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OBJECTIVES: Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making. DESIGN: Retrospective cohort study SETTING: ECMO centers contributing to the Extracorporeal Life Support Organization (ELSO) Registry PATIENTS: Children birth to 18 years who received ECMO support for 7 days or greater for respiratory failure from January 1(st) 2015 to December 31(st) 2019. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: 3685 children received at least seven days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (IQR 9.3-19.9), and in-hospital mortality was 38.7% (1426/3685). A tracheostomy was placed during ECMO support in 94/3685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR 6.3-25.9) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR 13.0-58.7); in-hospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age 15.8 years (IQR 4.7-15.5) versus 11.7 years (IQR 11.5-17.3); p-value=0.002) and more likely to have been supported on VV-ECMO (84% vs 52%, p=0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared to 19/44 (43%) of those who received a tracheostomy at 14 days or later (p=0.03). CONCLUSIONS: Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a “secondary” strategy for prolonged ECMO support.

Additional file 1: Supplemental Table 1. Predictive Characteristics of RAI for FO ≥ 15%. Supplemental Table 2. Median FO% over time among all patients. Supplemental Table 3. Median FO% over time among RA+ Patients. Supplemental Table 4. Median FO% among RAI- patients. Supplemental Table 5. Predictive Characteristics of RAI for Severe AKI. Supplemental Table 6: RAI status of FO/AKI phenotypes.