Abstract
BackgroundPercutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT.MethodsPDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed.ResultsIn total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y12 receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02).ConclusionIn this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy.
Highlights
Percutaneous dilatational tracheotomy (PDT) is an established procedure for medium to long-term ventilation of intensive care units (ICU) patients [9, 12, 27]
Our international, multicenter study is the largest investigation to date addressing whether PDT can still be regarded as a safe procedure for ICU patients even in a steadily growing cohort with high risk of bleeding and revealing independent risk factors for bleeding during and after PDT
In the current study, we provide strong evidence to revoke the perception of intensified antithrombotic therapy as contraindication for PDT
Summary
Percutaneous dilatational tracheotomy (PDT) is an established procedure for medium to long-term ventilation of ICU patients [9, 12, 27]. At cardiovascular ICUs critically ill patients receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy, constitute a significant and steadily growing proportion of patients today. Several authors suggested that PDT may be considered as relatively contraindicated in patients with coagulation disorders [19, 23] and there are still some relevant questions to answer [9] Against this background, our international, multicenter study is the largest investigation to date addressing whether PDT can still be regarded as a safe procedure for ICU patients even in a steadily growing cohort with high risk of bleeding and revealing independent risk factors for bleeding during and after PDT. The purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
