How to manage bleeding from a tracheostomy site?

From the Guidelines

To manage bleeding from a tracheostomy site, first identify the severity of bleeding and apply direct pressure with sterile gauze around the stoma while maintaining airway patency. The most recent and highest quality study on this topic is from the Global Tracheostomy Collaborative, which emphasizes the importance of a coordinated and systematic approach to caring for patients with a tracheostomy 1. According to this study, tracheostomy-specific hemorrhage is a significant concern and can be more frequent and serious than previously thought.

Key Considerations

• For minor bleeding, clean the site with sterile saline and apply a topical hemostatic agent such as silver nitrate sticks or topical epinephrine (1:1000 solution applied with gauze) 1.
• Replace the tracheostomy tube with a cuffed tube if possible and inflate the cuff to tamponade bleeding from the tracheal wall.
• For moderate bleeding, consider topical tranexamic acid (500 mg to 1 g applied directly) or nebulized epinephrine (1 mg in 5 mL normal saline).
• Severe bleeding requires immediate surgical consultation, volume resuscitation, and possible embolization or surgical intervention.

Preventive Measures

• Maintain proper humidification to prevent crusting 1.
• Use appropriate suction techniques to avoid trauma.
• Ensure the tracheostomy tube is properly sized and secured to prevent movement that could cause irritation.
• Regular stoma care with gentle cleaning and dressing changes helps prevent complications that lead to bleeding.
• Treating underlying causes with appropriate antibiotics for infection or silver nitrate for granulation tissue is essential 1.

The Global Tracheostomy Collaborative provides a framework for improving patient safety and quality of care for patients with a tracheostomy, and their recommendations should be followed to minimize the risk of bleeding and other complications 1.

From the Research

Managing Tracheostomy Bleeding

To manage bleeding from a tracheostomy site, several factors need to be considered, including the patient's coagulation status and the presence of any anticoagulant or antiplatelet therapies.

• Assessing Coagulation Status: Studies have shown that thromboelastometry can be a reliable method for assessing coagulation status in patients undergoing tracheostomy, even in those with prolonged prothrombin time (PT) 2.
• Bleeding Complications: The incidence of bleeding complications associated with percutaneous tracheostomy can be significant, with one study reporting a 40% incidence of bleeding, although most cases were minor 3.
• Severe Thrombocytopenia: Percutaneous tracheostomy can be safely performed in patients with severe thrombocytopenia, provided that platelets are administered beforehand and heparin infusions are temporarily interrupted during the procedure 4.
• Anticoagulant Therapies: Percutaneous tracheostomy can be safe in critically ill patients treated with anticoagulant therapies, although the risk of bleeding complications should be carefully considered 5.
• High-Risk Patients: Even in patients deemed to be at high risk of bleeding complications, percutaneous tracheostomy can be performed with a relatively low rate of complications when due precautions are taken 6.

Key Considerations

When managing tracheostomy bleeding, it is essential to:

• Carefully assess the patient's coagulation status using thromboelastometry or other methods
• Consider the risks and benefits of administering anticoagulant or antiplatelet therapies
• Take precautions to minimize the risk of bleeding complications, such as temporarily interrupting heparin infusions during the procedure
• Monitor the patient closely for signs of bleeding or other complications after the procedure.