1 Newcastle-upon-Tyne, UK
EditorA 61-yr-old lady, who 17 yr previously had had a cadaveric renal transplant, was admitted with a pancytopenia in a moribund condition. She appeared septic, had aspirated vomit and was extremely acidotic. She was resuscitated with mechanical ventilation, inotropes, renal support, and antibiotics.
She responded surprisingly well and 3 days later she had a failed trial of extubation requiring reintubation and reinstitution of mechanical ventilation after 8 h. Failure to progress further led us to plan a percutaneous dilational tracheostomy (PDT) 2 days later. Her prothrombin time was 16 s and platelet count 24x109 litre1. She was therefore given clotting factors and platelets, and haemofiltration discontinued prior to the procedure. Two other Ciagula PDTs had been performed by the same team that day uneventfully. It was noted that the patient had undergone a parathyroidectomy previously but that the neck was thin, with a visible scar and with no obvious abnormality, and the trachea was easily palpable.
The procedure was undertaken using a fibreoptic bronchoscope to visualize insertion in the normal way. The initial skin incision despite local anaesthetic with epinephrine infiltration was noted immediately to be more bloody than normal. The PDT was inserted but the bleeding persisted. Haemostatic sutures were placed around the insertion site, and direct pressure applied. Epinephrine i.v. was commenced to support the blood pressure and additional blood products ordered and transfused. When the bleeding persisted for 2 h, a surgical opinion was requested and the patient subsequently underwent surgical exploration of the neck. The patient was re-intubated orally and removal of the PDT was followed by torrential haemorrhage. The surgeon was able to identify several arterial bleeding points in the thyroid isthmus which were ligated. The effect of all these events meant that the patients condition worsened considerably and despite all support she died the next day. Post mortem confirmed correct placement of the PDT and extensive bleeding into the thyroid gland.
The operator had undertaken 35 PDTs (mainly Portex dilation technique) without major difficulties. Haemorrhage is a recognized hazard of any tracheostomy and significant haemorrhage has been cited as occurring in up to 5% of all cases, irrespective of the technique (surgical or PDT) used.13 The decision to undertake this procedure with deranged clotting is a common dilemma and the correction of clotting variables a common practice. Previous surgery of the neck has not been considered an absolute contraindication in the past, but with hindsight may have resulted in distortion of the blood supply.
In a cadaveric study of 20 cadavers, an attempt to place a percutaneous catheter between the first and second tracheal rings was made with success in only nine attempts, and in one-third the thyroid isthmus was punctured.4 Farmery and colleagues5 highlighted that there can be considerable variation in the anatomy of the adjacent arterial vessels. The most common arterial anomalies involve the position of the left subclavian artery, which in this study passed anterior to the trachea in 5% of patients, and in 6% the superior and inferior thyroid arteries ascend onto the anterior surface of the trachea. Venous anomalies also occur to such an extent that we now consider it mandatory to ultrasound the neck whenever the patient has previously had surgery in that area,6 and there is an argument for recommending that it be used on all patients necks routinely prior to PDT.
There is only one previous procedural death reported.7 Anecdotal reports suggest that it is likely to be an underestimate of the clinical experience of this particular problem. Our patient could have died at the time of surgical intervention and did die as a result of massive blood loss some hours later. The effect on the operator has been considerable in that the subsequent medicolegal delay and knock-on psychological consequences8 have led to a delay of 3 yr in reporting this case, and the operator has undertaken no further PDTs. Nevertheless, it is recognized as a safer technique in many respects than surgical procedures in this group of patients,1 so the procedure has been undertaken within the unit since then by other clinicians.
D. W. Ryan
A. J. Kilner
Newcastle upon Tyne, UK
References
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