The effect of tracheostomy on extracorporeal membrane oxygenation outcomes

Abstract

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 discharg...

Nomogram and Risk Calculator for Postoperative Tracheostomy after Heart Valve Surgery

“…Tracheostomies have been proven to be an effective treatment for various critically ill patients in recent years [ 15 , 17 , 45 ]. For patients undergoing high-risk surgeries, such as cardiovascular procedures, performing tracheostomies at an optimal time point when needed may significantly improve their prognoses [ 3 , 8 , 19 , 20 ].…”

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

“…Additionally, 35 patients (35.7%) underwent tracheostomy during ECMO with no intergroup differences, and our subgroup analysis showed that early tracheostomy was associated with favorable patient outcomes similar to those in subgroups who received tracheostomy during or after ECMO. A recent single-center, retrospective, observational study of 54 patients receiving ECMO in the United States of America compared the complications of tracheostomy during ECMO with those after ECMO removal in detail [ 22 ]. Major complications, such as bleeding requiring intervention and aspiration, were equivalent; however, minor complications, including oozing and mucous plugging, were significantly more frequent in patients undergoing tracheostomy during ECMO (65.5 vs. 32.0%).…”

“…It is generally required that mechanical ventilation is continued during ECMO, and tracheostomy is performed in 18–51% of patients undergoing ECMO [ 16 – 18 ]. Recently, some studies have examined and reported on the procedures and complications associated with tracheostomy [ 19 – 22 ], however, there is a lack of evidence regarding the impact of tracheostomy timing on patient outcomes in patients receiving ECMO.…”

Sepsis Associated with Extracorporeal Membrane Oxygenation

“…11 A recent single-center observational study of 92 patients by Grasselli et al, receiving ECMO (87% venovenous ECMO), in whom infections were systematically and prospectively identified through the application of well-established clinical practice guidelines, 12,13 reported high rates of NIs (55%), with VAP and multidrug-resistant organisms, found to be common. 14 Those who acquired NIs had higher overall mortality, longer mechanical ventilation, and ECMO durations, and spent longer in the ICU. Younger age (2-35 years old) was independently associated with a higher risk of NIs.…”

“…• Consider early tracheostomy in adult patients. 14 • Early and complete enteral nutrition should be used.…”