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(Chest. 2004;126:547-551.)
© 2004 American College of Chest Physicians

Percutaneous Tracheostomy Is Safe in Patients With Severe Thrombocytopenia*

Stefan Kluge, MD; Andreas Meyer, MD; Peter Kühnelt, MD; Hans Jörg Baumann, MD and Georg Kreymann, MD

* From the Department of Medicine, University Hospital Eppendorf, Hamburg, Germany.

Correspondence to: Stefan Kluge, MD, Department of Medicine, University Hospital Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany; e-mail: skluge{at}uke.uni-hamburg.de


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Study objectives: Severe thrombocytopenia has been described as a contraindication for percutaneous tracheostomy (PT). The objective of this study was to assess the safety of PT in mechanically ventilated patients with severe thrombocytopenia (defined by a platelet count of < 50 x 109 cells/L).

Design: Retrospective, single-center cohort study.

Setting: Medical ICU of the University Hospital Hamburg-Eppendorf, Germany.

Patients: Forty-two medical patients with acute respiratory failure and severe thrombocytopenia.

Interventions: Bedside PT under bronchoscopic guidance using the Griggs guidewire forceps technique.

Measurements and main results: The mean (± SD) intubation time prior to undergoing PT was 6.7 ± 3.9 days (range, 1 to 20 days). The mean platelet count was 26.4 ± 11.6 x 109 cells/L (range, 1 x 109 to 47 x 109 cells/L). The median transfusion of platelets before the procedure in 40 of the 42 patients was 6 ± 2.5 U (range, 3 to 12 U). Twenty-two patients (52%) had an additional coagulopathy (activated partial thromboplastin time [APTT], > 40 s; international normalized ratio, > 1.5). PT was safely performed in all 42 patients. Only two (5%) patients developed major postprocedural bleeding complications that required suturing. Both of these patients had an elevated APTT due to heparin therapy.

Conclusions: When performed by experienced personnel, PT with bronchoscopic guidance has a low complication rate in patients with severe thrombocytopenia, provided that platelets are administered beforehand. However, in order to minimize bleeding complications heparin infusions should be temporarily interrupted during the procedure.

Key Words: bone marrow transplantation • coagulopathy • complications • mechanical ventilation • percutaneous tracheostomy • thrombocytopenia


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Percutaneous tracheostomy (PT) has gained widespread acceptance in the ICU setting and presents a valid alternative to operative tracheostomy. In fact, recent data have suggested that it offers several potential advantages compared to surgical tracheostomy, including ease of performance, and a lower incidence of both peristomal bleeding and postoperative infection.1

Thrombocytopenia is a common finding in patients in the ICU setting, and is usually associated with hematologic disorders, sepsis, and liver disease. In addition, a higher incidence of bleeding, a prolonged stay in the ICU, and increased mortality are often associated with thrombocytopenia.234 Many physicians consider thrombocytopenia a contraindication for performing the procedure.56 Hence, thrombocytopenic patients often are excluded from comparative trials.1789

Despite the presence of thrombocytopenia in up to 41% of ICU patients,3 to the best of our knowledge, to date there has been no single study focusing on thrombocytopenic patients requiring bedside PT. In this report, we describe our experience with bedside PT in patients with severe thrombocytopenia at a tertiary care referral center.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Study Design
For this study, we identified all mechanically ventilated patients with severe thrombocytopenia (defined by a platelet count of < 50 x 109 cells/L) who required PT at the medical ICU during the period from January 1997 through February 2003.

In our ICU, it is protocol to routinely enter a patient’s general data and all perioperative complications into a computer file immediately following each procedure. Postoperative complications are also recorded in the same fashion. The complications noted in this retrospective study included bleeding, subcutaneous emphysema, pneumothorax, hypotension, arrhythmia, hypoxemia, infection of the stoma, paratracheal insertions, and tracheal injuries (eg, posterior wall perforation and fractures of tracheal rings). The patients were followed until death, decannulation, or transfer to another facility.

For the purpose of this study, bleeding was classified as major (ie, requiring transfusion or surgical intervention) or minor (ie, requiring dressing change or digital pressure), intraprocedural, and postprocedural. Infection of the stoma was defined as a documented purulent drainage from the stoma.

Platelet count, activated partial thromboplastin time (APTT), and international normalized ratio (INR) were determined daily throughout the ICU stay. Normal values for platelet count and APTT range from 150 to 400 x 109 cells/L and 25 to 38 s, respectively. Patients with an INR at ≥ 1.5 are considered to be at risk for bleeding complications. Severe thrombocytopenia in the current study was defined as a platelet count of < 50 x 109 cells/L. Platelets were transfused immediately before the bedside PT, as ordered by the doctor performing the procedure. The number of platelet units transfused was based on the individual platelet count and the clinical setting, with the goal being a platelet count of > 50 x 109 cells/L.

Those patients identified with both a prolonged APTT and a raised INR also received fresh-frozen plasma (FFP). Posttransfusion platelet count, APTT, and INR were not reported. Platelet counts were determined by an automated cell counter (Beckman Coulter; Fullerton, CA), and the APTT and INR were determined by the Dade-Behring method (ie, a coagulometric-photometric method).

PT
Since January 1997, PT with the Griggs guidewire forceps technique is the procedure of choice at our institution for treating medical patients experiencing respiratory failure who require long-term mechanical ventilation. All patients from the beginning of our experience in January 1997 were included in the study, resulting in a learning curve with a low skill level at the beginning.

All PT procedures took place under bronchoscopic control and were either performed or supervised by at least one of the first three authors (ie, by pulmonologists and critical care medicine physicians). Informed consent for these procedures was obtained from an agent designated under a power of attorney or family member.

All PT procedures were performed at the bedside in the ICU. For this purpose, all these orotracheally intubated patients received anesthesia with propofol or midazolam, sufentanyl, a short-acting paralytic agent, and 100% oxygen throughout the procedure. Routine monitoring included continuous electrocardiography, arterial BP measurement, and arterial oxygen saturation measurement. Intubation and resuscitation equipment were available at the bedside.

The procedure was performed in all patients following a standardized protocol, as previously described by Cantais et al,7 using a commercially available kit (SIMS; Portex; Hythe, Kent, UK). Our only modification consisted of a local administration of a 2% solution of lidocaine with epinephrine (1:200,000) before proceeding with puncturing of the trachea.

Immediately after the tracheostomy tube insertion, a bronchoscopic examination was performed through the tracheostomy tube to confirm the correct position of the tracheostomy tube and to identify injuries or bleeding. Then, the trachea proximal to the PT was inspected bronchoscopically via the remaining orotracheal tube to identify fractures of tracheal rings or blood. After the procedure, a chest radiograph was performed to rule out the presence of a pneumothorax.

Statistical Analysis
Data are presented as the mean ± SD.

Study Group
During the study period, 196 percutaneous and 47 surgical tracheostomies were performed. Nine of the 47 surgical tracheostomies were performed in thrombocytopenic (< 50 x 109 platelets/L) patients. One of these nine patients developed major postprocedural bleeding that required transfusion.

Forty-two patients (19 women and 23 men) with thrombocytopenia underwent PT under bronchoscopic control. Thirty-three of the patients received a 9-mm tracheostomy tube, and nine patients received an 8-mm tube. None of these patients required conversion to a surgical tracheostomy.

The mean age of the patients was 50.2 ± 12.4 years (range, 26 to 89 years). The mean intubation time prior to PT was 6.7 ± 3.9 days (range, 1 to 20 days). The indication for tracheostomy was respiratory failure attributed to a variety of underlying medical conditions, most commonly pneumonia and sepsis (Table 1 ). Twenty-seven patients were experiencing acute respiratory insufficiency after bone marrow transplantation. Seven patients were actually neutropenic (WBC count, < 1 x 109 cells/L) at the time of PT.


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  		Table 1. Patient Characteristics*

 
All of these patients had severe thrombocytopenia that usually was due to hematologic disorders, sepsis, and/or liver disease (Table 2 ). The mean platelet count, measured in the morning of the day on which the procedure was performed, was 26.4 ± 11.6 x 109 cells/L (range, 1 x 109 to 47 x 109 cells/L) [Table 3 ]. Forty patients received a median of 6 ± 2.5 U platelets (range, 3 to 12 U) before the procedure. Only two patients did not receive platelet transfusions because of high platelet antibody titers, one of whom had a platelet count of 42 x 109 cells/L and the other of whom had a platelet count of 38 x 109 cells/L. In addition to severe thrombocytopenia, 20 of these patients (48%) had an APTT of > 40 s, and 7 patients (17%) had an INR > 1.5.


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  		Table 2. Causes of Thrombocytopenia*

 

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  		Table 3. Laboratory Parameters*

 
Eight patients were being treated with heparin either for pulmonary embolism or for continuous hemofiltration. Five of these patients stopped receiving heparin therapy for a sufficient time (ie, > 3 h) prior to undergoing PT, and then started receiving therapy again 6 h later. In the other three patients, heparin therapy was continued even throughout the procedure because the risk for a thromboembolic event seemed higher than the bleeding risk in this special subgroup.

The mean preprocedure APTT and INR in all patients were 41.6 ± 10.6 s (range, 22 to 75 s) and 1.24 ± 0.4 (range, 0.83 to 2.85), respectively. Four patients (10%) received 4 U FFP each prior to undergoing PT. However, none of the patients received platelet or FFP infusions after the procedure. There were no reported complications related to platelet or FFP transfusions.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Despite the thrombocytopenia and the often elevated APTT and INR within our patient population, the actual number of bleeding complications related to PT were minimal. Minor bleeding during the procedure that stopped immediately after insertion of the tracheostomy tube was noted in 10 patients (24%). In three patients (7.1%), minor postprocedural bleeding occurred. Two cases of major postprocedural bleeding (5%) were noticed. In one patient with a platelet count of 24 x 109 cells/L, bleeding from the stoma wound edges began 3 h after undergoing PT and required suturing. The bleeding stopped immediately after this intervention. In the other patient with a platelet count of 45 x 109 cells/L, bleeding began 12 h after tracheostomy requiring several dressing changes, local compression, and ultimately placement of sutures to stop the bleeding. Both of these patients had an elevated APTT due to heparin therapy. The first patient received a continuous infusion (intraprocedural and postprocedural) of heparin. In the second patient, heparin therapy was stopped prior to PT and then was restarted 6 h later. In both cases, transfusions were not required.

Beyond the above-noted bleeding episodes, few other complications were noted. The only case of hypoxemia involved a decline of the arterial oxygen saturation to 85% for a few seconds and was without clinical significance. Thirteen patients (31%) had one bronchoscopically detected fracture of a tracheal ring. However, complications like infection of the stoma, paratracheal insertions, pneumothorax, or posterior tracheal injuries were not observed.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Our results demonstrate a low complication rate for PT with bronchoscopic guidance in patients with severe thrombocytopenia, when performed by experienced medical ICU staff and utilizing preprocedure platelet transfusions. To our knowledge, this is the first investigation with a special focus on thrombocytopenic/coagulopathic patients requiring PT.

There are only a few case reports or studies10111213141516 with small subgroups of patients with thrombocytopenia or coagulopathy requiring tracheostomy. One article14 described surgical tracheostomy in 26 thrombocytopenic patients (mean preprocedure platelet count 43 x 109 cells/L), most of whom received preprocedure platelet transfusions, with no significant bleeding complications.

Beiderlinden et al11 reported 133 patients receiving PT, including 18 patients with platelet counts of < 50 x 103 cells/µL, and more recently reported 198 patients,12 including 55 patients with < 60 x 103 platelets/µL, but without providing any information on transfusion modalities, bleeding incidence, and general complications in this special subgroup of patients. Another case13 described successful PT placement with only minor bleeding in a patient with severe hemophilia A. Walz et al15 reported on 50 patients who had undergone PT, of whom 8 had thrombocytopenia (ie, < 50 x 109 cells/L), but without mentioning details about the severity of thrombocytopenia and transfusion conditions. MacCallum et al16 published a report on 100 patients undergoing PT, of whom 8 had a platelet count of < 100 x 109 cells/L and another 8 had an APPT of > 50 s. None of these patients experienced major bleeding complications. In all of these publications, the authors were not specially focusing on patients with thrombocytopenia or coagulopathy, in the majority there was no further information on transfusion modalities, laboratory parameters, bleeding incidence, and general complications in this special subgroup of patients.

Our study included 42 patients and presented the largest reported experience so far focusing especially on thrombocytopenic patients undergoing PT. Twenty-seven of these patients were experiencing acute respiratory insufficiency after bone marrow transplantation. Despite the poor prognosis in this subgroup,1718 tracheostomy can be a valuable tool. Especially in those patients with severe oropharyngeal mucositis, early tracheostomy avoids further oral and laryngeal injuries, improves patient comfort, facilitates communication, and aids weaning from the respirator.

One metaanalysis1 has suggested potential advantages for performing PT relative to surgical tracheostomy, including ease of performance, and a lower incidence of both peristomal bleeding and postoperative infection. Although seven of our patients were neutropenic (ie, WBC count, < 1 x 109 cells/L), none developed an infection of the stoma. While another metaanalysis19 comparing PT to surgical tracheostomy found a higher prevalence of perioperative complications in the PT group, it included different PT techniques both with and without bronchoscopic guidance, and with major differences in the complication rate of each technique. Intraoperative bronchoscopy during PT has been shown to reduce perioperative complications, as it increases the safety of the tracheal puncture and dilation during PT.

There is controversy regarding which percutaneous technique should be used to perform a tracheostomy. Some authors20 have reported higher complication rates with the Griggs technique, while others721 had similar complication rates when comparing the Griggs technique with the Fantoni translaryngeal and the Ciaglia Blue Rhino techniques. Contemplating only the bleeding complications, the Griggs technique reveals a higher incidence of bleeding in all these studies. At the time when we started PT with the Griggs technique in 1997, the above-noted data were not available. In our study utilizing PT with the Griggs technique, the rate of relevant bleeding complications (5%) in patients with severe thrombocytopenia was in the acceptable range. Whether other PT techniques might have been "safer" and more suitable in these high-risk patients is unclear.

Both of the patients who developed major bleeding events were undergoing continuous heparin therapy at the time of bleeding. Of note, the bleeding complications in both of these patients were not life-threatening and did not require a blood transfusion. However, in our opinion continuous heparin therapy should be temporarily stopped in patients with severe thrombocytopenia who are undergoing this procedure.

Minor bleeding that was noted during the procedure in 10 patients (24%) stopped immediately after the insertion of the tracheostomy tube. The tight fit of the stoma effectively tamponades blood vessels. None of our patients developed a stoma infection. In contrast to surgical tracheostomy, PT is relatively atraumatic because of the small size of the skin incision and the smaller wound. In our experience, this leads to fewer bleeding complications and stoma infections.

One limitation of our study was that the platelet count immediately before the procedure was not recorded. As usual in peripheral surgery, platelets were transfused before the procedure to achieve a platelet count of > 50 x 109 cells/L. But since the number of platelet units transfused was based, among other things, on the platelet increases observed after earlier transfusions in each individual patient, one can assume that the majority of the transfused patients had a platelet count of 50 x 109 cells/L at the time of the procedure.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
Based on our experience, PT with bronchoscopic guidance has a low complication rate, even in patients with thrombocytopenia, when performed by experienced ICU medical staff and when platelet transfusions are given preprocedure. However, our data demonstrate that continuous heparin therapy, even in patients with a very high risk for thromboembolic events, should be temporarily interrupted during this procedure.


   Footnotes
 
Abbreviations: APTT = activated partial thromboplastin time; FFP = fresh-frozen plasma; INR = international normalized ratio; PT = percutaneous tracheostomy

Received for publication August 12, 2003. Accepted for publication February 13, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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