Tracheostomy Is Safe During Extracorporeal Membrane Oxygenation Support

Abstract

Patients receiving extracorporeal membrane oxygenation (ECMO) often require prolonged mechanical ventilation. Providers may be reluctant to perform tracheostomies on patients during ECMO due to their tenuous clinical status and systemic anticoagulation. We report our experience with performing open and percutaneous tracheostomies on patients supported on ECMO from August 2009 to December 2017. Of the 127 patients who underwent tracheostomy during ECMO support, the median age was 42 years (interquartile range [IQR], 29–54), 99 (78%) patients had venovenous (VV) cannulation, 22 (17%) patients had venoarterial (VA) cannulation, and six (5%) patients had hybrid configurations. Percutaneous tracheostomy was performed in 110 (87%) patients. Median-activated partial thromboplastin time (aPTT) at the time of tracheostomy was 47.5 seconds (IQR, 41–57.6 seconds). The median time from ECMO initiation to tracheostomy was 7 days (IQR, 4–11 days). A total of 55 patients (43%) received packed red blood cell (pRBC) transfusions within 48 hours after tracheostomy with a median transfusion of 2 units (IQR, 1–3). There was no procedural mortality. Overall, 88 (69%) patients survived to decannulation and 74 (58%) survived to hospital discharge. Our experience with the largest published series of tracheostomies during ECMO demonstrates that excellent outcomes can be achieved without significant morbidity.

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.…”

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance

“…No definitive evidence exists regarding the relative superiority of any technique in minimising infectivity or complications in patients on anticoagulants, including those given extracorporeal membrane oxygenation support. 35 Whichever technique is used, careful choice of tracheostomy tube and meticulous assessment of position once inserted are essential to minimise risks of later displacement, especially in patients who are obese. 36 Paralysis with neuromuscular blocking drugs eliminates patient movement and coughing, but tachyphylaxis in response to such drugs can occur in patients who are critically ill. 37,38 Neuromuscular monitoring is useful to ensure adequate paralysis during tracheostomy.…”

Multidisciplinary guidance for safe tracheostomy care during the COVID‐19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

“…Many critically ill tracheostomy candidates will be anticoagulated. There is no definitive evidence to guide the best technique to minimise complications in anticoagulated patients [46]. Regardless of technique, complete paralysis is essential and eliminates patient movement and coughing.…”