Abstract
Objectives
Fatal complications of percutaneous dilatational tracheostomy (PDT) are rare and intraoperative fatal complications of PDT even more so. We present the unique case of a fatal nonvascular intraoperative complication of PDT, previously unreported in the medical literature. We also present a review of all previously reported fatal complications of PDT.
Methods
A review of all previously reported fatal complications of PDT was conducted in order to examine the prevalent causes of death and 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. Patients with previous neck surgery, radiotherapy or unclear surgical anatomy should be regarded with caution. If a difficult intubation or a difficult 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.
1
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. The time required for performing bedside PDT is considerably shorter than that required for performing an open tracheostomy . One of the major advantages of PDT is the 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. For these reasons, PDT has become a standard technique in critical care medicine . There is evidence that the proportion of intensive care patients undergoing tracheostomy has increased since the introduction of percutaneous tracheostomy techniques, while the use of open surgical tracheostomy in the critically ill has decreased sharply .
A meta-analysis of five studies comparing PDT with surgical tracheostomy found similar overall complication rates in the 2 groups. Other studies have stated that the short-term and long-term complications of PDT are at least comparable to, and possibly less than, those following open surgical tracheostomy . Complications of PDT are traditionally divided into early and late . Early complications include bleeding, infection, pneumothorax, technical failures and perioperative hypoxia due to tube obstruction or accidental decannulation . The major reported late complications include development of granulation tissue resulting in airway stenosis, failure to decannulate or upper airway obstruction with respiratory failure after decannulation. Additional late complications include tracheoesophageal fistula, tracheomalacia, tracheal stenosis and tracheoinnominate artery fistula (TIF) .
Fatal complications of PDT are rare and intraoperative fatal complications of PDT even more so. We present the unique case of a fatal intraoperative complication of PDT, previously unreported in the medical literature. We will also review all previously reported fatal complications of PDT.
2
Case report
The patient, a 64-year-old woman, was admitted to an internal medicine department due to left abdominal pain, left flank pain and dyspnea. Her medical history was significant for morbid obesity and elephantiasis of the lower limbs. She was diagnosed as suffering from left pneumonia and treated with intravenous antibiotics. The patient became unresponsive and was subsequently intubated, ventilated and transferred to the intensive care unit. No difficulty was encountered during intubation. Attempts to wean the patient from mechanical ventilation were unsuccessful and an elective tracheostomy was requested. 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 to transfer the patient to the operating room and not to perform a bedside procedure. Once 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 attempt PDT and in the event of difficulty to convert to an open surgical tracheostomy. In order 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 (VMB Medizintechnik GmbH, Sulz, Germany). Efficient jet ventilation through the airway exchange catheter was demonstrated. Following accepted procedure for PDT, the endotracheal tube was retracted retrograde over the tube exchanger to the level of the vocal cords. PDT by two experienced surgeons was unsuccessful and a decision was made to convert to open surgical tracheostomy. Attempts to reintubate over the tube exchanger were unsuccessful, as was jet ventilation via the tube exchange. Further attempts to reintubate the patient and to ventilate her with a laryngeal mask airway were ineffective as was a final attempt to perform an emergency cricothyroidotomy. Subcutaneous emphysema or excessive escape of air 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.
2
Case report
The patient, a 64-year-old woman, was admitted to an internal medicine department due to left abdominal pain, left flank pain and dyspnea. Her medical history was significant for morbid obesity and elephantiasis of the lower limbs. She was diagnosed as suffering from left pneumonia and treated with intravenous antibiotics. The patient became unresponsive and was subsequently intubated, ventilated and transferred to the intensive care unit. No difficulty was encountered during intubation. Attempts to wean the patient from mechanical ventilation were unsuccessful and an elective tracheostomy was requested. 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 to transfer the patient to the operating room and not to perform a bedside procedure. Once 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 attempt PDT and in the event of difficulty to convert to an open surgical tracheostomy. In order 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 (VMB Medizintechnik GmbH, Sulz, Germany). Efficient jet ventilation through the airway exchange catheter was demonstrated. Following accepted procedure for PDT, the endotracheal tube was retracted retrograde over the tube exchanger to the level of the vocal cords. PDT by two experienced surgeons was unsuccessful and a decision was made to convert to open surgical tracheostomy. Attempts to reintubate over the tube exchanger were unsuccessful, as was jet ventilation via the tube exchange. Further attempts to reintubate the patient and to ventilate her with a laryngeal mask airway were ineffective as was a final attempt to perform an emergency cricothyroidotomy. Subcutaneous emphysema or excessive escape of air 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.
3
Discussion
Tasks which we successfully perform many times come to appear safer than they really are . Complications of tracheostomies have been reported to occur in 15% of patients and numerous studies have demonstrated an increased mortality rate in emergency situations, severely ill patients and children . Several hundred patients die of tracheostomy-related events (not due to the underlying disease) annually in the United States and the vast majority of catastrophes related to the tracheostomy occur after the immediate perioperative period .
A study reviewing 113 653 tracheostomy operations performed in the United States among patients aged 18 years or older during 2006 showed that 3.2% of patients experienced a tracheostomy-related complication and 0.6% experienced a tracheostomy-related complication and death.
In a recent survey of the membership of the American Academy of Otolaryngology, Head and Neck Surgery , respondents were asked, amongst other things, to report 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. The majority of events involved accidental decannulation (34.3%) or bleeding (31.6%). Only 19 of events (4.7%) were intraoperative. Only 3% of events were related to percutaneous tracheostomy. Of the 19 events that were intraoperative or in the immediate perioperative period, only 3 were clearly related to events during PDT: 2 involving major bleeding and 1 involving airway loss (personal communication with author). The authors state that due to the fact that most events happened after the immediate post-operative period, the initial technique of insertion is probably irrelevant in most cases.
In a retrospective study reviewing the prevalence of tracheostomy complications in 1175 patients , the majority of procedures were open tracheostomies performed in the operating room (69.2%). 14.3% of procedures were percutaneous tracheostomies at bedside, 8.6% were open tracheostomies at bedside and only 2.6% were percutaneous tracheostomies performed in the operating room. Intraoperative, early postoperative and late postoperative complication rates were: 1.4%, 5.6%, and 7.1%, respectively. The most common intraoperative complication was severe desaturation. The most common early postoperative complication was bleeding and the most common late complications were airway stenosis and accidental decannulation. Tracheostomy technique was not associated with the intraoperative complication rate. Overall, 5 cases (0.4%) of intraoperative death were recorded. Interestingly, 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. TIF is an uncommon but life threatening complication with mortality rates approaching 100% . Reported incidence is 0.1–1% after surgical tracheostomy with peak incidence 7–14 days post procedure. The incidence of TIF following PDT has been estimated to be 0.3% . Grant et al present 3 cases of TIF following PDT and resulting in the death of all patients.
In summary, most complications of tracheostomy are late complications, mainly airway stenosis and accidental decannulation and to a lesser extent TIF. Late complications are probably unrelated to the tracheostomy technique. Bleeding is most common in the early postoperative period and may be more prevalent in PDT. Intraoperative complications of tracheostomy by any technique including PDT are rare.
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, but not specifically described as such by the authors ([8], personal communication with author). In the case reported here, the exact cause of death remains unclear and has been classified simply as loss of airway. Table 1 includes all reported cases of death during or following PDT in which the technique is related to the cause of death. For example, reported cases of TIF causing delayed bleeding and death were only included if the cause of TIF was found to be low placement of the tracheostomy tube due to the blind PDT technique.
