In the Trauma ICU we often have patients who have severe injuries and require mechanical ventilation and an accompanying endotracheal tube for long periods of time. One complication of long-term intubation is tracheal stenosis. In order to prevent this complication we often replace the oral endotracheal tube for a tracheostomy tube if the patient has required (or most likely will require) mechanical ventilation for more than 10-14 days.
Besides preventing tracheal stenosis, some additional benefits to tracheostomy tubes include better pulmonary toilet (patient’s cough more easily, RNs and RTs are able to suction more thoroughly), airway protection, and patient comfort.
We have one such patient in our Trauma ICU now, who has developed severe ARDS from a severe blunt chest trauma he sustained. There are many different ways to place a tracheostomy (including percutaneously), but here is how we performed this patient’ tracheostomy:
Positioning:
- Supine
- Both arms tucked
- If safe (e.g. c-spine is cleared), optimal exposure is best obtained with neck extension and can be accomplished shoulder roll
Technique:
- With marking pen, mark out cricoid cartilage, sternal notch and
- With a 15-blade knife make a 2-3 cm horizontal incision at a point 1 – 1.5 finger-breadths above the sternal notch
- Using electrocautery, dissect through platysma to strap muscles, ligate anterior external jugular vein if necessary
- Bluntly retract right and left strap muscles laterally to expose the thyroid isthmus and tracheal rings
- Using a Kittner (“peanut”) clear off the tracheal rings inferior to thyroid
- Identify the 1st, 2nd and 3rd tracheal rings
- Using a 2-0 Polysorb stitch on a GU needle, go through the inferior skin edge, near midline
- With same suture, take a bite through 2nd tracheal, just right of midline
- Again with the same suture, take a bite just left of midline, but going the opposite direction (so that you have created a U-stitch thru the 2nd tracheal ring)
- Then pass same suture back out through the skin, next to where you went in, cut the needle so that there are two, 4-5cm free ends of the polysorb left outside the skin
- With electocautery, score an upside down U, thru the 2nd tracheal ring
- With an 11-blade knife cut thru the trachea along the scored area – this will create a “trap door” (also called a Bjork flap) that can be tied to the skin or just left in place. The free ends of the Polysorb stitch can now be used to hold the tracheotomy open, or as a guide in case the tracheostomy tube ever comes out).
- Prepare the tracheostomy tube (a size 6, Shiley is usually appropriate for most adults)
- Ask the anesthesiologist to deflate the endotracheal tube cuff and slowly back it out as you watch the tube through the tracheotomy.
- As soon as the endotracheal tube tip is cephalad to tracheotomy, carefully place the tracheostomy tube into the trachea, remove the obturator and hook the ventilator up to the tracheostomy
- Check to make sure that the patient is oxygenating and ventilating appropriately
- Secure the flange of the Shiley to the skin with 0-Nylon sutures then again with the umbilical tape that is usually provided with the tracheostomy tube.
This isn’t the definitive way of doing this procedure, and there are some idiosyncrasies to do it safely (i.e. lower the FiO2 the patient is getting while using the electrocautery near the trachea), but this is the basic outline for how we successfully placed a tracheostomy for this patient.
Thanks to Dr. Allan Peetz for this post.
No comments:
Post a Comment