Andreas Schäfer1, Martin Orban2,3, Enzo Lüsebrink4,5, Alexander Krogmann6, Franziska Tietz7, Matthias Riebisch8, Rainer Okrojek9, Friedhelm Peltz9, Carsten Skurk10, Carsten Hullermann11, Jan Sackarnd11, Dietmar Wassilowsky12, Karl Toischer13, Clemens Scherer4,5, Michael Preusch14, Christoph Testori15, Ulrike Flierl1, Sven Peterss16, Sabine Hoffmann17, Nikolaus Kneidinger18,19, Christian Hagl16, Steffen Massberg4,5, Sebastian Zimmer6, Peter Luedike8, Tienush Rassaf8, Holger Thiele7. 1. Klinik Für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany. 2. Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377, Munich, Germany. MartinOrban@gmail.com. 3. DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. MartinOrban@gmail.com. 4. Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377, Munich, Germany. 5. DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Munich, Germany. 6. Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Bonn, Germany. 7. Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology and Leipzig Heart Institute, Leipzig, Germany. 8. Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Essen, Germany. 9. Medizinische Klinik und Poliklinik I, Klinikum Rechts der Isar der Technischen Universität München, Munich, Germany. 10. Klinik Für Kardiologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Berlin, Germany. 11. Klinik Für Kardiologie I: Koronare Herzkrankheit, Herzinsuffizienz und Angiologie, Universitätsklinikum Münster, Münster, Germany. 12. Klinik Für Anästhesiologie, Klinikum der Universität München, Munich, Germany. 13. Klinik Für Kardiologie, Angiologie und Pneumologie, Herzzentrum Göttingen, Göttingen, Germany. 14. Klinik Für Kardiologie, Angiologie und Pneumologie, Universitätsklinikums Heidelberg, Heidelberg, Germany. 15. Landesklinikum Wiener Neustadt, Wien, Österreich. 16. Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Munich, Germany. 17. Institut Für Medizinische Informationsverarbeitung Biometrie und Epidemiologie, Klinikum der Universität München, Munich, Germany. 18. Medizinische Klinik und Poliklinik V, Klinikum der Universität München, Munich, Germany. 19. German Center for Lung Research (DZL), Medizinische Klinik und Poliklinik V, Klinikum der Universität München, Munich, Germany.
Abstract
BACKGROUND: Percutaneous 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. METHODS: PDT 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. RESULTS: In 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). CONCLUSION: In 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.
BACKGROUND: Percutaneous 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 illpatients 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. METHODS: PDT 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. RESULTS: In 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). CONCLUSION: In 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.
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