Abstract
IntroductionThe purpose of this study was to assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy.MethodsWe conducted a prospective cohort study in a 10-bed specialist liver intensive care unit of a tertiary university teaching hospital. The study consisted of 60 consecutive patients in need of tracheostomy insertion. Patients were categorized as having refractory coagulopathy if their platelet count was less than or equal to 50 × 109 cells/L or their international normalized ratio (INR) was greater than 1.5 on the day of PDT and for the 72 hours afterward despite clotting support.ResultsTwenty-five patients fulfilled the definition criteria of refractory coagulopathy. There was no significant difference in the number of adverse incidents between groups. Only one patient in the coagulopathy group had a severe bleeding complication, but this did not require open surgical intervention. The rate of clinically relevant early complications in all patients was not higher than expected (n = 7, 12%). Resource utilisation was higher for patients with coagulopathy who received significantly more platelet transfusions over the 3-day period (80 versus 49 units; p = 0.009) and who demonstrated a trend toward increased fresh frozen plasma requirements (p = 0.059). The number of patients requiring platelet transfusion was higher in the coagulopathy group (21/25 versus 20/35; p = 0.029). Hospital survival did not differ between groups.ConclusionPDT is safe and not contraindicated in patients with severe liver disease and refractory coagulopathy.
Highlights
The purpose of this study was to assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy
Resource utilisation was higher for patients with coagulopathy who received significantly more platelet transfusions over the 3-day period (80 versus 49 units; p = 0.009) and who demonstrated a trend toward increased fresh frozen plasma requirements (p = 0.059)
We report the results of a prospective study on the safety of PDT in patients with a wide range of liver disease, or following liver transplantation for acute liver failure, in which the incidence of refractory coagulopathy is high
Summary
The purpose of this study was to assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy. With increasing familiarity with the procedure, indications for PDT have been extended to include patients with previously defined contraindications, such as unfavourable anatomy due to obesity or short neck [3], inability to extend the neck, and coagulopathy or use of anticoagulants [3,4]. Refractory coagulopathy and thrombocytopenia or impaired coagulation is frequently seen in patients with liver disease requiring ICU admission. A comprehensive, prospective risk assessment of PDT in this patient population has not been performed far. We report the results of a prospective study on the safety of PDT in patients with a wide range of liver disease, or following liver transplantation for acute liver failure, in which the incidence of refractory coagulopathy is high
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