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Tracheostomy Practices and Outcomes in Children During Respiratory Extracorporeal Membrane Oxygenation
Joseph G Kohne1,2, Graeme MacLaren3,4, Erica Rider1
1Division of Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, MI.
Insights
Tracheostomy during extracorporeal membrane oxygenation (ECMO) is uncommon in children and carries a bleeding risk. Early tracheostomy (before 14 days) in pediatric ECMO patients was associated with better survival rates.
Area of Science:
- Pediatric Critical Care Medicine
- Cardiopulmonary Support
- Surgical Interventions
Background:
- Prolonged extracorporeal membrane oxygenation (ECMO) support in children may benefit from tracheostomy for rehabilitation.
- Tracheostomy during ECMO carries risks, particularly hemorrhagic complications.
Purpose of the Study:
- To investigate tracheostomy practices and outcomes in children supported by ECMO.
- To inform decision-making regarding tracheostomy during pediatric ECMO.
Main Methods:
- Retrospective cohort study of children (birth to 18 years) receiving ECMO for >= 7 days for respiratory failure.
- Data from ECMO centers contributing to the Extracorporeal Life Support Organization registry (2015-2019).
Main Results:
- Tracheostomy during ECMO was performed in 2.6% of 3,685 children.
- Surgical site bleeding occurred in 26% of tracheostomized children (12% post-procedure).
- Tracheostomy before 14 days was associated with younger patients and improved survival (22% vs 43% mortality).
Conclusions:
- Tracheostomies during pediatric ECMO are infrequent.
- Hemorrhagic complications are a significant risk.
- Placing tracheostomies later in the course of ECMO may indicate a secondary strategy with poorer outcomes.
Objectives:
Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however, the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making.
Design:
Retrospective cohort study.
Setting:
ECMO centers contributing to the Extracorporeal Life Support Organization registry.
Patients:
Children from birth to 18 years who received ECMO support for greater than or equal to 7 days for respiratory failure from January 1, 2015, to December 31, 2019.
Interventions:
None.
Measurements And Main Results:
Three thousand six hundred eighty-five children received at least 7 days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (interquartile range [IQR], 9.3-19.9 d), and inhospital mortality was 38.7% (1,426/3,685). A tracheostomy was placed during ECMO support in 94/3,685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR, 6.3-25.9 d) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR, 13.0-58.7 d); inhospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age, 15.8 yr [IQR, 4.7-15.5] vs 11.7 yr [IQR, 11.5-17.3 yr]; p =0.002) and more likely to have been supported on venovenous-ECMO (84% vs 52%; p = 0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared with 19/44 (43%) of those who received a tracheostomy at 14 days or later (p = 0.03).
Conclusions:
Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a "secondary" strategy for prolonged ECMO support.
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