 per cent) had been successfully discharged from hospital in a median (interquartile range) duration of 19 (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27) days and 32 (25-39) days, respectively.…”

Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects

“…However, recent retrospective studies reported that tracheostomy can be safely performed in selected ECMO patients in whom benefits outweigh the risks, without an associated increase of transfusions and with a consequent reduction in analgesic, inotropic, and vasopressor usage. 61,62 Larger prospective studies need to confirm these promising results. Finally, we consider ECMO weaning, which may be either before or after weaning from mechanical ventilation, depending on the preference and experience of the team as well as the clinical scenario.…”

Earlier tracheostomy is associated with an earlier return to walking, talking, and eating

“…6 There are studies that encourage clinicians to consider an early tracheostomy even in situations where the risks associated with a tracheostomy, such as bleeding, are especially high. 7 Conversely, randomisation of patients into an early versus a late tracheostomy group has shown that if one waits with performing a tracheostomy (the 'late' group), the patient may end up not needing a tracheostomy at all. 8 However, there is neither a globally accepted consensus that determines optimal timing of tracheostomy, nor consensus on what is considered early vs a late tracheostomy.…”