Tracheostomy in Patients on Venovenous Extracorporeal Membrane Oxygenation: Is It Safe?

Abstract

Background The anticoagulation and coagulopathy associated with venovenous extracorporeal membrane oxygenation (VV-ECMO) lead to concern for increased risks of tracheostomy. The purpose of this study is to evaluate the safety of tracheostomy in patients on VV-ECMO. Methods Patients admitted between November 2015 and January 2019 to a dedicated intensive care unit for VV-ECMO were reviewed retrospectively. Results 96 patients underwent tracheostomy. Tracheostomy was performed percutaneously in 51 patients, open in 24, and hybrid in 21. 28 patients had postprocedure bleeding which was from the tracheostomy site in 13, the airway in 13, and both in 2. 6 patients had major tracheostomy site bleeding and 3 patients had major airway bleeding. 7 patients had minor tracheostomy site bleeding, 10 patients had minor airway bleeding, and 2 patients had minor bleeding at both. Bleeding complications were more common following percutaneous tracheostomy. Being on anticoagulation prior to tracheostomy was protective. Discussion Bleeding following tracheostomy in VV-ECMO is common with higher bleeding rates observed for those done percutaneously. Most complications were minor. Tracheostomy in patients on VV-ECMO appears safe

Does Tracheostomy Improve Outcomes in Those Receiving Venovenous Extracorporeal Membrane Oxygenation?

“… 8 , 9 , 17 , 18 However, others have found a significant risk of bleeding, with an incidence of major bleeding between 2% and 11% and minor bleeding between 30% and 40%. 7 , 8 , 19 , 20 Other less frequent complications include ECMO circuit dysfunction, 7 pneumothorax, 19 and loss of airway, 21 among others. Adverse events following tracheostomy were rare in our cohort, the most common being bleeding, echoing the findings of previous studies.…”

Early Tracheostomy May Be Performed Safely in Obese COVID-19 Patients Supported on VV-ECMO

“…23 This rate is higher for patients receiving VV-ECMO and has been reported in 29% of patients. 24 In patients with COVID-19, bleeding has been found to be the most common complication of tracheostomy in a systematic review and meta-analysis of these patients. 10 A similar incidence of bleeding was noted in our study population.…”

“…This is comparable to historical rates. 24,25 Additional studies with larger cohorts consisting of both obese and nonobese patients may be necessary to determine any subtle impacts of BMI on outcomes in patients with COVID-19 on VV-ECMO who receive tracheostomies. However, the results of this study did not indicate any association between obesity and either increased bleeding risk or elevated mortality.…”

Tracheostomy Practices and Outcomes in Patients With COVID-19 Supported by Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry

“…Placement of a tracheostomy has been associated with reduced sedation, increased rehabilitation, improved communication, and better clinical outcomes in select patients (7)(8)(9)(10)(11). Placement of a tracheostomy in a patient supported by ECMO incurs the additional risk of bleeding related to anticoagulation and ECMO-associated coagulopathy (12,13). A recent analysis of four large-volume ECMO centers demonstrated that tracheostomies are commonly performed in patients supported by ECMO for severe acute respiratory distress syndrome from 2009 to 2017 (14).…”