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 ¼ .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 ¼ .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.

Introduction: Oxygenation and carbon dioxide removal during venoarterial extracorporeal membrane oxygenation (VA ECMO) depend on a complex interplay of ECMO blood and gas flows, native lung and cardiac function as well as the mechanical ventilation strategy applied.Objective: To determine the association of oxygenation, carbon dioxide removal, and mechanical ventilation practices with in-hospital mortality in patients who received VA ECMO.Methods: Single center, retrospective cohort study. All consecutive patients who received VA ECMO in a tertiary ECMO referral center over a 5-year period were included. Data on demographics, ECMO and ventilator support details, and blood gas parameters for the duration of ECMO were collected. A multivariable logistic time-series regression model with in-hospital mortality as the primary outcome variable was used to analyse the data with significant factors at the univariate level entered into the multivariable regression model.Results: Overall, 52 patients underwent VA ECMO: 26/52 (50%) survived to hospital discharge. The median PaO2 for the duration of ECMO support was 146 mmHg [IQR 131–188] and PaCO2 was 37.2 mmHg [IQR 35.3, 39.9]. Patients who survived to hospital discharge had a significantly lower median PaO2 (117 [98, 140] vs. 154 [105, 212] mmHg, P = 0.04) and higher median PaCO2 (38.3 [36.1, 41.1] vs. 36.3 [34.5, 37.8] mmHg, p = 0.03). Survivors also had significantly lower median VA ECMO blood flow rate (EBFR, 3.6 [3.3, 4.2] vs. 4.3 [3.8, 5.2] L/min, p = < 0.001) and greater measured minute ventilation (7.04 [5.63, 8.35] vs. 5.32 [4.43, 6.83] L/min, p = 0.01). EBFR, PaO2, PaCO2, and minute ventilation, however, were not independently associated with death in a multivariable analysis.Conclusion: This exploratory analysis in a small group of VA ECMO supported patients demonstrated that hyperoxemia was common during VA ECMO but was not independently associated with increased mortality. Survivors also received lower EBFR and had greater minute ventilation, but this was also not independently associated with survival. These findings highlight that interactions between EBFR, PaO2, and native lung ventilation may be more relevant than their individual association with survival. Further research is indicated to determine the optimal ECMO and ventilator settings on outcomes in VA ECMO.

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