Safety of Percutaneous Dilatational Tracheotomy in Patients on Dual Antiplatelet Therapy and Anticoagulation

Abstract

Percutaneous dilatational tracheotomy has become a routine procedure in ICUs. However, given the high and steadily growing number of patients receiving anticoagulation, dual antiplatelet therapy, or even a combination of both (also known as "triple therapy"), there are concerns about the safety of the procedure, in particular for critically ill patients with a high risk of bleeding. In this retrospective study, we investigated whether percutaneous dilatational tracheotomy in this high-risk population was associated with elevated procedural complications.

Design: Retrospective single-center study with analysis of all percutaneous dilatational tracheotomies performed in our cardiac ICU from January 2018 to May 2019.

Setting: Munich university hospital's cardiac ICU.

Patients and interventions: A total of 34 patients who underwent percutaneous dilatational tracheotomy according to Ciaglia technique with accompanying bronchoscopy in our cardiac ICU from January 2018 to May 2019 were included. Patients were stratified into clinically relevant risk groups based on anticoagulation and antiplatelet therapy considering standard laboratory coagulation parameters, that is, activated partial thromboplastin time, international normalized ratio, and platelet count with differentiated analysis of procedure-related complications in each risk group until hospital discharge.

Measurements and main results: A total of 34 patients who underwent percutaneous dilatational tracheotomy were included and assigned to five clinically relevant treatment groups: IV unfractionated heparin (prophylactic dosage) (n = 4), IV unfractionated heparin (therapeutic dosage) (n = 4), aspirin and IV unfractionated heparin (therapeutic dosage) (n = 7), dual antiplatelet therapy with IV unfractionated heparin (prophylactic dosage) (n = 5), and dual antiplatelet therapy with IV unfractionated heparin (therapeutic dosage) (n = 14). Three bleedings without surgical intervention or blood transfusion were documented in the whole cohort, but no single bleeding did occur in the triple therapy group. These were exclusively caused by skin bleedings at the immediate puncture site-each of which could be easily treated with one or two single stitches. There were no severe bleeding complications or potentially life-threatening procedure-related complications. Additionally, the rate of complications in patients with elevated body mass index was not increased.

Conclusions: Bronchoscopy-guided percutaneous dilatational tracheotomy according to Ciaglia technique with careful consideration of all potential indications and contraindications may be a safe and low-complication procedure for airway management, even in patients receiving dual antiplatelet therapy and therapeutic anticoagulation simultaneously in our cohort with a high risk of bleeding.

Keywords: airway management; anticoagulation; antiplatelet therapy; bleeding; percutaneous dilatational tracheotomy.

Figure 1.

Percutaneous dilatational tracheotomy according to Ciaglia technique (A) with accompanying bronchoscopy: Doppler ultrasound examination used to ensure that no blood vessels run under the intended puncture site. Median puncture of the trachea below the second or third tracheal clasp under bronchoscopic visualization (B) and insertion of a Seldinger wire (C). The Seldinger guidewire is used for bougienage with the dilator (Ciaglia Blue Rhino Set; Cook Medical) (D). Subsequently, the tracheal cannula (size: 9 mm) is inserted by means of an introducer and connected to the respiratory system. Final bronchoscopic position control of the tracheal cannula and postinterventional rule out of pneumothorax by chest radiograph. Two single-head sutures on the left and right of the tracheal cannula to prevent bleeding from the puncture site (E and F).