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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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Vudatha V, Alwatari Y, Ibrahim G, Jacobs T, Alexander K, Puig-Gilbert C, Julliard W, Shah RD. Percutaneous Dilatational Tracheostomy in a Cardiac Surgical Intensive Care Unit: A Single-Center Experience. J Chest Surg 2023; 56:346-352. [PMID: 37666674 PMCID: PMC10480402 DOI: 10.5090/jcs.23.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 06/29/2023] [Accepted: 07/17/2023] [Indexed: 09/06/2023] Open
Abstract
Background A significant proportion of cardiac surgery intensive care unit (CSICU) patients require long-term ventilation, necessitating tracheostomy placement. The goal of this study was to evaluate the long-term postoperative outcomes and complications associated with percutaneous dilatational tracheostomy (PDT) in CSICU patients. Methods All patients undergoing PDT after cardiac, thoracic, or vascular operations in the CSICU between January 1, 2013 and January 1, 2021 were identified. They were evaluated for mortality, decannulation time, and complications including bleeding, infection, and need for surgical intervention. Multivariable regression models were used to identify predictors of early decannulation and the complication rate. Results Ninety-three patients were identified for this study (70 [75.3%] male and 23 [24.7%] female). Furthermore, 18.3% of patients had chronic obstructive pulmonary disease (COPD), 21.5% had history of stroke, 7.5% had end-stage renal disease, 33.3% had diabetes, and 59.1% were current smokers. The mean time from PDT to decannulation was 39 days. Roughly one-fifth (20.4%) of patients were on dual antiplatelet therapy and 81.7% had anticoagulation restarted 8 hours post-tracheostomy. Eight complications were noted, including 5 instances of bleeding requiring packing and 1 case of mediastinitis. There were no significant predictors of decannulation prior to discharge. Only COPD was identified as a negative predictor of decannulation at any point in time (hazard ratio, 0.28; 95% confidence interval, 0.08-0.95; p=0.04). Conclusion Percutaneous tracheostomy is a safe and viable alternative to surgical tracheostomy in cardiac surgery ICU patients. Patients who undergo PDT have a relatively short duration of tracheostomy and do not have major post-procedural complications.
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Affiliation(s)
- Vignesh Vudatha
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Yahya Alwatari
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - George Ibrahim
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tayler Jacobs
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Kyle Alexander
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Walker Julliard
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Rachit Dilip Shah
- Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA
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Boudreaux JC, Urban M, Thompson SL, Castleberry AW, Moulton MJ, Siddique A. Does Tracheostomy Improve Outcomes in Those Receiving Venovenous Extracorporeal Membrane Oxygenation? ASAIO J 2023; 69:e240-e247. [PMID: 37071756 PMCID: PMC10226464 DOI: 10.1097/mat.0000000000001934] [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: 04/20/2023] Open
Abstract
Patients receiving venovenous extracorporeal membrane oxygenation (VV-ECMO) often require extended periods of ventilation. We examined the role of tracheostomy on outcomes of patients supported with VV-ECMO. We reviewed all patients at our institution who received VV-ECMO between 2013 and 2019. Patients who received a tracheostomy were compared with VV-ECMO-supported patients without tracheostomy. The primary outcome measure was survival to hospital discharge. Secondary outcome measures included length of intensive care unit (ICU) and hospital stay and adverse events related to the tracheostomy procedure. Multivariable analysis was performed to identify predictors of in-hospital mortality. We dichotomized patients receiving tracheostomy into an "early" and "late" group based on median days to tracheostomy following ECMO cannulation and separate analysis was performed. One hundred and fifty patients met inclusion criteria, 32 received a tracheostomy. Survival to discharge was comparable between the groups (53.1% vs. 57.5%, p = 0.658). Predictors of mortality on multivariable analysis included Respiratory ECMO Survival Prediction (RESP) score (odds ratio [OR] = 0.831, p = .015) and blood urea nitrogen (BUN) (OR = 1.026, p = 0.011). Tracheostomy performance was not predictive of mortality (OR = 0.837, p = 0.658). Bleeding requiring intervention occurred in 18.7% of patients following tracheostomy. Early tracheostomy (<7 days from the initiation of VV-ECMO) was associated with shorter ICU (25 vs. 36 days, p = 0.04) and hospital (33 vs. 47, p = 0.017) length of stay compared with late tracheostomy. We conclude that tracheostomy can be performed safely in patients receiving VV-ECMO. Mortality in these patients is predicted by severity of the underlying disease. Performance of tracheostomy does not impact survival. Early tracheostomy may decrease length of stay.
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Affiliation(s)
- Joel C. Boudreaux
- From the College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Marian Urban
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Shaun L. Thompson
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Michael J. Moulton
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Aleem Siddique
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Nebraska
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Elmelliti H, Mutkule DP, Imran M, Shallik NA, Hssain AA, Shehatta AL. Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series. J Cardiothorac Vasc Anesth 2023; 37:73-80. [PMID: 36229290 PMCID: PMC9487148 DOI: 10.1053/j.jvca.2022.09.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Tracheostomy usually is performed to aid weaning from mechanical ventilation and facilitate rehabilitation and secretion clearance. Little is known about the safety of percutaneous tracheostomy in patients with severe COVID-19 supported on venovenous extracorporeal membrane oxygenation (VV-ECMO). This study aimed to investigate the bleeding risk of bedside percutaneous tracheostomy in patients with COVID-19 infection supported with VV-ECMO. DESIGN A Retrospective review of electronic data for routine care of patients on ECMO. SETTING Tertiary, university-affiliated national ECMO center. PARTICIPANTS Patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support. INTERVENTIONS No intervention was conducted during this study. MEASUREMENTS AND MAIN RESULTS Electronic medical records of 16 confirmed patients with COVID-19 who underwent percutaneous tracheostomy while on VV-ECMO support, including patient demographics, severity of illness, clinical variables, procedural complications, and outcomes, were compared with 16 non-COVID-19 patients. The SPSS statistical software was used for statistical analysis. The demographic data were compared using the chi-square test, and normality assumption was tested using the Shapiro-Wilk test. The indications for tracheostomy in all the patients were prolonged mechanical ventilation and sedation management. None of the patients suffered a life-threatening procedural complication within 48 hours. Moderate-to-severe bleeding was similar in both groups. There was no difference in 30- and 90-days mortality between both groups. As per routine screening results, none of the staff involved contracted COVID-19 infection. CONCLUSIONS In this case series, percutaneous tracheostomy during VV-ECMO in patients with COVID-19 appeared to be safe and did not pose additional risks to patients or healthcare workers.
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Affiliation(s)
- Hussam Elmelliti
- Emergency Department, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Muhammad Imran
- Medical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Nabil Abdelhamid Shallik
- Department of Anesthesia, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar; Qatar University, Doha, Qatar; Tanta University, Tanta, Egypt
| | - Ali Ait Hssain
- Medical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Ahmed Labib Shehatta
- Medical Intensive Care Unit, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar; Weill Cornell Medicine - Qatar, Doha, Qatar
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Shahu A, Banna S, Applefeld W, Rampersad P, Alviar CL, Ali T, Luk A, Fajardo E, van Diepen S, Miller PE. Liberation From Mechanical Ventilation in the Cardiac Intensive Care Unit. JACC. ADVANCES 2023; 2:100173. [PMID: 38939038 PMCID: PMC11198553 DOI: 10.1016/j.jacadv.2022.100173] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/18/2022] [Accepted: 11/16/2022] [Indexed: 06/29/2024]
Abstract
The prevalence of respiratory failure is increasing in the contemporary cardiac intensive care unit (CICU) and is associated with a significant increase in morbidity and mortality. For patients that survive their initial respiratory decompensation, liberation from invasive mechanical ventilation (IMV) and the decision to extubate requires careful clinical assessment and planning. Therefore, it is essential for the CICU clinician to know how to assess and manage the various stages of IMV liberation, including ventilator weaning, evaluation of extubation readiness, and provide post-extubation care. In this review, we provide a comprehensive approach to liberation from IMV in the CICU, including cardiopulmonary interactions relative to withdrawal from positive pressure ventilation, evaluation of readiness for and assessment of spontaneous breathing trials, sedation management to optimize extubation, strategies for patients at a high risk for extubation failure, and tracheostomy in the cardiovascular patient.
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Affiliation(s)
- Andi Shahu
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Soumya Banna
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Willard Applefeld
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Penelope Rampersad
- The Tomsich Family Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Connecticut, USA
| | - Carlos L. Alviar
- The Leon H. Charney Division of Cardiovascular Medicine, New York University Langone Medicine Center, New York, New York, USA
| | - Tariq Ali
- Division of Pulmonary and Critical Care, Mayo, Rochester, Minnesota, USA
| | - Adriana Luk
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elaine Fajardo
- Division of Pulmonary, Critical Care, and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - P. Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Tracheostomy Practices and Outcomes in Patients With COVID-19 Supported by Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry. Crit Care Med 2022; 50:1360-1370. [PMID: 35607973 PMCID: PMC9380152 DOI: 10.1097/ccm.0000000000005579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The use of extracorporeal membrane oxygenation (ECMO) in patients with COVID-19 has been supported by major healthcare organizations, yet the role of specific management strategies during ECMO requires further study. We sought to characterize tracheostomy practices, complications, and outcomes in ECMO-supported patients with acute respiratory failure related to COVID-19. DESIGN Retrospective cohort study. SETTING ECMO centers contributing to the Extracorporeal Life Support Organization Registry. PATIENTS Patients 16 years or older receiving venovenous ECMO for respiratory support for: 1) COVID-19 in 2020 and 2021 (through October 2021) and 2) pre-COVID-19 viral pneumonia in 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We identified 7,047 patients who received ECMO support for acute respiratory failure related to COVID-19. A total of 32% of patients were recorded as having a tracheostomy procedure during ECMO, and 51% had a tracheostomy at some point during hospitalization. The frequency of tracheostomy was similar in pre-COVID-19 viral pneumonia, but tracheostomies were performed 3 days earlier compared with patients with COVID-19 (median 6.7 d [interquartile range [IQR], 3.0-12.0 d] vs 10.0 d [IQR, 5.0-16.5 d]; p < 0.001). More patients were mobilized with pre-COVID-19 viral pneumonia, but receipt of a tracheostomy during ECMO was associated with increased mobilization in both cohorts. More bleeding complications occurred in patients who received a tracheostomy, with 9% of patients with COVID-19 who received a tracheostomy reported as having surgical site bleeding. CONCLUSIONS Tracheostomies are performed in COVID-19 patients receiving ECMO at rates similar to practices in pre-COVID-19 viral pneumonia, although later during the course of ECMO. Receipt of a tracheostomy was associated with increased patient mobilization. Overall mortality was similar between those who did and did not receive a tracheostomy.
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Percutaneous dilatational tracheostomy with single use bronchoscopes versus reusable bronchoscopes – a prospective randomized trial (TraSUB). BMC Anesthesiol 2022; 22:90. [PMID: 35366806 PMCID: PMC8976163 DOI: 10.1186/s12871-022-01618-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/16/2022] [Indexed: 11/16/2022] Open
Abstract
Background Apart from conventional reusable bronchoscopes, single-use bronchoscopes (SUB) were recently introduced. Data suggest that SUB might prevent from the risk of cross contamination (i.e. multiresistant pathogens, SARS CoV-2) and save costs. We aimed to investigate visualization, ventilation, handling characteristics, changes in patients’ gas exchange, and costs associated with both types of bronchoscopes during percutaneous dilatational tracheostomy (PDT). Methods In this prospective, randomized, noninferiority study, 46 patients undergoing PDT were randomized 1:1 to PDT with SUB (Ambu aScope) or reusable bronchoscopes (CONV, Olympus BF-P60). Visualization of tracheal structures rated on 4-point Likert scales was the primary end-point. Furthermore, quality of ventilation, device handling characteristics, changes in the patients’ gas exchange, pH values, and costs were assessed. Results Noninferiority for visualization (the primary endpoint) was demonstrated for the SUB group. Mean visualization scores (lower values better) were 4.1 (95% confidence intervals: 3.9;4.3) for SUB vs. 4.1 (4.0;4.2) for CONV. Noninferiority of ventilation (estimated by minute volume and SpO2) during the procedure could be shown as well. Mean score was 2.6 (2.0;3.1) for SUB vs. 2.4 (2.1;2.7) for CONV (lower values better). No significant differences regarding handling (SUB: 1.2 (1.0;1.4), CONV: 1.3 (1.1;1.6)), blood gas analyses and respiratory variables were found. Cost analysis in our institution revealed 93 € per conventional bronchoscopy versus 232.50 € with SUB, not considering an estimate for possible infection due to cross-contamination with the reusable device. Conclusion In our study, visualization and overall performance of the SUB during PDT were noninferior to reusable bronchoscopes. Therefore, PDT with SUB is feasible and should be considered if favored by individual institution’s cost analysis. Trial registration. ClinicalTrials.gov, NCT03952247. Submitted for registration on 28/04/2019 and first posted on 16/05/2019.
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Matsuyoshi T, Shimizu K, Kaneko H, Kohsen D, Suzuki H, Sato Y, Hamaguchi J. Optimal timing of tracheostomy in patients on veno-venous extracorporeal membrane oxygenation for coronavirus 2019: a case series. Acute Med Surg 2021; 8:e662. [PMID: 34026232 PMCID: PMC8127047 DOI: 10.1002/ams2.662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/06/2021] [Accepted: 04/15/2021] [Indexed: 11/17/2022] Open
Abstract
Aim An early tracheostomy is often considered for patients with veno‐venous extracorporeal membrane oxygenation (VV‐ECMO). However, there is no consensus on the timing of a tracheostomy in patients on VV‐ECMO for coronavirus disease 2019 (COVID‐19). The present report described the optimal timing of tracheostomy for these patients. Method The present study was a single‐center case series. We retrospectively reviewed the medical records of nine consecutive patients who underwent tracheostomy either during or after VV‐ECMO treatment in our center between January 1, 2020 and December 31, 2020. Results All the patients received a percutaneous dilatational tracheostomy, which was performed during VV‐ECMO in four patients. Three of these patients experienced hemorrhagic complications, and the remaining patient required a circuit change on the day after the operation. Heparin was discontinued 8 h preoperatively and resumed 1–14 h later. The platelet count was below normal in two patients, but no transfusion was performed. APTT was almost normal, and D‐dimer was elevated postoperatively. The remaining five patients received a tracheostomy after weaning off VV‐ECMO, and no complication was observed. Eight patients were deeply sedated during VV‐ECMO to prioritize lung rest and prevent infecting the healthcare workers. Conclusion In the present study, patients who underwent a tracheostomy during VV‐ECMO tended to have more hemorrhagic complications. Because an early tracheostomy during ECMO has little benefit for patients with COVID‐19, it should be performed after weaning off VV‐ECMO to protect the safety of the healthcare workers concerned.
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Affiliation(s)
- Takeo Matsuyoshi
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
| | - Keiki Shimizu
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
| | - Hitoshi Kaneko
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
| | - Daiyu Kohsen
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
| | - Hiroaki Suzuki
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
| | - Yuichi Sato
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
| | - Jun Hamaguchi
- Department of Critical Care and Emergency Medicine Tokyo Metropolitan Tama Medical Center Fuchu Tokyo Japan
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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.
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10
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Retrospective analysis of open bedside tracheotomies in a German tertiary care university hospital. J Craniomaxillofac Surg 2020; 49:140-145. [PMID: 33423892 DOI: 10.1016/j.jcms.2020.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 11/22/2020] [Accepted: 12/25/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Open surgical tracheotomy performed beside (STB) is a standardized procedure in critical ill patients. The aim of the study was to evaluate perioperative complications and the safety of STB in a tertiary care university hospital setting. MATERIALS AND METHODS Intra- and postoperative complications were retrospectively recorded and associations based on the evaluation of clinical and laboratory parameters were studied using regression analyses. RESULTS A total of 562 patients were included. Early tracheotomy shortened ventilation time after tracheotomy (ventilation before STB ≤ 5 days: mean 9.2 ± 9.1 days; ventilation before STB ≥ 6 days: mean 11.5 ± 10.5 days, p = 0.0001). Overall complications were found in 30/562 cases (5.3%), major complications in 12/562 cases (2.1%). Significant risk factors for overall tracheotomy related complications were higher body mass index (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.07, p = 0.02), lower CRP (OR 0.99, CI 0.99-1.00, p = 0.03), higher INR (OR 5.67, CI 1.27-25.34, p = 0.02), longer duration of operation (OR 1.03, CI 1.00-1.06, p = 0.04) and tracheotomy during extracorporeal membrane oxygenation (ECMO) support (OR 6.26, CI 1.21-32.44, p = 0.03). CONCLUSION STB represents a safe surgical procedure, also suitable for patients with an increased risk profile. Careful evaluation of individual risk factors should be favored to reduce procedure related complications.
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11
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Kelley KM, Galvagno SM, Wallis M, Mazzeffi MA, Deatrick K, Betzold R, Scalea T, Menaker J. Tracheostomy in Patients on Venovenous Extracorporeal Membrane Oxygenation: Is It Safe? Am Surg 2020; 87:1292-1298. [PMID: 33342297 DOI: 10.1177/0003134820979595] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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.
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Affiliation(s)
- Katherine M Kelley
- 21668RA Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Samuel M Galvagno
- 21668RA Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marianne Wallis
- 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Richard Betzold
- 21668RA Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- 21668RA Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay Menaker
- 21668RA Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, MD, USA.,12264University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Tracheostomy while on Extracorporeal Membrane Oxygenation: A Comparison of Percutaneous and Open Procedures. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:266-271. [PMID: 33343028 DOI: 10.1182/ject-2000027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 09/03/2020] [Indexed: 11/20/2022]
Abstract
Although the ideal timing of tracheostomy for critically ill patients is controversial, transitioning from an endotracheal tube can be beneficial. Concerns arise for patients under extracorporeal membrane oxygenation (ECMO) support. Studies have described percutaneous and open tracheostomy approaches for critically ill patients but, to our knowledge, have not compared the two specifically in ECMO patients. This study analyzed safety and aimed to identify if there was a difference in major bleeding or other tracheostomy-associated complications. A single-center retrospective cohort study of all patients who received tracheostomy while on ECMO from July 2013 to May 2019 was completed. The primary endpoint was a significant difference in the incidence of a major bleeding adverse event at 48 hours. Secondary endpoints included differences in the incidence of complications (e.g., procedure-related mortality, ECMO decannulation, tracheal/esophageal injury, and pneumothorax/pneumomediastinum) and survival to discharge. A secondary analysis separated the groups further by comparing those with bleeding events and those without. The study included 27 ECMO patients: 16 (59%) in the percutaneous arm and 11 in the open arm. The median number of ECMO days before tracheostomy was 10 vs. 13, respectively. There were no statistically significant differences between the two groups for major bleeding events (percutaneous 44% vs. open 27%, p = .45), procedure-related mortality, or procedure-related complications. Both percutaneous and open tracheostomies in patients on ECMO require a multidisciplinary approach to minimize adverse effects. Major bleeding does occur, but there was no statistically significant correlation between bleeding events and the type of the tracheostomy approach. Thus, both open and percutaneous tracheostomy approaches have a favorable safety profile.
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Smith MC, Evans PT, Prendergast KM, Schneeberger SJ, Henson CP, McGrane S, Kopp EB, Collins NE, Guillamondegui OD, Dennis BM. Surgical outcomes and complications of bedside tracheostomy in the ICU for patients on ECMO. Perfusion 2020; 37:26-30. [PMID: 33280528 DOI: 10.1177/0267659120979564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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.
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Affiliation(s)
- Michael C Smith
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Parker T Evans
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - C Patrick Henson
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Stuart McGrane
- Department of Anesthesiology, St. Thomas West Hospital, Nashville, TN, USA
| | - Eugene B Kopp
- Department of Nursing, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nina E Collins
- Office of Advanced Practice, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Bradley M Dennis
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Percutaneous dilatational tracheostomy in patients with mechanical circulatory support: Is the procedure safe? TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 28:435-441. [PMID: 32953205 DOI: 10.5606/tgkdc.dergisi.2020.19642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 05/27/2020] [Indexed: 11/21/2022]
Abstract
Background We aimed to investigate the efficacy and safety of percutaneous dilatational tracheostomy procedure following cardiac surgery in patients receiving extracorporeal membrane oxygenation and/or left ventricular assist device. Methods A total of 42 patients (10 males, 32 females; mean age 51±14.6 years; range, 18 to 77 years) who underwent percutaneous dilatational tracheostomy procedure under extracorporeal membrane oxygenation and/or left ventricular assist device support between January 2017 and January 2019 were retrospectively analyzed. Laboratory data, Simplified Acute Physiology Score-II and Sequential Organ Failure Assessment scores, and major and minor complications were recorded. The 30-day and one-year follow-up outcomes of the patients were reviewed. Results Of 42 patients, 17 (42.5%), 14 (33.3%), and 11 (26.2%) received left ventricular assist device, extracorporeal membrane oxygenation, and extracorporeal membrane oxygenation + left ventricular assist device, respectively. During percutaneous dilatational tracheostomy, the laboratory values of the patients were as follows: international normalized ratio, 2.3±0.9; partial thromboplastin time, 59.4±19.5 sec; platelet count, 139.2±65.8×109/L, hemoglobin, 8.8±1.0 g/dL, and creatinine, 1.6±1.0 mg/dL. No peri-procedural mortality, major complication, or bleeding was observed. We observed minor complications including localized stomal ooze in four patients (8.3%) and local stomal infection in three patients (6.2%). Conclusion Our study results suggest that percutaneous dilatational tracheostomy is an effective and safe technique in this patient population.
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15
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Na SJ, Jeon K. Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome. Expert Rev Respir Med 2020; 14:511-519. [PMID: 32089016 DOI: 10.1080/17476348.2020.1734457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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16
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DiChiacchio L, Boulos FM, Brigante F, Raithel M, Shah A, Pasrija C, Mackowick K, Menaker J, Mazzeffi M, Herr D, Kon ZN, Deatrick KB. Early tracheostomy after initiation of venovenous extracorporeal membrane oxygenation is associated with decreased duration of extracorporeal membrane oxygenation support. Perfusion 2020; 35:509-514. [PMID: 32020840 DOI: 10.1177/0267659119898327] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Timing of tracheostomy placement for patients with respiratory failure requiring venovenous extracorporeal membrane oxygenation support is variable and continues to depend on surgeon preference. We retrospectively reviewed all consecutive adult patients supported with peripheral venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome at a single institution with the hypothesis that early tracheostomy (within 7 days of extracorporeal membrane oxygenation initiation) decreases the duration of extracorporeal membrane oxygenation support. The primary endpoint was duration of extracorporeal membrane oxygenation support. Secondary endpoints included mortality, overall and intensive care unit length of stay, duration of mechanical ventilation, and time from extracorporeal membrane oxygenation initiation to liberation from ventilator, intensive care unit discharge, and hospital discharge. Overall and extracorporeal membrane oxygenation-associated hospital costs were compared. A total of 50 patients were identified for inclusion (early n = 21; late n = 29). Baseline characteristics including indices of disease severity were similar between groups. Duration of extracorporeal membrane oxygenation support was significantly shorter in the early tracheostomy group (12 vs. 21 days; p = 0.005). Median extracorporeal membrane oxygenation-related costs were significantly decreased in the early tracheostomy group ($3,624 vs. $5,603, p = 0.03). Early tracheostomy placement is associated with decreased time on extracorporeal membrane oxygenation support and reduced extracorporeal membrane oxygenation-related costs in this cohort. Validation in a prospective cohort or a clinical trial is indicated.
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Affiliation(s)
- Laura DiChiacchio
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Francesca M Boulos
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Francis Brigante
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Maxwell Raithel
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aakash Shah
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chetan Pasrija
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kristen Mackowick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jay Menaker
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.,Lung Rescue Unit, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA
| | - Michael Mazzeffi
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Herr
- Department of Critical Care, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Zachary N Kon
- Department of Cardiothoracic Surgery, New York University-Langone Health, New York, NY, USA
| | - Kristopher B Deatrick
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
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Herman DD, Thomson CC, Brosnhan S, Patel R, Trosini-Desert V, Bilaceroglu S, Poston JT, Liberman M, Shah PL, Ost DE, Chatterjee R, Michaud GC. Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review. Respir Med 2019; 153:76-84. [PMID: 31176274 DOI: 10.1016/j.rmed.2019.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 05/28/2019] [Indexed: 01/22/2023]
Abstract
As many as 25% of all patients undergoing invasive pulmonary procedures are receiving at least one antiplatelet or anticoagulant agent. For those undergoing elective procedures, the decision-making process is uncomplicated and the procedure may be postponed until the antiplatelet or anticoagulant agent may be safely held. However, many invasive pulmonary procedures are semi-elective or emergent in nature in which case a risk-benefit calculation and discussion occur between the provider and patient or surrogate decision-maker. Therefore, it is critical for providers to have an awareness of the risk of bleeding complications with different pulmonary procedures on various antiplatelet and anticoagulant agents. This systematic review summarizes the bleeding complications associated with different pulmonary procedures in patients on various antiplatelet or anticoagulant agents in the literature and reveals a paucity of high-quality evidence across a wide spectrum of pulmonary procedures and antiplatelet or anticoagulant agents. The results of this review can help inform providers of the bleeding risk in these patients to aid in the shared decision-making process and risk vs benefit discussion.
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Affiliation(s)
- D D Herman
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ohio State University, 201L Dorothy M. Davis Heart & Lung Research Institute, 473W. 12th Avenue, Columbus, OH, 43210, USA.
| | - C C Thomson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mount Auburn Hospital, 300 Mt Auburn St #419, Cambridge, MA, 02138, USA
| | - S Brosnhan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, NYU Lagone Health, 550 1st, Avenue New York, New York, 10016, USA
| | - R Patel
- Departments of Critical Care Medicine and Medicine, University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, USA
| | - V Trosini-Desert
- Service de Pneumologie et Réanimation, Unité d'Endoscopie Bronchique, Groupe Hospitalier Pitié Salpétrière, 7 Avenue de la République, 94200, Ivry-sur-Seine, France
| | - S Bilaceroglu
- Department of Pulmonary Medicine, Izmir Dr. Suat Seren Training and Research Hospital for Thoracic Medicine and Surgery, Health Sciences University, 35110, Yenisehir, Izmir, Turkey
| | - J T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - M Liberman
- Division of Thoracic Surgery, CHUM Endoscospic Tracheobronchial and Oesophageal Center, Department of Surgery, University of Montreal, 1560 rue Sherbrooke Est 8e CD - Pavillon Lachapelle, Bureau D, 8051, Montréal, Québec, H2L 4M1, Canada
| | - P L Shah
- Department of Respiratory Medicine, Royal Brompton Hospital, London, United Kingdom National Heart & Lung Institute, Imperial College London, South Kensington Campus, London, SW7 2AZ, UK
| | - D E Ost
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd # 853, Houston, TX, 77030,, USA
| | - R Chatterjee
- Brooke Army Medical Center, 3551 Roger Brooke Dr, Jbsa Ft Sam Houston, Texas, 78234, USA
| | - G C Michaud
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, NYU Lagone Health, 530 1st Avenue, HCC, Suite 5D, New York, NY, 10016, USA
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18
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Lother A, Bode C, Staudacher DL. Tracheostomy in Patients on Extracorporeal Membrane Oxygenation: Is it Really Safe? J Intensive Care Med 2019:885066619851067. [PMID: 31122107 DOI: 10.1177/0885066619851067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Affiliation(s)
- Achim Lother
- 1 Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
- 2 Department of Medicine III (Interdisciplinary Medical Intensive Care), University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- 1 Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
- 2 Department of Medicine III (Interdisciplinary Medical Intensive Care), University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- 1 Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
- 2 Department of Medicine III (Interdisciplinary Medical Intensive Care), University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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19
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Grewal J, Sutt AL, Shekar K, Fraser JF. Steps to Enhance Safety of Tracheostomy on ECMO. J Intensive Care Med 2019:885066619851074. [PMID: 31106651 DOI: 10.1177/0885066619851074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jatinder Grewal
- 1 Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
- 2 University of Queensland, Brisbane, Queensland, Australia
| | - Anna-Liisa Sutt
- 1 Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
- 2 University of Queensland, Brisbane, Queensland, Australia
| | - Kiran Shekar
- 1 Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
- 2 University of Queensland, Brisbane, Queensland, Australia
- 3 Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- 4 Bond University, Gold Coast, Queensland, Australia
| | - John F Fraser
- 1 Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
- 2 University of Queensland, Brisbane, Queensland, Australia
- 3 Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
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20
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Grewal J, Sutt AL, Cornmell G, Shekar K, Fraser J. Safety and Putative Benefits of Tracheostomy Tube Placement in Patients on Extracorporeal Membrane Oxygenation: A Single-Center Experience. J Intensive Care Med 2019; 35:1153-1161. [PMID: 30895877 DOI: 10.1177/0885066619837939] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Patients supported with extracorporeal membrane oxygenation (ECMO) have been reported to have increased sedation requirements. Tracheostomies are performed in intensive care to facilitate longer term mechanical ventilation, reduce sedation, improve patient comfort, secretion clearance, and ability to speak and swallow. We aimed to investigate the safety of tracheostomy (TT) placement on ECMO, its impact on fluid intake, and the use of sedative, analgesic, and vasoactive drugs. METHODS Prospective data were collated for all ECMO patients over a 5.5-year period. Data included the cumulative dose of sedatives and analgesics, fluid balance, inotrope and vasopressor requirements, and number of packed red cell (PRC) units transfused. Data were analyzed to determine the differences in the aforementioned between 5 days pre-TT and post-TT insertion. RESULTS Thirty-one (22.1%) of 140 patients underwent TT while on ECMO in the study period. Inotrope and vasopressor use was significantly less in the post-TT period compared to pre-TT dose (P value = .01). This was in the setting of Sequential Organ Failure Assessment scores the day before TT placement being significantly greater than those on days 2, 3, and 4. There was a trend toward reduction in analgesic usage in the post-TT period. No major complications of TT were reported. There was no significant difference (P value = .46) in the amount of PRC used post-TT. CONCLUSIONS These data indicate that TT may result in a reduction in vasopressor and inotropic requirement. Data do not suggest increased major bleeding with placement of TT in patients on ECMO. The potential risk and benefits of inserting a TT in ECMO patients need further validation in prospective clinical studies.
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Affiliation(s)
- Jatinder Grewal
- 3883Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia
| | - Anna-Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia
| | - George Cornmell
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Kiran Shekar
- Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Bond University, Gold Coast, Queensland, Australia
| | - John Fraser
- Critical Care Research Group, Adult Intensive Care Unit, The Prince Charles Hospital and University of Queensland, Brisbane, Queensland, Australia.,University of Queensland, Brisbane, Queensland, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
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21
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Dimopoulos S, Joyce H, Camporota L, Glover G, Ioannou N, Langrish CJ, Retter A, Meadows CIS, Barrett NA, Tricklebank S. Safety of Percutaneous Dilatational Tracheostomy During Veno-Venous Extracorporeal Membrane Oxygenation Support in Adults With Severe Respiratory Failure. Crit Care Med 2019; 47:e81-e88. [PMID: 30431492 DOI: 10.1097/ccm.0000000000003515] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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 PO2 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 PO2 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 PO2 is an independent predictor of major complications following percutaneous dilatational tracheostomy.
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Affiliation(s)
- Stavros Dimopoulos
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Holly Joyce
- Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Guy Glover
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Nicholas Ioannou
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Christopher J Langrish
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Andrew Retter
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Christopher I S Meadows
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Stephen Tricklebank
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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22
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Juthani BK, Macfarlan J, Wu J, Beman S, Misselbeck TS. Incidence of general surgical procedures in adult patients on extracorporeal membrane oxygenation. J Intensive Care Soc 2018; 20:155-160. [PMID: 31037108 DOI: 10.1177/1751143718801705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose Extracorporeal membrane oxygenation use may predispose patients to developing conditions that require either consultation with a general surgeon or a general surgical procedure. We aimed to evaluate the incidence and outcomes of adult extracorporeal membrane oxygenation patients who underwent general surgical procedure. Methods This was a single institution retrospective study of adult extracorporeal membrane oxygenation patients from 2012 to 2015. Outcomes were compared between patients who underwent general surgical procedure with those that did not. Results Of the 115 patients, 54 (46.9%) required a general surgeon while 42 (36.5%) required a general surgical procedure. No significant differences were observed in mortality (35.7% vs. 46.6%; p = 0.256) and extracorporeal membrane oxygenation-related complications (45.7% vs. 32.5%; p = 0.175). Patients with general surgical procedure had longer extracorporeal membrane oxygenation duration (13 vs. 5 days; p < 0.0001), longer length of stay (36 vs. 15 days; p = 0.0005), more wound infections (19.05% vs. 5.5%; p = 0.029), more urinary tract infections (38.1% vs. 10.96%; p = 0.0006), and more pulmonary emboli (19.05% vs. 5.48%; p = 0.029). In general surgical procedure patients, no difference in bleeding complications was observed regardless of anti-coagulation status (29.4% vs. 16%; p = 0.44). Conclusion Common general surgical procedures are safe and feasible in adult extracorporeal membrane oxygenation patients. Duration of extracorporeal membrane oxygenation was longer for patients requiring general surgical procedure. Despite the common use of anticoagulants, there was no increase in bleeding events in general surgical procedure patients.
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Affiliation(s)
- Biren K Juthani
- Department of Surgery, Danbury Hospital, Danbury, CT, USA.,Lehigh Valley Health Network, Network Office of Research and Innovation, Allentown, PA, USA
| | - Jennifer Macfarlan
- Lehigh Valley Health Network, Network Office of Research and Innovation, Allentown, PA, USA
| | - James Wu
- Lehigh Valley Physician Group, Cardiac and Thoracic Surgery, Allentown, PA, USA
| | - Scott Beman
- Lehigh Valley Physician Group, LVPG General and Bariatric Surgery, Allentown, PA, USA
| | - Timothy S Misselbeck
- Lehigh Valley Health Network, Network Office of Research and Innovation, Allentown, PA, USA
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23
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Harris DD, Shafii AE, Baz M, Tribble TA, Ferraris VA. Increased blood transfusion and its impact in patients having tracheostomy while on extracorporeal membrane oxygenation. Perfusion 2018; 34:143-146. [DOI: 10.1177/0267659118795390] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Tracheostomy has been utilized in combination with venovenous extracorporeal membrane oxygenation (VV-ECMO) to enable early spontaneous breathing and minimize sedation requirements. Tracheostomy has been previously reported to be safe in patients supported on VV-ECMO; however, the impact of tracheostomy on blood loss in VV-ECMO patients is unknown. Methods: We analyzed VV-ECMO patients with and without tracheostomy over a 5-year period. In order to avoid other potential sources of blood loss not related to tracheostomy or ECMO-related blood loss, patients who underwent a recent surgery prior to ECMO or during ECMO (other than tracheostomy) were excluded. Results: Sixty-three patients meeting the inclusion criteria were identified (tracheostomy n=30, non-tracheostomy n=33). Tracheostomy patients were found to require more daily transfusions of red blood cells (RBC) (0.47 [0.20-1.0] vs. 0.23 [0.06-0.40] units/day, p=0.02) and total blood products (0.60 [0.32-1.0] vs. 0.31 [0.10-0.50] units/day, p=0.01). Conclusions: These results suggest that tracheostomy while on VV-ECMO predisposes patients to increased transfusion burden. Based on previous research, this increased transfusion burden could potentially be linked to increased complications and mortality.
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Affiliation(s)
| | - Alexis E. Shafii
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY, USA
| | - Maher Baz
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY, USA
| | - Thomas A. Tribble
- Gill Heart Institute, University of Kentucky Gill Heart Institute, University of Kentucky, Lexington, KY, USA
| | - Victor A. Ferraris
- Department of Surgery, Division of Cardiothoracic Surgery, University of Kentucky, Lexington, KY, USA
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Trester JT, Grawe ES, Hurford WE. Percutaneous Tracheostomy On Veno-Venous Extracorporeal Membrane Oxygenation: Balancing the Risk of Bleeding With Thrombosis. J Cardiothorac Vasc Anesth 2018; 32:1167-1168. [DOI: 10.1053/j.jvca.2017.09.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Indexed: 02/03/2023]
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Clinical Pearls in Venovenous Extracorporeal Life Support for Adult Respiratory Failure. ASAIO J 2018; 64:1-9. [DOI: 10.1097/mat.0000000000000657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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26
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Grensemann J, Eichler L, Kähler S, Jarczak D, Simon M, Pinnschmidt HO, Kluge S. Bronchoscopy versus an endotracheal tube mounted camera for the peri-interventional visualization of percutaneous dilatational tracheostomy - a prospective, randomized trial (VivaPDT). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:330. [PMID: 29284503 PMCID: PMC5747130 DOI: 10.1186/s13054-017-1901-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 11/29/2017] [Indexed: 11/16/2022]
Abstract
Background Percutaneous dilatational tracheostomy (PDT) in critically ill patients often involves bronchoscopic optical guidance. However, this procedure is not without disadvantages. Therefore, we aimed to study a recently introduced endotracheal tube-mounted camera (VivaSightTM-SL tube [VST]; ETView, Misgav, Israel) for guiding PDT. Methods This was a randomized controlled trial involving 46 critically ill patients who received PDT using optical guidance with a VST or with bronchoscopy. The primary outcome measure was visualization of the tracheal structures (i.e., identification and monitoring of the thyroid, cricoid, and tracheal cartilage and the posterior wall) rated on 4-point Likert scales. Secondary measures were the quality of ventilation (before puncture and during the tracheostomy procedure rated on 4-point Likert scales) and blood gases sampled at standardized time points. Results The mean ratings for visualization (lower values better; values given for per-protocol analysis) were 5.4 (95% CI 4.5–6.3) for the VST group and 4.0 (95% CI 4.0–4.0) for the bronchoscopy group (p < 0.001). Mean ventilation ratings were 2.5 (95% CI 2.1–2.9) for VST and 5.0 (95% CI 4.4–5.7) for bronchoscopy (p < 0.001). Arterial carbon dioxide increased to 5.9 (95% CI 5.4–6.5) kPa in the VST group vs. 8.3 (95% CI 7.2–9.5) kPa in the bronchoscopy group (p < 0.001), and pH decreased to 7.40 (95% CI 7.36–7.43) in the VST group vs. 7.26 (95% CI 7.22–7.30) in the bronchoscopy group (p < 0.001), at the end of the intervention. Conclusions Visualization of PDT with the VST is not noninferior to guidance by bronchoscopy. Ventilation is superior with less hypercarbia with the VST. Because visualization is not a prerequisite for PDT, patients requiring stable ventilation with normocarbia may benefit from PDT with the VST. Trial registration ClinicalTrials.gov, NCT02861001. Registered on 13 June 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1901-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Lars Eichler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sophie Kähler
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marcel Simon
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans O Pinnschmidt
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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Charlesworth M, Szentgyorgyi L, Ashworth AD, Feddy L. Tracheostomy Insertion During Venovenous Extracorporeal Membrane Oxygenation: Do the Benefits Outweigh the Risks? J Cardiothorac Vasc Anesth 2017; 32:e69-e70. [PMID: 29336965 DOI: 10.1053/j.jvca.2017.12.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | - Lajos Szentgyorgyi
- Consultant in Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - Alan D Ashworth
- Consultant in Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
| | - Lee Feddy
- Consultant in Cardiothoracic Anaesthesia, Critical Care and ECMO, Wythenshawe Hospital, Manchester, UK
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Kruit N, Valchanov K, Blaudszun G, Fowles JA, Vuylsteke A. Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane Oxygen Support: A 10-Year Institutional Experience. J Cardiothorac Vasc Anesth 2017; 32:1162-1166. [PMID: 29129346 DOI: 10.1053/j.jvca.2017.08.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To evaluate the bleeding complications associated with percutaneous tracheostomy while a patient is receiving venovenous extracorporeal membrane oxygen (VV ECMO) support. DESIGN Retrospective, observational analysis. SETTING Single-center, tertiary, academic institution. PARTICIPANTS All consecutive patients on VV ECMO over a 10 year-period undergoing percutaneous tracheostomy. INTERVENTIONS Percutaneous tracheostomy. MEASUREMENTS AND MAIN RESULTS Fifty percutaneous tracheostomies were performed in patients requiring VV ECMO support over the 10-year period. The authors observed a 40% incidence of bleeding, with 32% of these incidences characterized as minor (self-limiting, localized stomal ooze) and 8% characterized as significant (necessitating surgical control and frequent packing or accompanied by a decrease in hemoglobin >20%). CONCLUSIONS Bleeding is associated with percutaneous tracheostomy and is self-limiting in the majority of patients.
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Affiliation(s)
- Natalie Kruit
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK.
| | - Kamen Valchanov
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Gregoire Blaudszun
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Jo-Anne Fowles
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Pathak V, Allender JE, Grant MW. Management of anticoagulant and antiplatelet therapy in patients undergoing interventional pulmonary procedures. Eur Respir Rev 2017; 26:26/145/170020. [PMID: 28724563 PMCID: PMC9488580 DOI: 10.1183/16000617.0020-2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 05/05/2017] [Indexed: 12/25/2022] Open
Abstract
There has been great progress in antithrombotic therapy over the past several years. Its use has increased with the advent of novel anticoagulants, as these medications do not require frequent blood tests for monitoring. Antithrombotic therapy is aimed at reducing the risk of thromboembolic events in patients with atrial fibrillation, coronary artery disease, deep vein thrombosis, valvular heart disease and pulmonary embolism. These patients are often critically ill and frequently undergo urgent interventions requiring discontinuation of anticoagulant or antiplatelet therapy which can increase the risk of thrombosis; however, continuing these agents can lead to increased risk of haemorrhage. The purpose of this article is to summarise the literature surrounding the safety of using antiplatelet and anticoagulant therapies in patients undergoing interventional pulmonary procedures. Available studies suggest some antithrombotic agents may be used in interventional pulmonary procedureshttp://ow.ly/vSF030bRqjt
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Affiliation(s)
- Vikas Pathak
- Dept of Pulmonary Disease and Critical Care Medicine, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - J Erin Allender
- Dept of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
| | - Mollie W Grant
- Dept of Pharmacy, WakeMed Health and Hospitals, Raleigh, NC, USA
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Grensemann J, Eichler L, Hopf S, Jarczak D, Simon M, Kluge S. Feasibility of an endotracheal tube-mounted camera for percutaneous dilatational tracheostomy. Acta Anaesthesiol Scand 2017; 61:660-667. [PMID: 28493334 DOI: 10.1111/aas.12904] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 03/08/2017] [Accepted: 04/13/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Percutaneous dilatational tracheostomy (PDT) in critically ill patients is often led by optical guidance with a bronchoscope. This is not without its disadvantages. Therefore, we aimed to study the feasibility of a recently introduced endotracheal tube-mounted camera (VivaSight™-SL, ET View, Misgav, Israel) in the guidance of PDT. METHODS We studied 10 critically ill patients who received PDT with a VivaSight-SL tube that was inserted prior to tracheostomy for optical guidance. Visualization of the tracheal structures (i.e., identification and monitoring of the thyroid, cricoid, and tracheal cartilage and the posterior wall) and the quality of ventilation (before puncture and during the tracheostomy) were rated on four-point Likert scales. Respiratory variables were recorded, and blood gases were sampled before the interventions, before the puncture and before the insertion of the tracheal cannula. RESULTS Visualization of the tracheal landmarks was rated as 'very good' or 'good' in all but one case. Monitoring during the puncture and dilatation was also rated as 'very good' or 'good' in all but one. In the cases that were rated 'difficult', the visualization and monitoring of the posterior wall of the trachea were the main concerns. No changes in the respiratory variables or blood gases occurred between the puncture and the insertion of the tracheal cannula. CONCLUSION Percutaneous dilatational tracheostomy with optical guidance from a tube-mounted camera is feasible. Further studies comparing the camera tube with bronchoscopy as the standard approach should be performed.
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Affiliation(s)
- J. Grensemann
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - L. Eichler
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - S. Hopf
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - D. Jarczak
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - M. Simon
- Department of Respiratory Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - S. Kluge
- Department of Intensive Care Medicine; University Medical Center Hamburg-Eppendorf; Hamburg Germany
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Yeo HJ, Yoon SH, Lee SE, Jeon D, Kim YS, Cho WH, Kim D. Safety of Surgical Tracheostomy during Extracorporeal Membrane Oxygenation. Korean J Crit Care Med 2017; 32:197-204. [PMID: 31723634 PMCID: PMC6786719 DOI: 10.4266/kjccm.2017.00059] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/21/2017] [Accepted: 03/21/2017] [Indexed: 12/04/2022] Open
Abstract
Background The risk of bleeding during extracorporeal membrane oxygenation (ECMO) is a potential deterrent in performing tracheostomy at many centers. To evaluate the safety of surgical tracheostomy (ST) in critically ill patients supported by ECMO, we reviewed the clinical correlation between preoperative coagulation status and bleeding complication-related ST during ECMO. Methods From April 1, 2012 to March 31, 2016, ST was performed on 38 patients supported by ECMO. We retrospectively reviewed and analyzed the medical records including complications related to ST. Results Heparin was administered to 23 patients (60.5%) for anticoagulation during ECMO, but 15 patients (39.5%) underwent ECMO without anticoagulation. Of the 23 patients administered anticoagulation therapy, heparin infusion was briefly paused in 13 prior to ST. The median platelet count, international normalized ratio, and activated partial thromboplastin time before ST were 126 × 109/L (range, 46 to 434 × 109/L), 1.2 (range, 1 to 2.3) and 62 seconds (27 to 114.2 seconds), respectively. No peri-procedural clotting complications related to ECMO were observed. Two patients (5.3%) suffering from ST-related major bleeding required surgical hemostasis. Minor bleeding after ST occurred in two cases (5.3%). No significant difference was found according to anticoagulation management (P = 0.723). No fatality was attributable to ST. Conclusions The complication rates of ST in the patients supported by ECMO were low. Therefore, ST performed by an experienced operator, and with careful optimization of coagulation status, is a relatively safe procedure; the use of ST with ECMO should thus not be dismissed on account of the potential for bleeding caused by the administration of anticoagulants.
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Affiliation(s)
- Hye Ju Yeo
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Seong Hoon Yoon
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Seung Eun Lee
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Doosoo Jeon
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Yun Seong Kim
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Woo Hyun Cho
- Department of Pulmonology and Critical Care Medicine, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
| | - Dohyung Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University Yangsan Hospital, Research Institute for Convergence of Biomedical Science and Technology, Yangsan, Korea
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Braune S, Sieweke A, Jarczak D, Kluge S. [Extracorporeal lung support]. Med Klin Intensivmed Notfmed 2017; 112:426-436. [PMID: 28555443 DOI: 10.1007/s00063-017-0304-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 04/18/2017] [Indexed: 01/28/2023]
Abstract
Systems for extracorporeal lung support have recently undergone significant technological improvements leading to more effective and safe treatment. Despite limited scientific evidence these systems are increasingly used in the intensive care unit for treatment of different types of acute respiratory failure. In general two types of systems can be differentiated: devices for extracorporeal carbon dioxide removal (ECCO2R) for ventilatory insufficiency and devices for extracorporeal membrane oxygenation (ECMO) for severe hypoxemic failure. Despite of all technological developments extracorporeal lung support remains an invasive and a potentially dangerous form of treatment with bleeding and vascular injury being the two main complications. For this reason indications and contraindications should always be critically considered and extracorporeal lung support should only be carried out in centers with appropriate experience and expertise.
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Affiliation(s)
- S Braune
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
- IV. Medizinische Klinik, Internistische Intensivmedizin und Notaufnahme, St. Franziskus-Hospital, 48145, Münster, Deutschland
| | - A Sieweke
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - D Jarczak
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Schaefer A, Schneeberger Y, Reichart D, Bernhardt AM, Kubik M, Barten MJ, Wagner FM, Kluge S, Reichenspurner H, Philipp SA. Percutaneous Dilatation Tracheostomy in Patients with Left Ventricular Assist Device and Established Phenprocoumon Therapy. ASAIO J 2016; 62:715-718. [DOI: 10.1097/mat.0000000000000426] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Sen A, Callisen HE, Alwardt CM, Larson JS, Lowell AA, Libricz SL, Tarwade P, Patel BM, Ramakrishna H. Adult venovenous extracorporeal membrane oxygenation for severe respiratory failure: Current status and future perspectives. Ann Card Anaesth 2016; 19:97-111. [PMID: 26750681 PMCID: PMC4900379 DOI: 10.4103/0971-9784.173027] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure was proposed more than 40 years ago. Despite the publication of the ARDSNet study and adoption of lung protective ventilation, the mortality for acute respiratory failure due to acute respiratory distress syndrome has continued to remain high. This technology has evolved over the past couple of decades and has been noted to be safe and successful, especially during the worldwide H1N1 influenza pandemic with good survival rates. The primary indications for ECMO in acute respiratory failure include severe refractory hypoxemic and hypercarbic respiratory failure in spite of maximum lung protective ventilatory support. Various triage criteria have been described and published. Contraindications exist when application of ECMO may be futile or technically impossible. Knowledge and appreciation of the circuit, cannulae, and the physiology of gas exchange with ECMO are necessary to ensure lung rest, efficiency of oxygenation, and ventilation as well as troubleshooting problems. Anticoagulation is a major concern with ECMO, and the evidence is evolving with respect to diagnostic testing and use of anticoagulants. Clinical management of the patient includes comprehensive critical care addressing sedation and neurologic issues, ensuring lung recruitment, diuresis, early enteral nutrition, treatment and surveillance of infections, and multisystem organ support. Newer technology that delinks oxygenation and ventilation by extracorporeal carbon dioxide removal may lead to ultra-lung protective ventilation, avoidance of endotracheal intubation in some situations, and ambulatory therapies as a bridge to lung transplantation. Risks, complications, and long-term outcomes and resources need to be considered and weighed in before widespread application. Ethical challenges are a reality and a multidisciplinary approach that should be adopted for every case in consideration.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Harish Ramakrishna
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, USA
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Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9367464. [PMID: 27127794 PMCID: PMC4835630 DOI: 10.1155/2016/9367464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/03/2016] [Indexed: 01/19/2023]
Abstract
Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.
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Pasin L, Frati E, Cabrini L, Landoni G, Nardelli P, Bove T, Calabro MG, Scandroglio AM, Pappalardo F, Zangrillo A. Percutaneous tracheostomy in patients on anticoagulants. Ann Card Anaesth 2016; 18:329-34. [PMID: 26139737 PMCID: PMC4881694 DOI: 10.4103/0971-9784.159802] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Aims: To determine if percutaneous tracheostomy is safe in critically ill patients treated with anticoagulant therapies. Settings and Design: Single-center retrospective study including all the patients who underwent percutaneous dilatational tracheostomy (PDT) placement over a 1-year period in a 14-bed, cardiothoracic and vascular Intensive Care Unit (ICU). Materials and Methods: Patients demographics and characteristics, anticoagulant and antiplatelet therapies, coagulation profile, performed technique and use of bronchoscopic guidance were retrieved. Results: Thirty-six patients (2.7% of the overall ICU population) underwent PDT over the study period. Twenty-six (72%) patients were on anticoagulation therapy, 1 patient was on antiplatelet therapy and 2 further patients received prophylactic doses of low molecular weight heparin. Only 4 patients had normal coagulation profile and were not receiving anticoagulant or antiplatelet therapies. Overall, bleeding of any severity complicated 19% of PDT. No procedure-related deaths occurred. Conclusions: PDT was proved to be safe even in critically ill-patients treated with anticoagulant therapies. Larger prospective studies are needed to confirm our findings.
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Affiliation(s)
- Laura Pasin
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Anand S, Jayakumar D, Aronow WS, Chandy D. Role of extracorporeal membrane oxygenation in adult respiratory failure: an overview. Hosp Pract (1995) 2016; 44:76-85. [PMID: 26848884 DOI: 10.1080/21548331.2016.1151325] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides complete or partial support of the heart and lungs. Ever since its inception in the 1960s, it has been used across all age groups in the management of refractory respiratory failure and cardiogenic shock. While it has gained widespread acceptance in the neonatal and pediatric physician community, ECMO remains a controversial therapy for Acute Respiratory Distress Syndrome (ARDS) in adults. Its popularity was revived during the swine flu (H1N1) pandemic and advancements in technology have contributed to its increasing usage. ARDS continues to be a potentially devastating condition with significant mortality rates. Despite gaining more insights into this entity over the years, mechanical ventilation remains the only life-saving, yet potentially harmful intervention available for ARDS. ECMO shows promise in this regard by offering less dependence on mechanical ventilation, thereby potentially reducing ventilator-induced injury. However, the lack of rigorous clinical data has prevented ECMO from becoming the standard of care in the management of ARDS. Therefore, the results of two large ongoing randomized trials, which will hopefully throw more light on the role of ECMO in the management of this disease entity, are keenly awaited. In this article we will provide a basic overview of the development of ECMO, the types of ECMO, the pathogenesis of ARDS, different ventilation strategies for ARDS, the role of ECMO in ARDS and the role of ECMO as a bridge to lung transplantation.
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Affiliation(s)
- Suneesh Anand
- a Division of Pulmonary, Critical Care and Sleep Medicine , New York Medical College , Valhalla , NY , USA
| | - Divya Jayakumar
- b Department of Medicine , New York Medical College , Valhalla , NY , USA
| | - Wilbert S Aronow
- b Department of Medicine , New York Medical College , Valhalla , NY , USA.,c Division of Cardiology , New York Medical College , Valhalla , NY , USA
| | - Dipak Chandy
- a Division of Pulmonary, Critical Care and Sleep Medicine , New York Medical College , Valhalla , NY , USA
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Huh JW. Update on the Extracorporeal Life Support. Tuberc Respir Dis (Seoul) 2015; 78:149-55. [PMID: 26175765 PMCID: PMC4499579 DOI: 10.4046/trd.2015.78.3.149] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 02/17/2015] [Accepted: 02/23/2015] [Indexed: 01/19/2023] Open
Abstract
Extracorporeal life support (ECLS) is a type of cardiopulmonary bypass. It is an artificial means of supplying oxygen and removing CO2 on behalf of damaged lungs while patients are recovering from underlying diseases. Recently, the use of ECLS is rapidly increasing as this machine becomes smaller, less invasive and easier to use. In addition, the improvement of clinicians' technique and outcome is increasing their application to patients with acute respiratory distress. In this regard, the purpose of this review is to introduce the physiological principles, risk factors, and advantages of ECLS, clinical rationale for using ECLS, ventilatory strategy during ECLS, which are still causing different opinions, the weaning from ECLS, and the use of anticoagulant.
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Affiliation(s)
- Jin-Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Year in review in Intensive Care Medicine 2013: II. Sedation, invasive and noninvasive ventilation, airways, ARDS, ECMO, family satisfaction, end-of-life care, organ donation, informed consent, safety, hematological issues in critically ill patients. Intensive Care Med 2014; 40:305-19. [PMID: 24458282 DOI: 10.1007/s00134-014-3217-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 01/11/2014] [Indexed: 01/02/2023]
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40
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Extracorporeal life support for adults with severe acute respiratory failure. THE LANCET RESPIRATORY MEDICINE 2013; 2:154-64. [PMID: 24503270 DOI: 10.1016/s2213-2600(13)70197-8] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Extracorporeal life support (ECLS) is an artificial means of maintaining adequate oxygenation and carbon dioxide elimination to enable injured lungs to recover from underlying disease. Technological advances have made ECLS devices smaller, less invasive, and easier to use. ECLS might, therefore, represent an important step towards improved management and outcomes of patients with acute respiratory distress syndrome. Nevertheless, rigorous evidence of the ability of ECLS to improve short-term and long-term outcomes is needed before it can be widely implemented. Moreover, how to select patients and the timing and indications for ECLS in severe acute respiratory distress syndrome remain unclear. We describe the physiological principles, the putative risks and benefits, and the clinical evidence supporting the use of ECLS in patients with acute respiratory distress syndrome. Additionally, we discuss controversies and future directions, such as novel technologies and indications, mechanical ventilation of the native lung during ECLS, and ethics considerations.
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