Percutaneous tracheostomy in patients with severe liver disease and a high incidence of refractory coagulopathy: a prospective trial

INTRODUCTION: The purpose of this study was to assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy. METHODS: We conducted a prospective cohort study in a 10-bed specialist liver intensive care unit of a tertiary university teaching hospital. The study consisted of 60 consecutive patients in need of tracheostomy insertion. Patients were categorized as having refractory coagulopathy if their platelet count was less than or equal to 50 × 10(9 )cells/L or their international normalized ratio (INR) was greater than 1.5 on the day of PDT and for the 72 hours afterward despite clotting support. RESULTS: Twenty-five patients fulfilled the definition criteria of refractory coagulopathy. There was no significant difference in the number of adverse incidents between groups. Only one patient in the coagulopathy group had a severe bleeding complication, but this did not require open surgical intervention. The rate of clinically relevant early complications in all patients was not higher than expected (n = 7, 12%). Resource utilisation was higher for patients with coagulopathy who received significantly more platelet transfusions over the 3-day period (80 versus 49 units; p = 0.009) and who demonstrated a trend toward increased fresh frozen plasma requirements (p = 0.059). The number of patients requiring platelet transfusion was higher in the coagulopathy group (21/25 versus 20/35; p = 0.029). Hospital survival did not differ between groups. CONCLUSION: PDT is safe and not contraindicated in patients with severe liver disease and refractory coagulopathy.