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Asi K, Gorelik D, Syed T, Thekdi A, Yiu Y. Outcomes for COVID-19 Patients Undergoing Tracheostomy With or Without Extracorporeal Membrane Oxygenation (ECMO). Cureus 2024; 16:e55750. [PMID: 38586787 PMCID: PMC10998924 DOI: 10.7759/cureus.55750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Introduction The coronavirus disease 2019 (COVID-19) pandemic led to the more common use of venovenous (VV) extracorporeal membrane oxygenation (ECMO) for adults with acute respiratory distress syndrome (ARDS). While tracheostomy is generally understood to decrease the risks of prolonged endotracheal intubation, there is conflicting data regarding the benefit of tracheostomy in patients on ECMO. The purpose of this study is to determine whether ECMO cannulation before tracheostomy impacted patient outcomes. Methods This is a retrospective chart review of patients who underwent tracheostomy for COVID-19-related ARDS at a tertiary academic center from March 2020 through March 2022. Patients were separated into two groups based on whether they were cannulated for ECMO prior to tracheostomy. Fisher's exact test or Wilcoxon rank sum test was used to compare the two groups. Results A total of 24 patients were included in the study, with 13 in the ECMO group and 11 in the non-ECMO group. There was no significant difference in age, comorbidities, race, or gender between the groups. Patients on ECMO had a longer time from admission to intubation (seven days vs. three days, p=.002), were more likely to have multiple intubations (54% vs 9%, p= .033), had increased rates of postoperative bleeding (62% vs. 18%, p = .047), and had a higher mortality rate (39% vs. 0%, p= .041). Conclusions ECMO cannulation prior to tracheostomy for COVID-19-related ARDS is associated with poorer outcomes. It is unclear whether this is related to a more severe disease burden in these patients. Further study is needed to evaluate this and guide future management.
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Affiliation(s)
- Karim Asi
- Department of Otorhinolaryngology - Head and Neck Surgery, McGovern Medical School at UTHealth Houston, Houston, USA
| | - Daniel Gorelik
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
| | - Tariq Syed
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
| | - Apurva Thekdi
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
| | - Yin Yiu
- Texas Voice Center, Department of Otolaryngology - Head and Neck Surgery, Houston Methodist Hospital, Houston, USA
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Morosin M, Azzu A, Antonopoulos A, Kuhn T, Anandanadesan R, Garfield B, Aw TC, Ledot S, Bianchi P. Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience. Artif Organs 2023; 47:1762-1772. [PMID: 37610348 DOI: 10.1111/aor.14633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients. METHODS This is a retrospective observational single-center study. RESULTS Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0). CONCLUSIONS Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.
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Affiliation(s)
- Marco Morosin
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Alessia Azzu
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Alexios Antonopoulos
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Timothy Kuhn
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Rathai Anandanadesan
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Benjamin Garfield
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Tuan-Chen Aw
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Stephane Ledot
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
| | - Paolo Bianchi
- Adult Intensive Care Unit, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Anaesthesia, Royal Brompton Hospital, Royal Brompton & Harefield Hospitals (part of Guy's and St Thomas's Foundation Trust), London, UK
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Tamargo IA, Creel-Bulos C, Callahan MC, Miller C, Dave SB, Parrilla GA, Chan JL, Daneshmand MA, Javidfar J. Early Tracheostomy May Be Performed Safely in Obese COVID-19 Patients Supported on VV-ECMO. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:472-478. [PMID: 37864489 DOI: 10.1177/15569845231200226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2023]
Abstract
OBJECTIVE Obese patients with coronavirus disease 2019 (COVID-19)-associated acute respiratory failure (ARDS) often require prolonged intubation. However, data are sparse regarding optimal tracheostomy timing in obese adults with COVID-19 requiring venovenous extracorporeal membrane oxygenation (VV-ECMO). This study retrospectively describes the course of obese patients with COVID-19 who underwent tracheostomy on VV-ECMO between March 2020 and December 2022. METHODS There were 62 participants with a median age of 43 (interquartile range [IQR] 33 to 53) years and a median body mass index of 42 (IQR 34 to 50) kg/m2 who received VV-ECMO for COVID-19-associated ARDS. Of those, 42 underwent tracheostomy on VV-ECMO, and 50% (n = 21) of the 42 patients underwent early (within 14 days of initiated ventilatory support) tracheostomy. RESULTS Among patients who received tracheostomies, the combined respiratory tract and lung parenchymal bleeding rate was 29% (n = 12), but only 7% required surgical intervention for bleeding from the tracheostomy site (n = 3). The hospital length of stay (LOS) was 42 (IQR 36 to 57) days, and mortality rate was 38% (n = 16). Tracheostomy timing was not associated with differences in respiratory tract bleeding, mechanical ventilatory support duration, VV-ECMO support duration, intensive care unit LOS, hospital LOS, mortality, or survival probability. CONCLUSIONS Although an individualized and holistic approach to clinical decision making continues to be necessary, the findings of this study suggest that early tracheostomy may be performed safely in obese patients with COVID-19 on VV-ECMO.
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Affiliation(s)
- Ian A Tamargo
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Casey Miller
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Sagar B Dave
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Gustavo A Parrilla
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Joshua L Chan
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey Javidfar
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Akkanti B, Suarez EE, O'Neil ER, Rali AS, Hussain R, Dinh K, Tuazon DM, MacGillivray TE, Diaz-Gomez JL, Simpson L, George JK, Kar B, Herlihy JP, Shafii AE, Gregoric ID, Masud F, Chatterjee S. Extracorporeal Membrane Oxygenation for COVID-19: Collaborative Experience From the Texas Medical Center in Houston With 2 Years Follow-Up. ASAIO J 2022; 68:1443-1449. [PMID: 36150083 DOI: 10.1097/mat.0000000000001791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Patients with severe refractory hypoxemic respiratory failure may benefit from extracorporeal membrane oxygenation (ECMO) for salvage therapy. The Coronavirus disease 2019 (COVID-19) pandemic offered three high-volume independent ECMO programs at a large medical center the chance to collaborate to optimize ECMO care at the beginning of the pandemic in Spring 2020. Between March 15, 2020, and May 30, 2020, 3,615 inpatients with COVID-19 were treated at the Texas Medical Center. During this time, 35 COVID-19 patients were cannulated for ECMO, all but one in a veno-venous configuration. At hospital discharge, 23 (66%) of the 35 patients were alive. Twelve patients died of vasodilatory shock (n = 9), intracranial hemorrhage (n = 2), and cannulation-related bleeding and multiorgan dysfunction (n = 1). The average duration of ECMO was 13.6 days in survivors and 25.0 days in nonsurvivors ( p < 0.04). At 1 year follow-up, all 23 discharged patients were still alive, making the 1 year survival rate 66% (23/35). At 2 years follow-up, the overall rate of survival was 63% (22/35). Of those patients who survived 2 years, all were at home and alive and well at follow-up.
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Affiliation(s)
- Bindu Akkanti
- From the Divisions of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - Erik E Suarez
- DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Erika R O'Neil
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Department of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Aniket S Rali
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Rahat Hussain
- From the Divisions of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - Kha Dinh
- From the Divisions of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - Divina M Tuazon
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, Texas
| | | | - Jose L Diaz-Gomez
- Department of Anesthesia, Division of CV Anesthesia & Critical Care Medicine, Baylor College of Medicine, Houston, Texas
| | - Leo Simpson
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Joggy K George
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Biswajit Kar
- The Center for Advanced Heart Failure, Department of Advanced Cardiopulmonary Therapies and Transplantation, University of Texas McGovern Medical School, University of Texas Health Sciences Center-Houston, Houston, Texas
| | - J Patrick Herlihy
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Alexis E Shafii
- Department of Cardiovascular Surgery, Baylor St. Luke's Medical Center-Texas Medical Center, Houston, Texas
| | - Igor D Gregoric
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Faisal Masud
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, Texas
| | - Subhasis Chatterjee
- Department of Cardiovascular Surgery, Baylor St. Luke's Medical Center-Texas Medical Center, Houston, Texas
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
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Karampinis I, Al-Shammari A, Hartley P, Patel M, Arachchillage DRJ, Jordan S, Thakuria L, Garfield B, Ledot S, Buderi S. Thoracic surgery in patients on veno-venous extracorporeal membrane oxygenation for COVID-19 associated acute respiratory distress syndrome. Perfusion 2022; 38:837-842. [PMID: 35514055 PMCID: PMC9082097 DOI: 10.1177/02676591221090618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The COVID-19 pandemic has generated a new type of acute respiratory distress syndrome (ARDS) arising as a complication of COVID-19 pneumonia. Extreme cases require the support of extracorporeal membrane oxygenation (ECMO). Here we present the outcomes of patients that underwent surgical tracheostomy or thoracic surgery at a single tertiary centre whilst on ECMO support for COVID-19 related ARDS. METHODS 18 patients requiring thoracic input whilst on ECMO support during the first wave of COVID-19 (March-June 2020) were included. Thoracic surgery was required both for performing surgical tracheostomies in the operating theatre and for treating emergencies arising under the ECMO treatment such as bleeding complications. RESULTS Thirteen patients underwent a surgical tracheostomy, whilst five patients had an invasive thoracic procedure. Anticoagulation was withheld for at least 12 h in the perioperative setting regardless of the indication. One patient was re-operated for haemothorax immediately after the end of the primary operation. 94.5% of the patients were successfully decannulated from ECMO support. Overall 30-day mortality in the cohort was 5.5% (1/18). CONCLUSIONS Thoracic surgeons can play a valuable role in supporting an ECMO unit during the COVID pandemic, by treating ECMO related complications and by safely performing surgical tracheostomies. Withholding anticoagulation in the perioperative window was not associated with increased thromboembolic events and is desirable when interventions or surgery is indicated in this patient cohort to avoid excessive bleeding.
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Affiliation(s)
- Ioannis Karampinis
- Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Academic Thoracic Center, University Medical Center Mainz, Johannes Gutenberg University Mainz, Germany
| | - Abdullah Al-Shammari
- Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Philip Hartley
- Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Mehul Patel
- Division of Critical Care, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Deepa R J Arachchillage
- Division of Hematology, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Centre for Hematology, Imperial College London, London, UK
| | - Simon Jordan
- Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Louit Thakuria
- Division of Critical Care, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ben Garfield
- Division of Critical Care, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Stephane Ledot
- Division of Critical Care, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Silviu Buderi
- Division of Thoracic Surgery, Royal Brompton Hospital, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
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