Surgical outcomes and complications of bedside tracheostomy in the ICU for patients on ECMO

Abstract

Objective: Extracorporeal membrane oxygenation (ECMO) is increasingly employed in the management of patients with severe cardiac and pulmonary dysfunction. Patients commonly require tracheostomy for ventilator liberation. Though bedside percutaneous tracheostomy is commonly performed, it has the potential for increased complications, both surgical and with the ECMO circuit. We examined surgical outcomes of bedside percutaneous tracheostomy in the ECMO population. Methods: Patients were identified from an institutional database for bedside procedures. Demographics and data on complications were recorded. Descriptive statistics were calculated. Results: 37 patients on ECMO at the time of tracheostomy were identified. Median age and BMI were 43.2 and 28.0, respectively. 33 patients (89%) were on VV ECMO, and 4 (11%) were on VA ECMO. All were on anticoagulation prior to tracheostomy, which was held for 4 h before and after the procedure in all cases. There were no procedure-related deaths or airway losses. No patients experienced periprocedural clotting events of their ECMO circuit or oxygenator within 24 h. 3 patients (8%) required reintervention (re-exploration or bronchoscopy) for bleeding. Four other patients (10%) had minor bleeding controlled with packing. One patient had pneumomediastinum which resolved without intervention, and one had an occlusion of their tracheostomy which was treated with tracheostomy exchange. Conclusions: Bedside percutaneous tracheostomy is feasible for patients on ECMO. Further study is needed to determine specific risk factors for complications and means to mitigate these. Bedside percutaneous tracheostomy may be considered as part of the management of patients on ECMO to help facilitate liberation from mechanical support.

Early Tracheostomy for ARDS Patients Supported by Venovenous Extracorporeal Membrane Oxygenation Is Associated With A Decreased Incidence of Ventilator-Associated Pneumonia, Duration of Extracorporeal Membrane Oxygenation and Mechanical Ventilation: Experience From A Single-Center Retrospective Cohort.

“…The safety of tracheostomy during ECMO support is another important issue. This study showed that the rate of tracheostomy-related local bleeding was approximately 30%, which is similar to previous reports (9,10,12). In addition, there was no signi cant difference in bleeding between the ET and DT groups.…”

“…Less than 15% of the centers reported that they would perform a tracheostomy within one week after the onset of ECMO support(8). Although several single-center studies reported potential complications of tracheostomy during ECMO support, such as minor bleeding (with an incidence rate of approximately 10-30%), major bleeding (2-11%), pneumothorax (approximately 1.5%), ECMO circuit dysfunction (0 to 3.1%), and analgosedation-related hypotension (less than 1%) (9)(10)(11), a recent international multicenter retrospective study conducted over a 9-year period and including 1,168 severe ARDS patients treated with ECMO reported that major complications were uncommon and that the rate of minor complications was acceptable (12).…”

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.…”

“…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.…”

Apneic Tracheostomy in COVID-19 Patients on Veno-Venous Extracorporeal Membrane Oxygenation

“…Patients who require V-V ECMO routinely need tracheostomy; these are the sickest patients and require tracheostomy early and systematically [ 8 , 9 , 10 , 11 ]. Turning the ventilator to ‘standby’ mode and allowing decompression of the breathing circuit might lead to de-recruitment and desaturation, but aerosolization is minimized.…”