Oral care protocols with specialty training lead to safe oral care practices and reduce iatrogenic bleeding in extracorporeal membrane oxygenation patients

Introduction Oral care, using either a mouth rinse, gel, toothbrush, or combination of them, together with aspiration of secretions, may reduce the risk of ventilator-acquired pneumonia in intubated patents. Oral care procedure in patients on venovenous extracorporeal membrane oxygenation (VV-ECMO) may cause bleeding due to the systemic anticoagulation required. Purpose The aim of this study was to investigate the rate of bleeding episodes during oral care in patients supported by VV-ECMO. Methods A retrospective observational study was performed. All patients admitted to an Italian ECMO center during 2014 were included in the study. Results Data from 14 patients were analyzed. The median intensive care unit length of stay was 39.0 days (interquartile range, 27.3-83.3 days), and median days on VV-ECMO was 19.5 (10.3-46.0). There were 440 ECMO days, with 1320 oral care maneuvers. In 7 patients, bleeding episodes occurred: 2 with orotracheal intubation and 5 initially managed with orotracheal intubation, thereafter via Translaryngeal tracheostomy tube (according to Fantoni's technique). In 61 oral care procedures (4.6%), bleeding was detected during or after the maneuver, whereas the total numbers of days with at least 1 bleeding episode were 35 (8%). The presence or absence of bleeding during ECMO days was statistically significant for international normalized ratio (1.01 [0.95-1.11] vs 1.13 [1.03-1.25], P <.0001), platelets (163 000 [93 500-229 000] vs 61 000 [91 00-100 000], P <.0001), and mouth care score (6 [5-7] vs 8 [7-9], P <.001). Conclusion Oral care can cause bleeding in patients on VV-ECMO. Implementation of protocols for daily oral care in patients on ECMO may reduce risks. As recommended by the literature, this category of patients should be treated in selected centers distinguished by a regular volume of ECMO activity and the presence of dedicated ECMO specialist nurses.