The use of percutaneous tracheostomy in patients with severe acute or chronic liver disease

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Introduction

Percutaneous tracheostomy (PT) is recognised as a safe and effective method for prolonged ventilatory support, avoiding the complications of lengthy endotracheal intubation. Bleeding has been reported as the most common perioperative complication in most series [1]. Patients with severe liver disease frequently have a coagulopathy and thrombocytopaenia. We wished to assess the safety of PT in this group of patients, who are at high risk of haemorrhagic complications.

Methods

A retrospective study of PT's performed in patients admitted to a dedicated liver intensive care unit in a supraregional liver centre over two years. All procedures followed the Ciaglia technique [2] and were performed by, or under the supervision of, experienced operators. All patients had liver disease, which included decompensated chronic disease, hyperacute and acute liver failure and liver transplantation with severe postoperative complications.

Patients considered to be at particularly high risk for bleeding, based on platelet count (Plts) and international normalised ratio (INR) received transfusions of platelets and/or fresh frozen plasma prior to the procedure.

Results

The median age was 46.5 years with 20 males and 14 females. Five of the thirty-four patients suffered complications, none of which were fatal, and included minor bleeding only (requiring no treatment). The Mann-Whitney U test was used to compare differences in INR and Plts between those with and without complications. The median pre-correction INR for the group without complications was 1.1 (0.82–1.79) and for those with complications was 1.34 (0.92–1.76) and this did not reach statistical significance. There was a trend towards lower Plts in those with a complication (median 44; range 21–84) compared to those without (median 76; range 3–510) but again this was not statistically significant (P<0.3).

Conclusions

Although this is a small study, based on the data presented, PT appears to be a safe procedure in this group of patients, at high risk of bleeding, when standard precautions are followed.