Safety of Percutaneous Dilatational Tracheostomy During Veno-Venous Extracorporeal Membrane Oxygenation Support in Adults With Severe Respiratory Failure

Abstract

Objectives: To investigate the safety of percutaneous dilatational tracheostomy in severe respiratory failure patients during veno-venous extracorporeal membrane oxygenation support. Design: A single-center, retrospective, observational cohort study. Setting: Tertiary referral severe respiratory failure center, university teaching hospital. Patients: Severe respiratory failure patients consecutively admitted and supported with veno-venous extracorporeal membrane oxygenation between January 2010 and December 2015. Intervention: A bronchoscopy-guided percutaneous dilatational tracheostomy was performed in all cases. Measurements and Main Results: Sixty-five veno-venous extracorporeal membrane oxygenation patients (median [interquartile range] age, 47 yr [interquartile range, 35-59 yr]; 39 males; Acute Physiology and Chronic Health Evaluation-II score, 18 [interquartile range, 17-22] Sequential Organ Failure Assessment score, 10 [interquartile range, 7-16]) underwent percutaneous dilatational tracheostomy. Ten patients (15%) developed one or more major complications. Of these, seven (11%) had major bleeding, and three of these also required circuit change due to extracorporeal membrane oxygenation circuit dysfunction. Two more patients (3.1%) presented with isolated extracorporeal membrane oxygenation circuit dysfunction requiring circuit change, and one developed bilateral pneumothoraces (1.5%) requiring intercostal drain insertion. Patients who developed complications had significantly lower extracorporeal membrane oxygenation postoxygenator Po 2 prior to percutaneous dilatational tracheostomy (45.8 kPa [interquartile range, 36.9–56.5 kPa] vs 57.9 kPa [interquartile range, 45.1–64.2 kPa]; p = 0.019]. On multivariate analysis, including demographic, clinical, biochemical, hematologic variables, and extracorporeal membrane oxygenation circuit functional variables, extracorporeal membrane oxygenation postoxygenator Po 2 was the only independent variable associated with major complications following percutaneous dilatational tracheostomy (beta = –0.09; odds ratio, 0.9; 95% CI, 0.84–0.99; p = 0.03). Conclusions: Percutaneous dilatational tracheostomy is associated with a considerable complication rate in veno-venous extracorporeal membrane oxygenation patients. Preprocedure circuit performance as indicated by extracorporeal membrane oxygenation postoxygenator Po 2 is an independent predictor of major complications following percutaneous dilatational tracheostomy.

Experience of percutaneous tracheostomy in critically ill COVID-19 patients

“…In our study, the median procedure time was 10 11 minutes, which is similar to [22] or slightly longer than other studies [17]. Studies published up to the early 2000s showed that surgical tracheostomy was better for complications [22,23], but later studies showed that there was little difference in complications between surgical and dilated tracheostomy even in ECMO environments [24][25][26]. Regarding complications, in our study bleeding did not occur immediately after tracheostomy but developed within 24 hours after the procedure in two cases (28.6%), both of which were on ECMO support and anticoagulation therapy.…”

“…One case (14.3%) required blood transfusion, and the other (14.3%) was minor bleeding. A study [26] reported that dilated tracheostomy patients had 11% major bleeding requiring blood transfusion and 25% had minor bleeding in the ECMO environment. Therefore, compared with that study [26], our complication rate was similar.…”

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

“…However, in both patient groups they did not reach the anticoagulation target, with values of aPTT/INR of 1.4 and 1.3, respectively (18,22).…”

“…A low post-oxygenating PaO 2 has also been seen in patients who develop major complications including bleeding after percutaneous tracheostomy. One possible hypothesis is that there could be a dysfunction in the circuit causing a circuit related disseminated intravascular coagulopathy (DIC) that is unmasked during the tracheostomy (22).…”

Extracorporeal Strategies in Acute Respiratory Distress Syndrome

“…The main risk factor for major complications found in their study was the postmembrane PaO 2 . 88 One possible explanation for this is that their very restrictive anticoagulation strategy led to more thrombus formation in the membrane, with an ensuing need for circuit change, and membrane thrombus induced hyperfibrinolysis and consumptive coagulopathy leading to more bleeding complications. Finally, fatal air embolism during a tracheostomy has been described in the presence of a dual-lumen cannula in the internal jugular vein, but this seems to be an isolated case.…”