PULM1: Percutaneous Tracheostomy Associated Bleeding in Patients on Mechanical Circulatory Support

Purpose of Study: The literature supports that performing bedside percutaneous dilational tracheostomy (PDT) on patients receiving therapeutic anticoagulation is associated with a low risk of major bleeding. There has been an increased use of mechanical circulatory support (MCS) in patients with cardiac and respiratory failure, but the majority continue to require prolonged mechanical ventilation. MCS induces a consumptive coagulopathy as well as an acquired von Willebrand syndrome due to bioincompatibility which changes the underlying hemostatic properties resulting in an increased risk of bleeding when performing PDT in patients on MCS and therapeutic anticoagulation. We report our experience and compare the results of performing PDT in patients receiving therapeutic anticoagulation for all types of MCS devices versus non-MCS indications. Methods: We performed a retrospective observational study in which we reviewed a single center database from 2014 to 2020 for patients who underwent a bedside PDT while receiving therapeutic anticoagulation for MCS or a non-MCS indication. Patient demographics and risk factors were evaluated between the study groups. The primary study endpoint was occurrence of any bleeding event in the peri-procedural time frame. Nonparametric statistical methods were used. Wilcoxon rank sum test was used for continuous variables and chi square test was used for categorical variables. A multivariate logistic regression model was also used to compare the variables. Results: A total of 137 patients underwent bedside PDT while receiving therapeutic anticoagulation during the study period. MCS was the primary indication for therapeutic anticoagulation in 56 (38%) patients and 42 (75%) of those patients were extracorporeal membrane oxygenation (ECMO). MCS patients were likely to be male (77% vs 60%, p = 0.04), older (60 vs 55 years, p = 0.03) and diabetic (34% vs 19%, p = 0.04). Prior to PDT, MCS patients had lower platelets (126 vs 184, p < 0.01), but the INR (1.27 vs 1.21, p = 0.13) was comparable. The occurrence of any bleeding event was significantly higher in the MCS group (14% vs 2%, p = 0.01). While all patients with a bleeding event required intervention, none required surgical intervention. Between the two groups, the MCS group required significantly higher post PDT blood transfusions compared to the non-MCS group (7% v. 0% p = 0.02), but the other interventions were similar between the groups. Multivariate analysis showed that only the non-MCS patients had a significantly lower likelihood of bleeding (OR 0.091, 95% CI 0.01 – 0.874). Summary: Although patients requiring PDT while anticoagulated on MCS have a higher occurrence of any bleeding event compared to non-MCS anticoagulated patients, no surgical intervention was required, and all cases were effectively managed medically. This data supports the safety of performing bedside PDT in patient on MCS requiring therapeutic anticoagulation without serious complications.