Percutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience and bronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury are at a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. We would like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to lay emphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especially with cervical spine injury, as the need to respect the steep-learning curve in its performance

Banić, Tihomir

Bartolek, Dubravka

Bartolek, Franjo

Cavrić, Gordana

Kovačić-Vicić, Vesna

Lajtman, Zoran

Somun, Nenad

Zdravčević-Šakić, Kata

English

University of Zagreb Medical School Repository

Coll. Antropol. 33 (2009) 4: 1409–1413Case reportLife Threatening Complications afterUnsuccessful Attempt of the Guidewire DilatingForceps Tracheostomy in Multi-Trauma Patientwith Cervical Spine InjuryDubravka Bartolek1, Nenad Somun2, Franjo Bartolek3, Kata Zdrav~evi}-[aki}4, Zoran Lajtman5,Tihomir Bani}2, Gordana Cavri}6 and Vesna Kova~i}-Vici}11 Department of Anesthesiology and Intensive Care Unit, University Clinic of Traumatology, Zagreb, Croatia2 Department of Spine Surgery, University Clinic of Traumatology, Zagreb, Croatia3 Department of Neurosurgery, Children’s Hospital Zagreb, Zagreb, Croatia4 Department of Anaesthesiology and Intensive Care Unit, University Hospital Centar Zagreb, Croatia5 Department of Otorhinolaryngology, University Hospital »Merkur«, Zagreb, Croatia6 Intensive Care Unit, Department of Internal Medicine, University Hospital Dubrava, Zagreb, CroatiaA B S T R A C TPercutaneous tracheostomy (PCT) is a safe method under proper patient selection, increased technical experience andbronchoscopy- or ultrasound-guided procedure. Trauma patients with cervical spine fractures and spinal cord injury areat a high risk for respiratory failure and require a definitive airway followed by prolonged mechanical ventilation. Wewould like to present multiple, life- threatening complications after unsuccessful attempt of the guidewire dilating for-ceps tracheostomy (GWDF) in one trauma patient with a cervical spine injury. With this case report we would like to layemphasis on the importance of continuously bronchoscopy- or ultrasound-guided PTC in trauma patients, especiallywith cervical spine injury, as the need to respect the steep-learning curve in its performance.Key words: percutaneous tracheostomy, cervical spine trauma, complications, critical careIntroductionPercutaneous tracheostomy (PCT) is a safe methodunder proper patient selection, increased technical expe-rience and bronchoscopy- or ultrasound-guided proce-dure1–7. Early perioperative complications classified asserious (cardiorespiratory arrest, death, loss of airway,pneumothorax, pneumomediastinum), intermediate (hy-poxia/hypotension, tracheal wall injury, guidewire andcannula misplacement, perforation of the esophagus, as-piration) and minor (hemorrhage, subcutaneous emphy-sema, false passage) are procedure-specific and well de-scribed by many authors8,16. Trauma patients with cervi-cal spine fractures and spinal cord injury are at a highrisk for respiratory failure and require a definitive air-way followed by prolonged mechanical ventilation17. Highcervical levels, the presence of pneumonia, a preexistinglung disease and the patient age were identified as pre-disposing factors for frequent early tracheostomy place-ment18. Previous neck surgery and unstable cervical spi-ne fracture were adverse conditions for PCT3,19,20. Fewauthors have made an extended indication (short, fatneck, previous tracheostomy, reduction or inability toperform neck extension, anti-coagulation therapy) forPCT performed by experienced surgeons21–24. Ben Nun Ahas found PCT to be a feasible and safe procedure withminimal short and long term morbidity in 34 multi--trauma patients with cervical spine fracture and avail-able anatomical landmarks without neck extension25. Onthe other side, Massick DD has shown that 60% of all com-plications occurred in the course of the first 20 PCTs5.Further, the suboptimal cervical anatomy is responsible1409Received for publication April 4, 2007for a significantly higher total complication incidencerate (65%), which is independent of the experience levelwith PCT technique described by Massick DD and LiaoL3,5.We would like to present multiple, life- threateningcomplications after unsuccessful attempt of the guide-wire dilating forceps tracheostomy (GWDF) in one trau-ma patient with a cervical spine injury. The procedurewas performed by a young staff, under failed anatomicselection criteria and without clear bronchoscopy detec-tion during PCT.Case ReportA 72-old man was admitted to ICU after accident-re-lated head, neck and brain injuries. CT scans confirmed aleft temporal lobe contusion, fractures of the middleskull base and the right pyramid. Lamellar epiduralhaematoma covered the both temporal lobes. There werealso fractures of the dens axis and anterior arch of thefirst cervical vertebra without significant dislocations.These injuries were treated non-operatively. Chronic ob-structive pulmonary disease with a left-sided liquid- andpartial right-sided fibrothorax were detected by chest ra-diography. Tracheostomy was indicated 13 days afterintubation in view of prolonged ventilatory dependence,excessive mucus production and need for frequent bron-chopulmonary toilet. A shorter distance between thecricoid’s cartilage and the sternal angle (3 cm; it was noteither less but nor longer, retrospectively) with no possi-bility for the appropriate cervical spine extension wasnoted. Under these circumstances, the PCT was per-formed in the operating room under bronchoscope-gui-ded procedure. The guidewire dilating forceps technique(GWDF) was used. The procedure was performed undergeneral anesthesia (propofol 2.5 mg kg–1, vecuronium 0.1mg kg–1, sufentanil 0.15 mg kg–1, 50% 02 air mixture, 0.8% sevoflurane). Bronchofiberscope was placed throughthe tracheal tube on its top and the tube was pulled tothe cuff position between the vocal cords and the imme-diate subglottis. A junior critical care physician providedbronchoskopic evaluation of the procedure.A horizontal incision was made between the secondand third tracheal ring. Hemorrhage close to the incisionfield stopped after reinfiltration of lidocaine 1% with epi-nephrine (1:100.000). The blood loss was less than 5 mL.The trachea was punctured twice. In the first attempt,the cannulated needle was inserted vertically to the tra-chea, approximately at the 2.0 cm-depth with clear aspi-ration of air but without clearly confirmation of its top bybronchoscopy. In the second attempt, the same hap-pened. This time the needle was placed deeper (2.5 cm)and directed something more lateral to the right side,retrospectively. Clear aspiration of air was present in sy-ringe but the cannulated needle’s top was not confirmedby bronchoscope, again. The surgeon’s decision was tocontinue the procedure in spite of negative broncho-scopic evaluation. The guidewire passed through veryeasily. Retrospectively, we supposed, it was dislocated outof the posterior tracheal wall at that time and penetratedthe esophagus. The forceps dilatation of the trachea wasperformed without difficulty. The guidewire slip pastwithout resistance. But the tracheostomy tube was notpassing by easily. Capnography did not confirm its cor-rect position. It was placed paratracheally as a result ofthe guidewire kinking, retrospetively. Profound tran-sient hypoxemia (SaO 34%) and bradyarrhytima occu-rred followed with severe hypotension and cardiac arrest.The patient was re-intubated under suspicion on unin-tentional draw out of tracheal tube, successfully resusci-tated in one minute and kept on mechanical ventilation.Chest radiography detected a pneumomediastinum and abilateral pneumothorax (Figure 1). CT scans have con-firmed these findings but also included suspected com-munication between the posterior tracheal wall and theesophagus on the one site and mediastinum on the othersite (Figure 2). The false route of the tracheostomy tubepassed by the right paratracheal side in the anteriormediastinum. Thoracic drains were inserted into thepleural cavity on both sides. The patient stabilized andopen surgical tracheostomy was done. To detect esopha-gus and tracheal injury, a spine and chest surgeon per-formed exploration of the neck and a right-sided tho-racotomy. Fenestrations on the posterior tracheal andanterior esophageal wall were minimal and did not re-quire any surgical reconstructions. A nasogastric tubewas placed. Drainage of mediastinal cavity was per-formed in order to prevent mediastinal and subcutane-ous emphysema.After 3 days the patient developed fever with hightemperature. Wound infection of the right-sided thora-cotomy was detected. Antibiotics were introduced imme-diately according to the wound culture results. Both tho-racic drains were removed on the eight-day after completeregression of pneumomediastinum and pneumothoraxhad been confirmed. In the following month the patientD. Bartolek et al.: Complications of Percutaneous Tracheostomy, Coll. Antropol. 33 (2009) 4: 1409–14131410Fig. 1. Chest radiography with detected 1- pneumomediastinum,and 2- right- and left-sided pneumothorax.was treated in the ICU due to the presence of right andleft liquidothorax, right-sided pneumonia and weaningfrom mechanical ventilation. One and half month afterhis injury, he was admitted conscious, respiratory suffi-cient with spontaneous breathing over the tracheal can-nula to the department of neurosurgery.DiscussionThe PCT has become, as minimally invasive tech-nique, an alternative method to conventional surgicaltracheostomy (ST) for long-term intubated patients.Early meta- analyses showed that the PCT techniqueproved to be associated with a higher incidence of compli-cations as compared to the ST: 4–10% vs. 2–3% for earlyperioperative complications, 0.33% vs. 0.06% for seriouscardiorespiratory events and 0.44% vs. 0.03% for perio-perative deaths26,27.Delaney A and Higgiss K.M have shown in their recen-tly meta-analysis significant higher complications of deca-nnulation/obstruction (The pooled odds ratio, OR=2.79)during PTC to compare with ST and no significantly evi-dence of increased incidence of clinically significant blee-ding 5.7% (OR=0.6), major perioperative 2.6% (false passa-ge, OR=0.37, minor hemorrhage, OR=1.09) or long termcomplication during PCT (subglotic stenosis, OR=0.59).There were significantly less wound infection 6.6%(OR=0.28–0.37) and unfavorable scarring (OR=0.44).Their subgroup analysis of PCT pointed out that it wasassociated with a reduction in overall mortality (OR=O.70)to compare with ST28,29. These conclusions could not beaccepted for cardiac arrest, sepsis, posterior tracheal wallinjugy, pneumomediastinum, tracheo-innominate fistula,mediastinitis, pneumonia, atelectasis, aspiration and sub-cutaneous emphysema because of minimal events of re-porting29.Pneumothorax and pneumomediastinum are relevantbut infrequent complications of PCT. Pneumothorax in-cidence ranges from 0.0–6.7%1,3,16. The posterior trachealwall injury is the most often cause of pneumothorax inPCT technique. Pleural cavity extends around the lateralto the posterior tracheal wall and might be punctured bythe tip of the needle even when puncturing the trachea inthe middle. The short distance between dorsal trachealwall and pleural cavity enhance the possibility of pleuralpuncture. The air leak through mediastinal pleura aftertracheal wall injury might be the occurrence of pneumo-mediastinum with incidence of 0.005–0.06%3,8. The mid-line puncture of the tracheal anterior wall and reductionin potentially serious complications can only be achievedby bronchoscopic or ultrasound monitoring4,10.Esophageal perforation is a rare (0–0.6%) but seriouscomplication of PCT20. It could be expected in presence ofposterior tracheal wall injury by needle, guidewire or tipof dilatator15. Early surgical reconstruction of any recog-nized extensive posterior tracheal wall and esophagus in-jury is required to avoid the life-treating complication astracheo-esophageal, tracheo-innominate fistula and con-secutive mediastinitis. We supposed that the left-sidedpneumothorax and esophageal perforation were causedin our case in the second attempt by the needle andguidewire that penetrated to deep thru the posterior tra-cheal wall. According to the extension of tracheal andesophageal injury measured by CT scans, we could not beable to exclude the possibility that the tip of GWFTdilatator’s penetrated thru this structures also.The incidence of paratracheal insertion of tracheo-stomy tube, reported by various authors, ranges from 0.5to 6.7%1,27,30–32. Despite proper placement of needle andguidewire, calcified cartilage of tracheal rings especiallyin elderly may deflect the dilators and bend the guide-wire making a predisposition for creating a false passageof tracheostomy tube into the anterior mediastinum. Inour case, we supposed that the guidewire was dislocatedoutside the trachea as the consequence of the needle mis-placement under inappropriate bronchoscope visualiza-tion. The false passage on the right tracheal side causedpneumomediastinum and right sided pneumothorax. Ourinconvenient experience has proved the statement ofPolderman K that bronchoscopy-assisted PTC, in corre-lation with blind procedure provides the lower rate ofmoderate and serious complications (3.0% vs. 7.3%) andmortality (3.8% vs. 9.7%)33.Patients with adverse conditions (short, fat neck, obe-sity cervical injury, coagulopathy, emergency) had a lowPTC complication rate similar to patients with normalconditions by Ben Nun A21. Mayberry JC has reportedabout safely performed PCT in trauma patients withoutcervical spine clearance and neck extension, includingpatients with stabilized cervical spine or spinal cordinjury22. PCT my be advantageous and safe in early tra-D. Bartolek et al.: Complications of Percutaneous Tracheostomy, Coll. Antropol. 33 (2009) 4: 1409–14131411Fig. 2. CT scan of the thorax: 1-pnemomediastinum, 2-right- andleft-sided pneumothorax, 3-tracheal posterior wall injury withesophagus perforation, 4-suspected communication between theposterior tracheal wall and the anterior mediastinum.cheotomy insertion 6–10 days after anterior cervicalspine fixation, particularly in the presence of cervicalcord injury and under ultrasound-guided performance asreported by O’Keeffe T23. PCT is equally safe as ST in pa-tients with anterior cervical spine fixation as describedby [usti} A24.Following the results of a meta-analysis and random-ized controlled studies, PTC appears to be a safe tech-nique in experienced hands. Under this condition thecervical spine fracture would not be considered a contra-indication for PTC10,25. In conclusion, the complicationrate of PTC depends on local medical expertise and thelevel of experience of the person performing the proce-dure. Initial PCT attempts should be supervised by anexperienced surgeon3,18. With this case report we wouldlike to stress the importance of continuous bronchos-copy- or ultrasound-guided PTC in trauma patients, es-pecially with cervical spine injury, as the need to respectthe steep-learning curve in its performance.AcknowledgementsAuthors’ special thanks go to Mrs B.A Gordana Ram-ljak, Medical Librarian-University Hospital of Trauma-tology for English assistance and correction.R E F E R E N C E S1. RAVI KUMAR A, SANJEEV M, SENTHIL K, GOPINATH M, In-dian J Otolaryngol Head Neck Surg, 57 (2005) 202. — 2. MASSICK DD,YAO S, POWELL DM, GRIESEN D, HOBGOOD T, ALLEN JN, SCHU-LLER DE, Laryngosc, 111 (2001) 494. — 3. LIAO L, MYERS J, JOHN-STON J, CORNEILLE M, DANIELSON D, DENT D, STEWART R, PRU-ITT B, ROOT D, COHN S, Am J Surg, 190 (2005) 923. — 4. OBERWAL-DER M, WEIS H, NEHODA H, KAFKA-RITSCH R, BONATTI H, PRO-MMEGGER R, AIGNER F, PROFANTER C, Surg Endosc, 18(5) (2004)839. — 5. 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BEN NUNA, ORLOVSKY M, BEST LA, Interact CardioVasc Thorac Surg, 5 (2006)427. — 26. DULGUEROV P, GYSIN C, PERNEGER T, CHEVROLET JC,Crit Care Med, 27 (1999) 1677. — 27.FREEMAN BD, ISABELLA K, LINN, BUCHMAN TG, Chest, 118 (2000) 1412. — 28. DELANEY A,BAGSHAW SM, NALOS M, Critical Care, 10 (2006) R55. — 29. HIGGINSKM, PUNTHAKEE X, The Laryngoscope, 117 (2007) 447. — 30. LIM JW,FRIEDMANM, TANYERI H, Ann Otol Rhinol Laryngol, 109 (2000) 791. —31. MOE KS, SCHMID S, STOECKLI SJ, WEYMULLER EA, Ann OtolRhinol Laryngol, 108 (1999) 384. — 32. POWELL DM, PRICE PD, FOR-RESTLA, Laryngosc, 108 (1998) 170.— 33. POLDERMANKH, SPIJKSTRAJJ, DE BREE R, HERMAN MT, CHRISTIAANS HMT, GELISSENHPMM, WESTER JPJ, GIRBES ARJ, Chest, 123 (2003) 1595.D. BartolekDepartment of Anaesthesiology and Intensive Care Unit, University Hospital of Traumatology, Dra{kovi}eva 18,10000 Zagreb, Croatiae-mail: dubravka.bartolek1@zg.t-com.hrD. Bartolek et al.: Complications of Percutaneous Tracheostomy, Coll. Antropol. 33 (2009) 4: 1409–14131412@IVOTNO UGRO@AVAJU]E KOMPLIKACIJE NAKON NEUSPJELA POKU[AJA PERKUTANETRAHEOTOMIJE KOD POLITRAUMATIZIRANOG BOLESNIKA SA OZLJEDOM VRATNEKRALJE@NICES A @ E T A KPerkutana traheotomija (PTC) je klini~ki {iroko prihva}ena metoda osiguravanja di{nog puta u jedinicama inten-zivne skrbi. Pravilna selekcija bolesnika prema op}e prihva}enim indikacijama i anatomskim markacijama uz konti-nuiranu vizualizaciju postupka bronhoskopom (ili ultrazvukom) osigurava sigurno izvo|enje svakog njegovog segmenta.Sveukupni porast tehni~koga iskustva u izvo|enju PCT neminovno doprinosi smanjenju nastanka mogu}ih ne`eljenihkomplikacija. Bolesnici sa ozljedom vratne kralje`nice, sa ili bez pridru`ene ozljede vratnoga dijela le|ne mo`dine ~inevisokorizi~nu skupinu bolesnika sa pojavom produ`ene respiracijske insuficijencije i potrebom za mehani~kom venti-lacijom kod kojih je traheotomija u ve}ini slu~ajeva neizbje`na. Ovim opisom klini~kog slu~aja `elimo prikazati nastalevi{estuke, po `ivot opasne komplikacije nakon neuspje{noga poku{aja izvo|enja PCT kod politraumatiziranog bolesni-ka sa pridru`enom povredom vratnog dijela kralje`nice. Njime tako|er `elimo ista}i va`nost kontinuirane vizualizacijecjelokupnog postupka izvo|enja PTC (bronhoskopom ili ultrazvukom) kao i po{tivanja graduacije stjecanja tehni~ke iprakti~ne vje{tine osobe kao i tima koje je izvodi.D. Bartolek et al.: Complications of Percutaneous Tracheostomy, Coll. Antropol. 33 (2009) 4: 1409–14131413

Life threatening complications after unsuccessful attempt of the guidewire dilating forceps tracheostomy in multi-trauma patient with cervical spine injury [Životno ugrožavajuće komplikacije nakon neuspjela pokušaja perkutane traheotomije kod politraumatizitanog bolesnika s ozljedom vratne kralježnice]

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