Fatal air embolism as complication of percutaneous dilatational tracheostomy on venovenous extracorporeal membrane oxyge
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CASE REPORT
Open Access
Fatal air embolism as complication of percutaneous dilatational tracheostomy on venovenous extracorporeal membrane oxygenation, two case reports Achim Lother1, Tobias Wengenmayer1, Christoph Benk2, Christoph Bode1 and Dawid L. Staudacher1*
Abstract Background: Tracheostomy is recommended in case of prolonged mechanical ventilation. Therefore, most patients with an indication for venovenous extracorporeal membrane oxygenation (ECMO) will also have an indication for tracheostomy. Case presentation: We report 2 cases of fatal air embolism into the ECMO system as complication of percutaneous dilatational tracheostomy. Both patients had an AVALON ELITE® bi-caval cannula implanted draining blood from the vena cava superior and inferior. Conclusion: Since there is limited safety data on this specific group of patients, a routine early dilatational tracheostomy might be associated with a significant risk. Keywords: ECMO, Extracorporeal membrane oxygenation, Complication, Air embolization, Percutaneous dilatational tracheostomy, Case report
Background Tracheostomy is recommended in critical ill patients when prolonged mechanical ventilation is presumed [1]. Optimal timing of tracheostomy is still under debate [1, 2]. However, a recently published meta-analysis suggests that performing tracheostomy within 7 days after intubation may reduce intensive care unit stay [2]. Most studies comparing early to late tracheostomy defined late tracheostomy as performed in week two after intubation [1, 2]. Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a treatment option for severe adult respiratory failure [3]. The average time on mechanical ventilation of vv-ECMO patients is 23 days [4]. Therefore most vv-ECMO patients will have an indication for tracheostomy. We have to report 2 cases of fatal air embolism into the vv-ECMO in patients undergoing percutaneous dilatational tracheostomy while being on full ECMO support.
* Correspondence: [email protected] 1 Department of Cardiology and Angiology I, Heart Center Freiburg University, Hugstetterstrasse 55, 79106 Freiburg, Germany Full list of author information is available at the end of the article
Case 1 A 65 year old male without significant comorbidities presented at a non-ECMO hospital with H1N1 pneumonia. As a severe ARDS developed (Horovitz index 58) a vv-ECMO was implanted via the right jugular vein using a 31 Fr AVALON ELITE® bi-caval catheter and the patient was transferred to our intensive care unit. Six days after ECMO initiation, the patient was still ECMO dependent (blood flow 3.9 l/min, gas flow of 5.0 l/min) while on invasive mechanical ventilation (FiO2 45 %, PEEP 15 mbar). We therefore presumed a prolonged weaning and aimed for a percutaneous dilatational tracheostomy using the ULTRAperc system (Portex®, Smith medical, England) with bronchoscopic guidance. After puncture of the trachea and immediately after the first dilation step a significant air embolism into the ECMO system was observed. The ECMO sys
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