PURPOSE: Percutaneous dilatational tracheostomy (PDT) is a common procedure performed in critically ill patients. While the rate of mortality from the procedure remains low, the cause is usually vascular hemorrhage. The use of portable ultrasound preoperatively may help to reduce this complication.
METHODS: The Anesthesiology Tracheostomy Service was consulted from ICU services throughout the hospital for elective tracheostomy placement. Patients with difficult anatomy (ie, short neck, non-palpable airway surface anatomy) or severe coagulopathy were excluded. The remaining patients with acceptable anatomy and ventilator parameters were examined with portable ultrasound at bedside to assess for aberrant pretracheal anatomy.
RESULTS: Twenty patients were examined via ultrasound for prominent pretracheal vasculature. In one patient, vascular anatomy was determined to be a contraindication to percutaneous tracheostomy and the patient was referred for open surgical tracheostomy. Two patients revealed prominent pretracheal vasculature that resulted in intraoperative ultrasound to avoid inadvertent vascular puncture. No intraoperative complications were observed.
CONCLUSION: PDT is a common procedure with the benefits of low risk, efficiency, and decreased hospital cost. Most reported fatalities have been due to hemorrhage from arterial bleeding. Current use of fiberoptic bronchoscopy has aided in midline placement and the detection of intratracheal complications; however, it has not helped to identify pretracheal vessels that may lead to bleeding complications. The use of preoperative bedside ultrasound may help to further determine which patients may be more suitable for surgical tracheostomy with elective vessel ligation in the operating room. If percutaneous tracheostomy is performed, ultrasound may also be performed to help determine a safe site puncture to avoid prominent anterior vessel puncture.
CLINICAL IMPLICATIONS: Percutaneous tracheostomy is safe procedure performed frequently in critically ill patients; however, bleeding remains the most common early complication. Preoperative portable ultrasound may help to detect patients with aberrant pretracheal anatomy that are prone to a higher risk of intraoperative hemorrhage. We suggest that routine preoperative or intraoperative-guided ultrasound may be useful to further reduce the complications associated with percutaneous dilatational tracheostomy.
DISCLOSURE: Nicole Howell, No Financial Disclosure Information; No Product/Research Disclosure Information