Bleeding is a common complication of extracorporeal membrane oxygenation (ECMO) support. While chest tube treatment is infrequently linked to bleeding in non-ECMO patients, several reports suggest a markedly increased risk during ECMO support, sometimes requiring surgical intervention. The true incidence, contributing factors, and effect on outcome from chest tube related bleeding in ECMO patients is unknown.

This was a single-centre observational study conducted between 2010 and 2024, including both paediatric and adult patients treated with chest tube for pneumothorax or non-haemorrhagic pleural fluid during their ECMO treatment. Major bleeding was defined by chest tube output amount adjusted to patient age, need for multiple red blood cell transfusions, or need for surgical intervention.

Of the 1158 screened ECMO patients, 168 (14.5%) required chest drainage for pleural effusions or pneumothorax during the study period, and a total of 279 chest tubes were analysed. Major bleeding occurred in 21 patients (12.5%) and from 23 chest tubes (8.1%). Fourteen patients required thoracotomy. Bleeding was more common with tubes placed during ECMO support (11.3%) compared to pre-ECMO (4.7%, P = .036). Affected patients had longer ECMO durations (median 42 vs 17 days, P = .003) and lower hospital survival (47.6% vs 71.4%, P = .043). No associations were observed between bleeding and tube size, laterality, type, insertion technique, or ECMO mode. The chest wall was the most commonly identified bleeding location.

There was a markedly increased risk of major bleeding from chest tubes during ECMO, particularly when inserted after cannulation. Patients who experienced bleeding complications had longer hospital stays and lower survival.