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

BACKGROUND To assess the safety of percutaneous dilational tracheostomy (PDT) performed by experienced operators in critically ill patients with liver disease and coagulopathy. METHODS Prospective cohort study in a ten bed specialist liver intensive care unit of a tertiary university teaching hospital. Sixty consecutive patients in need of tracheostomy insertion. Patients were categorized as having refractory coagulopathy if their platelet count was < or = 50 x 10(9) cells/L or the INR > 1.5 on the day of and the subsequent 72 hours following PDT 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 1 patient in the coagulopathy group had a severe bleeding complication, however 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 vs 49 units, p = 0.009) and demonstrated a trend towards 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.