Fatal complications of percutaneous dilatational

tracheostomy Peter Gilbey, MDa,b,⁎

aThe Otolaryngology, Head and Neck Surgery Unit, Ziv Medical Center, Zefat, Israel bBar-Ilan University Faculty of Medicine in the Galilee, Israel

Received 19 June 2012

Tutor : dr.Erica Gilda Simanjuntak,SpAnPresentated by : Astri Marsa Zulkarnaen,S.Ked

Abstract

Objectives

Fatal complications of percutaneous dilatational tracheostomy (PDT) are rare and intraoperative fatal complications of PDT even more so.

Methods

A review of all previously reported fatal complications of PDT was conducted in order to :

•examine the prevalent causes of death

•to attempt to recommend measures designed to prevent similar fatal complications in the future

Results

•Cases of death during or following PDT in which the technique is related to the cause of death have only been reported in a small number of cases.

•Almost all fatal complications of PDT result from vascular injury.

Conclusions

Any vascular pulsation palpated over the tracheostomy site mandates preoperative ultrasound or conversion to open surgical tracheostomy.

History of previous neck surgery, radiotherapy or unclear surgical anatomy should be regarded with caution.

If a difficult intubation or procedure is anticipated it may be preferable not to attempt PDT with a plan to convert to surgical tracheostomy if necessary but instead to perform surgical tracheostomy without attempting PDT.

Introduction

Percutaneous dilatational tracheostomy (PDT), first described by Ciaglia et al in 1985, is the placement of a tracheostomy tube without direct visualization of the trachea.

It is considered to be a minimally invasive procedure that is performed in the intensive care unit or at the patient's bedside.

Andvantages of PDT

The time required for performing bedside PDT is considerably shorter than that required for performing an open tracheostomy

eradication of scheduling difficulty associated with the operating room and anesthesiology teams.

Bedside PDT also prevents the necessity to transport critically ill patients requiring intensive monitoring to the operating room.

The cost of PDT is roughly half that of performing open surgical tracheostomy.

A meta-analysis of five studies comparing PDT with

surgical tracheostomy found similar overall complication

rates in the 2 groups.

Early Late

Bleeding development of granulation tissue resulting in airway stenosis

infection failure to decannulate or upper airway obstruction with respiratory

failure after decannulation

Pneumothorax tracheoesophageal fistula

technical failures and perioperative hypoxia due to tube obstruction or accidental

decannulation

tracheomalacia

tracheal stenosis

tracheoinnominate artery fistula (TIF)

Case report

Name : Mrs.K

Age : 64th

Chief complaint : > left abdominal pain

> left flank pain

> dyspnea

on going disease : She was diagnosed as suffering from left pneumonia and treated with intravenous antibiotics

Medical History : morbid obesity and elephantiasis of the lower limbs

intravenous antibiotics

patient became unresponsive

Decided to

intubated ventilated transferred to the intensive care unit

Attempts to wean the patient from mechanical ventilation were unsuccessful

Requested

an elective tracheostomy

Due to the fact that the patient was morbidly obese with a short neck, a joint decision by the Intensive Care unit and the Otolaryngology, Head and Neck Surgery unit was made

transfer the patient to the operating room and not to perform a bedside procedure

in the operating room, the patient was re-evaluated by an otolaryngologist and an anesthesiologist

Despite the short neck the cricoid cartilage was palpated and a decision was made

to increase airway safety, a Cook Airway Exchange Catheter (Cook Critical Care. Bloomington, IN) was inserted into the trachea through the lumen of the endotracheal tube via a swivel connector

Attempt PDT

unsuccessful

Efficient jet ventilation through the airway exchange catheter was demonstrated

Attempts to reintubate over the tube exchanger ≠ berhasil

unsuccessful

further attempts to reintubate the patient and to ventilate with a laryngeal mask airway were ineffective

Final decision

attempt to perform an emergency cricothyroidotomy

via the opening in the anterior neck were not observed at any time during the procedure

The patient subsequently desaturated and expired

Post mortem examination was requested but refused by the family.

Discussion

In a recent survey of the membership of the American Academy of Otolaryngology, Head and Neck Surgery ,reported the number of catastrophic tracheostomy complications they had experienced during their career and the number of complications leading to death or permanent disability

55% of respondents reported caring for at least one patient with a catastrophic event related to a tracheostomy, accidental decannulation (34.3%) or bleeding (31.6%).

complication rates were

The most common Complications

Bleeding was the only early (within 1 week of the procedure) complication found to be significantly higher in the group of patients undergoing percutaneous tracheostomy

Minor bleeding during the performance of PDT has been reported to occur in fewer than 20% of cases.

Major bleeding occurred in fewer than 5% of cases and was usually venous.

Catastrophic hemorrhage is rare, usually delayed and in most cases is the result of a TIF

Fatal complications of PDT have only been reported in a small number of cases and fatal intraoperative complications of PDT are even less common.

Almost all result from vascular injury.

One case of intraoperative death during PDT resulting from loss of airway has been included in a national US survey of tracheostomy-related catastrophic events.

Ultrasound (US)

improve the safety profile of PDT

to identify the tracheal midline and the levels of the tracheal cartilages and is also of benefit in identifying overlying or vulnerable adjacent structures such as the thyroid gland and isthmus and blood vessels

Intraoperative tracheal endoscopy

can reduce the possibility of

paramedian or extratracheal

placement of the seeker needle

Authors Year of Publication

Time of death Cause of Death Comments

Shlugman 2003 Intraoperative Damage to right subclavian artery

Previous thyroid surgery

Ryan 2003 Intraoperative Bleeding into thyroid gland

Previous parathyroid surgery

McCormick 2005 Intraoperative

5 d postoperative

22 d postoperative

Damage to left innominate artery

Damage to arch of aorta

Damage to innominate vein resulting in bilateral hemothorax

Right mastectomy with postoperative radiotherapy

Low placement of tracheostomy between 8–9 tracheal rings

Low placement of tracheostomy between 8–12 tracheal rings

Ayoub 2006 6 d postoperative Damage to arch of aorta

Low placement of tracheostomy between 8–9 tracheal rings

Das (personal communication 2011 with author)

2011 Intraoperative IntraoperativeIntraoperative

Major bleeding Major bleeding

Airway loss

Present study 2012 Intraoperative Airway loss

Conclusion

Fatal complication of PDT is very rare

Fatal complications of PDT are extremely rare and usually result from vascular injury

US and/or intraoperative tracheal endoscopy seem to improve the safety profile of the procedure but are logistically demanding and probably not routinely required in all patients

Case selection is of great importance and patients with previous neck surgery or radiotherapy

if a difficult intubation or a difficult procedure are anticipated, it may be preferable not to attempt PDT with a plan to convert to surgical tracheostomy if necessary, but instead to perform surgical tracheostomy without attempting PDT