Bleeding Complications Associated With Percutaneous Tracheostomy Insertion in Patients Supported With Venovenous Extracorporeal Membrane Oxygen Support: A 10-Year Institutional Experience

Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience

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.

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

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.

Bleeding Hazard of Percutaneous Tracheostomy in COVID-19 Patients Supported With Venovenous Extracorporeal Membrane Oxygenation: A Case Series

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.

Timing of tracheostomy and patient outcomes in critically ill patients requiring extracorporeal membrane oxygenation: a single-center retrospective observational study

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is an integral method of life support in critically ill patients with severe cardiopulmonary failure; however, such patients generally require prolonged mechanical ventilation and exhibit high mortality rates. Tracheostomy is commonly performed in patients on mechanical ventilation, and its early implementation has potential advantages for favorable patient outcomes. This study aimed to investigate the association between tracheostomy timing and patient outcomes, including mortality, in patients requiring ECMO.

METHODS

We conducted a single-center retrospective observational study of consecutively admitted patients who were supported by ECMO and underwent tracheostomy during intensive care unit (ICU) admission at a tertiary care center from April 2014 until December 2021. The primary outcome was hospital mortality. Using the quartiles of tracheostomy timing, the patients were classified into four groups for comparison. The association between the quartiles of tracheostomy timing and mortality was explored using multivariable logistic regression models.

RESULTS

Of the 293 patients treated with ECMO, 98 eligible patients were divided into quartiles 1 (≤ 15 days), quartile 2:16-19 days, quartile 3:20-26 days, and 4 (> 26 days). All patients underwent surgical tracheostomy and 35 patients underwent tracheostomy during ECMO. The complications of tracheostomy were comparable between the groups, whereas the duration of ECMO and ICU length of stay increased significantly as the quartiles of tracheostomy timing increased. Patients in quartile 1 had the lowest hospital mortality rate (19.2%), whereas those in quartile 4 had the highest mortality rate (50.0%). Multivariate logistic regression analysis showed a significant association between the increment of the quartiles of tracheostomy timing and hospital mortality (adjusted odds ratio for quartile increment:1.55, 95% confidence interval 1.03-2.35, p for trend = 0.037).

CONCLUSIONS

The timing of tracheostomy in patients requiring ECMO was significantly associated with patient outcomes in a time-dependent manner. Further investigation is warranted to determine the optimal timing of tracheostomy in terms of mortality.

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

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.

The effect of tracheostomy on extracorporeal membrane oxygenation outcomes

INTRODUCTION

The optimal timing for pursuing tracheostomy in patients with prolonged mechanical ventilation with either veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is a discussion of risk versus benefit. Depending on the etiology, cardiothoracic surgical patients carry some of the highest risk for respiratory failure postprocedure. Given that patients with end-stage cardiopulmonary status may be fraught with substantial comorbidities, it is critically important to manage the risk-benefit profile of performing a tracheostomy procedure on a patient requiring ECMO support. These cohorts have risk factors that may depend on each patient's inflammatory state, lung de-recruitment peri-procedure and postprocedure and bleeding requiring transfusions to name a few. We provide a descriptive analysis of ECMO patients on both VA and VV configurations who survived to hospital discharge receiving tracheostomy either during or after their ECMO course.

METHODS

A retrospective single-institutional study collected all consecutive patients age 18 and above who received any form of ECMO between 2016 and 2020. Five hundred forty-five patients were screened based on having received ECMO. Patients with mixed EMCO modality were excluded due to heterogeneity of disease process. A total of 521 patients received either VV or VA ECMO. A total of 54 patients received tracheostomy and had sufficiently clean data for analysis. Tracheostomy patients were compared based on survival to discharge, tracheostomy surgical complications, ECMO duration, ECMO configuration, inotrope and vasopressor use, transfusion rates, total ventilator days, total days on intravenous sedation, and history of cardiotomy or heart transplant were assessed. Baseline characteristics of race, age, gender, and body mass index (BMI) were also collected.

RESULTS

A total of 54 patients received tracheostomy. Twenty-nine of those patients received tracheostomy during the course of their ECMO, of whom 13 were on VV ECMO, 16 on VA ECMO. Another 25 patients underwent tracheostomy after successful ECMO explant; 8 of those were VV ECMO with the remaining 17 were on VA ECMO before explantation, with mean delay to tracheostomy, 10 and 19 days after explant between both modalities, respectively. A statistically significantly greater proportion of VV ECMO patients received a tracheostomy at any point versus VA ECMO patients (25.93% vs. 8.35%, p ≤ .0001). No statistically significant difference was noted in timing of tracheostomy when stratified by EMCO modality (VA 51.51% after explant vs. VV 38.10% after explant, p = .33). There was a greater frequency of minor tracheostomy complications in patients who were on ECMO at the time of their tracheostomy (p = .014) than in those who received their tracheostomy after being explanted. However, these minor complications did not contribute to a change in survival to hospital discharge (p = .58). Similarly, the small number of major complications (n = 13) did not impair survival to hospital discharge (p = .84). Finally, mean duration of ECMO was longer in those who received tracheostomy during ECMO versus after ECMO. (488.45 vs. 259.72 h, p < .01).

CONCLUSIONS

Tracheostomy is known to increase patient mobility, clinical participation, and overall decrease in sedation use. Pursuing tracheostomy during ECMO is feasible, does not result in major bleeding, and is associated with only minor complications that overall do not decrease survival. While there is an increased duration of ECMO support in the tracheostomy cohort, this may be due to existing patient conditions, and may not be causal. Research is needed to further determine the external patient factors and specific timing to optimize both VV and VA ECMO courses.

CLINICAL IMPLICATIONS

We hope that our analysis will pave the initial pathway for an evidence-based guideline on optimal timing of tracheostomy in ECMO patients, whether initiated during or after ECMO and taking into consideration ECMO configuration, its expected duration, and patient comorbidities.

Tracheostomy management in patients with severe acute respiratory distress syndrome receiving extracorporeal membrane oxygenation: an International Multicenter Retrospective Study

Background

Current practices regarding tracheostomy in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown. Our objectives were to assess the prevalence and the association between the timing of tracheostomy (during or after ECMO weaning) and related complications, sedative, and analgesic use.

Methods

International, multicenter, retrospective study in four large volume ECMO centers during a 9-year period.

Results

Of the 1,168 patients treated with ECMO for severe ARDS (age 48 ± 16 years, 76% male, SAPS II score 51 ± 18) during the enrollment period, 353 (30%) and 177 (15%) underwent tracheostomy placement during or after ECMO, respectively. Severe complications were uncommon in both groups. Local bleeding within 24 h of tracheostomy was four times more frequent during ECMO (25 vs 7% after ECMO, p < 0.01). Cumulative sedative consumption decreased more rapidly after the procedure with sedative doses almost negligible 48–72 h later, when tracheostomy was performed after ECMO decannulation (p < 0.01). A significantly increased level of consciousness was observed within 72 h after tracheostomy in the “after ECMO” group, whereas it was unchanged in the “during-ECMO” group.

Conclusion

In contrast to patients undergoing tracheostomy after ECMO decannulation, tracheostomy during ECMO was neither associated with a decrease in sedation and analgesia levels nor with an increase in the level of consciousness. This finding together with a higher risk of local bleeding in the days following the procedure reinforces the need for a case-by-case discussion on the balance between risks and benefits of tracheotomy when performed during ECMO.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03649-8.

Optimal timing of tracheostomy in patients on veno-venous extracorporeal membrane oxygenation for coronavirus 2019: a case series

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.

Tracheostomy Is Safe During Extracorporeal Membrane Oxygenation Support

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.

Retrospective analysis of open bedside tracheotomies in a German tertiary care university hospital

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.

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

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.

Tracheostomy while on Extracorporeal Membrane Oxygenation: A Comparison of Percutaneous and Open Procedures

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.

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

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.

Pilot Study of Trans-oral Robotic-Assisted Needle Direct Tracheostomy Puncture in Patients Requiring Prolonged Mechanical Ventilation

COVID-19 can induce severe respiratory problems that need prolonged mechanical ventilation in the intensive care unit. While Open Tracheostomy (OT) is the preferred technique due to the excellent visualization of the surgical field and structures, Percutaneous Tracheostomy (PT) has proven to be a feasible minimally invasive alternative. However, PT's limitation relates to the inability to precisely enter the cervical trachea at the exact spot since the puncture is often performed based on crude estimation from anatomical laryngeal surface landmarks. Besides, there is no absolute control of the trajectory and force required to make the percutaneous puncture into the trachea, resulting in inadvertent injury to the cricoid ring, cervical esophagus, and vessels in the neck. Therefore, we hypothesize that a flexible mini-robotic system, incorporating the robotic needling technology, can overcome these challenges by allowing the trans-oral robotic instrument of the cervical trachea. This approach promises to improve current PT technology by making the initial trachea puncture from an “inside-out” approach, rather than an “outside-in” manner, fraught with several technical uncertainties.

Percutaneous dilatational tracheostomy in patients with mechanical circulatory support: Is the procedure safe?

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.

Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome

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.

Risk of bleeding in patients undergoing pulmonary procedures on antiplatelet or anticoagulants: A systematic review

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.