To evaluate the safety of percutaneous dilatational tracheostomy (PDT) in critically ill patients on an extracorporeal lung assist device requiring therapeutic anticoagulation.
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.
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.
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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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.
Electronic supplementary material
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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
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
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.  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
- Percutaneous tracheostomy
- Extracorporeal lung support
- Respiratory weaning