title: Safety of percutaneous dilatational tracheostomy in patients on extracorporeal lung support.
abstract: OBJECTIVE
  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 × 10(9)/L (range 16-617 × 10(9)/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.
authors.affiliation: Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany, sbraune@uke.de.
authors.forename: Stephan
authors.initials: S
authors.lastname: Braune
authors.forename: Susanne
authors.initials: S
authors.lastname: Kienast
authors.forename: Johannes
authors.initials: J
authors.lastname: Hadem
authors.forename: Olaf
authors.initials: O
authors.lastname: Wiesner
authors.forename: Dominic
authors.initials: D
authors.lastname: Wichmann
authors.forename: Axel
authors.initials: A
authors.lastname: Nierhaus
authors.forename: Marcel
authors.initials: M
authors.lastname: Simon
authors.forename: Tobias
authors.initials: T
authors.lastname: Welte
authors.forename: Stefan
authors.initials: S
authors.lastname: Kluge
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D016913:Blood Component Transfusion; D016638:Critical Illness; D015199:Extracorporeal Membrane Oxygenation / Q000009:adverse effects*; D005260:Female; D005858:Germany; D006801:Humans; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D061214:Patient Safety; D010976:Platelet Count; D011183:Postoperative Complications / Q000209:etiology / Q000517:prevention & control; D019106:Postoperative Hemorrhage / Q000209:etiology / Q000517:prevention & control*; D012189:Retrospective Studies; D014139:Tracheostomy / Q000009:adverse effects / Q000379:methods*; D015300:Ventilator Weaning / Q000379:methods*; D055815:Young Adult
chemical_list: D000925:Anticoagulants
references.citation: Crit Care Med. 2005 Nov;33(11):2527-33
references.pmid: 16276177
references.citation: Chest. 2000 Nov;118(5):1412-8
references.pmid: 11083694
references.citation: Crit Care. 2007;11(5):R110
references.pmid: 17922915
references.citation: Minerva Anestesiol. 2011 Aug;77(8):797-801
references.pmid: 21730927
references.citation: J Trauma Acute Care Surg. 2012 Apr;72(4):815-20; quiz 1124-5
references.pmid: 22491591
references.citation: Ear Nose Throat J. 2010 Aug;89(8):387-95
references.pmid: 20737378
references.citation: Crit Care. 2006;10(2):R55
references.pmid: 16606435
references.citation: Blood Transfus. 2012 Apr;10(2):213-20
references.pmid: 22337277
references.citation: Thorac Cardiovasc Surg. 2013 Apr;61(3):234-9
references.pmid: 23344764
references.citation: Anesth Analg. 2000 Oct;91(4):882-6
references.pmid: 11004042
references.citation: Intensive Care Med. 2012 Oct;38(10):1632-9
references.pmid: 22836139
references.citation: Lancet. 2009 Oct 17;374(9698):1351-63
references.pmid: 19762075
references.citation: Perfusion. 2013 May;28(3):201-6
references.pmid: 23201816
references.citation: Chest. 2004 Aug;126(2):547-51
references.pmid: 15302743
references.citation: Acta Anaesthesiol Scand. 2007 Oct;51(9):1231-6
references.pmid: 17850564
references.citation: Br J Anaesth. 2010 Dec;105(6):782-8
references.pmid: 20813838
references.citation: Minerva Anestesiol. 2013 Feb;79(2):156-64
references.pmid: 23174923
references.citation: Chest. 2004 May;125(5):1805-14
references.pmid: 15136394
references.citation: J Crit Care. 2008 Sep;23(3):394-8
references.pmid: 18725046
references.citation: Intensive Care Med. 2012 Feb;38(2):210-20
references.pmid: 22147116
references.citation: Crit Care. 2011;15(6):243
references.pmid: 22188792
references.citation: Crit Care Med. 2012 Oct;40(10):2890-6
references.pmid: 22824938
references.citation: Anaesthesia. 2007 Apr;62(4):342-6
references.pmid: 17381569
references.citation: Intensive Care Med. 2009 Dec;35(12):2105-14
references.pmid: 19768656
references.citation: Anesth Analg. 2008 Nov;107(5):1639-43
references.pmid: 18931225
references.citation: Minerva Anestesiol. 2008 Oct;74(10):565-7
references.pmid: 18854797