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Safety of percutaneous dilatational tracheostomy in patients on extracorporeal lung support

Abstract

Purpose

To evaluate the safety of percutaneous dilatational tracheostomy (PDT) in critically ill patients on an extracorporeal lung assist device requiring therapeutic anticoagulation.

Methods

This was a retrospective, observational study on all patients undergoing tracheostomy while on pumpless extracorporeal lung assist or extracorporeal membrane oxygenation in intensive care units of two university hospitals in Germany between 2007 and 2013.

Results

During the study period PDT was performed on 118 patients. The median platelet count, international normalized ratio, and activated partial thromboplastin time before tracheostomy were 126 × 109/L (range 16–617 × 109/L), 1.1 (0.9–2.0) and 49 s (28–117 s), respectively. Seventeen patients (14.4 %) received a maximum of three bags of pooled platelets, and eight patients (6.8 %) received a maximum of four units of fresh frozen plasma before the procedure. In all patients the administration of intravenous heparin was briefly paused periprocedurally. No periprocedural clotting complication within the extracorporeal circuit was observed. Two patients (1.7 %) suffered from procedure-related major bleeding, with one patient requiring conversion to a surgical tracheostomy. Two pneumothoraces (1.7 %) were related to the PDT. One patient (0.8 %) had analgosedation-related hypotension with brief and successful cardiopulmonary resuscitation. Minor bleeding from the tracheostomy site occurred in 37 cases (31.4 %). No fatality was attributable to tracheostomy.

Conclusions

The complication rates of PDT in the patients on extracorporeal lung support were low and comparable to those of other critically ill patients. Based on these results, we conclude that PDT performed by experienced operators with careful optimization of the coagulation state is a relatively safe procedure and not contraindicated for this patient group.

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References

  1. 1.

    Vargas M, Servillo G, Arditi E, Brunetti I, Pecunia L, Salami D et al (2013) Tracheostomy in Intensive Care Unit: a national survey in Italy. Minerva Anestesiol 79:156–164

  2. 2.

    Kluge S, Baumann HJ, Maier C, Klose H, Meyer A, Nierhaus A et al (2008) Tracheostomy in the intensive care unit: a nationwide survey. Anesth Analg 107:1639–1643

  3. 3.

    Freeman BD, Morris PE (2012) Tracheostomy practice in adults with acute respiratory failure. Crit Care Med 40:2890–2896

  4. 4.

    Dempsey GA, Grant CA, Jones TM (2010) Percutaneous tracheostomy: a 6 yr prospective evaluation of the single tapered dilator technique. Br J Anaesth 105:782–788

  5. 5.

    Auzinger G, O’Callaghan GP, Bernal W, Sizer E, Wendon JA (2007) Percutaneous tracheostomy in patients with severe liver disease and a high incidence of refractory coagulopathy: a prospective trial. Crit Care 11:R110

  6. 6.

    Kluge S, Baumann HJ, Nierhaus A, Kroger N, Meyer A, Kreymann G (2008) Safety of percutaneous dilatational tracheostomy in hematopoietic stem cell transplantation recipients requiring long-term mechanical ventilation. J Crit Care 23:394–398

  7. 7.

    Kluge S, Meyer A, Kuhnelt P, Baumann HJ, Kreymann G (2004) Percutaneous tracheostomy is safe in patients with severe thrombocytopenia. Chest 126:547–551

  8. 8.

    Beiderlinden M, Eikermann M, Lehmann N, Adamzik M, Peters J (2007) Risk factors associated with bleeding during and after percutaneous dilational tracheostomy. Anaesthesia 62:342–346

  9. 9.

    Pandian V, Vaswani RS, Mirski MA, Haut E, Gupta S, Bhatti NI (2010) Safety of percutaneous dilational tracheostomy in coagulopathic patients. Ear Nose Throat J 89:387–395

  10. 10.

    Veelo DP, Dongelmans DA, Phoa KN, Spronk PE, Schultz MJ (2007) Tracheostomy: current practice on timing, correction of coagulation disorders and peri-operative management: a postal survey in the Netherlands. Acta Anaesthesiol Scand 51:1231–1236

  11. 11.

    Deppe AC, Kuhn E, Scherner M, Slottosch I, Liakopoulos O, Langebartels G et al (2013) Coagulation disorders do not increase the risk for bleeding during percutaneous dilatational tracheotomy. Thorac Cardiovasc Surg 61:234–239

  12. 12.

    Barton CA, McMillian WD, Osler T, Charash WE, Igneri PA, Brenny NC et al (2012) Anticoagulation management around percutaneous bedside procedures: is adjustment required? J Trauma Acute Care Surg 72:815–820

  13. 13.

    Cabrini L, Bergonzi PC, Mamo D, Dedola E, Colombo S, Morero S et al (2008) Dilatative percutaneous tracheostomy during double antiplatelet therapy: two consecutive cases. Minerva Anestesiol 74:565–567

  14. 14.

    Veelo DP, Vlaar AP, Dongelmans DA, Binnekade JM, Levi M, Paulus F et al (2012) Correction of subclinical coagulation disorders before percutaneous dilatational tracheotomy. Blood Transfus 10:213–220

  15. 15.

    Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM et al (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374:1351–1363

  16. 16.

    Nierhaus A, Frings D, Braune S, Baumann HJ, Schneider C, Wittenburg B et al (2011) Interventional lung assist enables lung protective mechanical ventilation in acute respiratory distress syndrome. Minerva Anestesiol 77:797–801

  17. 17.

    Gattinoni L, Carlesso E, Langer T (2011) Clinical review: extracorporeal membrane oxygenation. Crit Care 15:243

  18. 18.

    Maclaren G, Combes A, Bartlett RH (2012) Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era. Intensive Care Med 38:210–220

  19. 19.

    Nieszkowska A, Combes A, Luyt CE, Ksibi H, Trouillet JL, Gibert C et al (2005) Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med 33:2527–2533

  20. 20.

    Byhahn C, Wilke HJ, Halbig S, Lischke V, Westphal K (2000) Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy. Anesth Analg 91:882–886

  21. 21.

    Freeman BD, Isabella K, Lin N, Buchman TG (2000) A meta-analysis of prospective trials comparing percutaneous and surgical tracheostomy in critically ill patients. Chest 118:1412–1418

  22. 22.

    Delaney A, Bagshaw SM, Nalos M (2006) Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care 10:R55

  23. 23.

    Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL (2009) Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 35:2105–2114

  24. 24.

    Kluge S, Braune SA, Engel M, Nierhaus A, Frings D, Ebelt H et al (2012) Avoiding invasive mechanical ventilation by extracorporeal carbon dioxide removal in patients failing noninvasive ventilation. Intensive Care Med 38:1632–1639

  25. 25.

    Gregoric ID, Harting MT, Kosir R, Patel VS, Ksela J, Messner GN et al (2005) Percutaneous tracheostomy after mechanical ventricular assist device implantation. J Heart Lung Transpl 24:1513–1516

  26. 26.

    Fikkers BG, van Veen JA, Kooloos JG, Pickkers P, van den Hoogen FJ, Hillen B et al (2004) Emphysema and pneumothorax after percutaneous tracheostomy: case reports and an anatomic study. Chest 125:1805–1814

  27. 27.

    Rigby M, Kamat P, Vats A, Heard M (2013) Controlling intrathoracic hemorrhage on ECMO: help from Factor VIIa and Virchow. Perfusion 28(3):201–206

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Conflicts of interest

SB and AN have received lecture honoraria from Novalung GmbH, Talheim, Germany. SK is a member of the advisory board of Novalung GmbH and therefore has received advisor honoraria. All other authors declare that they have no conflicts of interest.

Author information

Correspondence to Stephan Braune.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 14 kb)

Table 1. Clinical characteristics of 10 surgical tracheostomies. ST Surgical tracheostomy, PDT percutaneous dilatational tracheostomy, vvECMO veno-venous extracorporeal membrane oxygenation, vaECMO venoarterial ECMO, PECLA pumpless extracorporeal lung assist

Supplementary material 2 (DOCX 15 kb)

Table 2. Baseline respiratory and haemodynamic parameters prior to PDT, MV invasive mechanical ventilation, ECLA extracorporeal lung assist, PEEP positive end-expiratory pressure, FiO 2 fraction inspired oxygen, PaO 2 partial pressure arterial oxygen, PaCO 2 partial pressure arterial carbon dioxide, NA noradrenaline. Asterisk FiO2 of PECLA sweep gas fixed at 100 % and not adjustable

Supplementary material 3 (DOCX 14 kb)

Table 3. Outcomes of patients with PDT under ECLA. TC Tracheal cannula, ICU intensive care unit.

Attachment 1. Description of the PDT technique used. The standard percutaneous tracheostomy technique applied in both centres by experienced operators was the Ciaglia single-step dilator technique under videobronchoscopic visualization throughout the procedure. All PDT procedures took place under bronchoscopic control and were performed by a senior intensivist who had performed at least 50 procedures, often more than 100. The clinician performing the video bronchoscopy was either a senior intensivist or an experienced respiratory physician, in either case having performed at least 50 video bronchoscopies during PDT. The local protocols did not change throughout the study period. Informed consent for these procedures was obtained from an agent designated under a power of attorney or a family member. All PDTs were performed at the bedside in the ICU. The procedure was performed in all patients following a standardized protocol, as previously described by Byhahn et al. [20] using a commercially available kit. To facilitate access to the trachea, the endotracheal tube in place was withdrawn to the level of the glottic opening, and the trachea was punctured in midline between the 1st and 3rd tracheal cartilage rings. The guidewire was then introduced using Seldinger’s technique. After withdrawal of the needle and introduction of the guiding catheter, the puncture canal was pre-dilated with the small dilator. The Blue Rhino dilator was then advanced over the guidewire and guiding catheter through the soft tissues and into the trachea up to its marking of 38 F external diameter. Immediately after insertion of the tracheostomy tube, a bronchoscopic examination was performed through the tracheostomy tube to confirm the correct position of the tracheostomy tube and to identify injuries or bleeding.

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Braune, S., Kienast, S., Hadem, J. et al. Safety of percutaneous dilatational tracheostomy in patients on extracorporeal lung support. Intensive Care Med 39, 1792–1799 (2013). https://doi.org/10.1007/s00134-013-3023-8

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Keywords

  • Percutaneous tracheostomy
  • Safety
  • Extracorporeal lung support
  • Respiratory weaning
  • ECMO
  • ECLA