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CORRESPONDENCE
Year : 2011  |  Volume : 55  |  Issue : 2  |  Page : 215  

Guidewire impaction during percutaneous dilatational tracheostomy


Department of Anaesthesia and Critical Care, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication22-Apr-2011

Correspondence Address:
Pramendra Agrawal
A-148, Sector-15, Noida, Uttar Pradesh-201 301
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.79888

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How to cite this article:
Agrawal P, Gupta B, D'souza N, Soni KD, Sinha C. Guidewire impaction during percutaneous dilatational tracheostomy. Indian J Anaesth 2011;55:215

How to cite this URL:
Agrawal P, Gupta B, D'souza N, Soni KD, Sinha C. Guidewire impaction during percutaneous dilatational tracheostomy. Indian J Anaesth [serial online] 2011 [cited 2019 Jul 20];55:215. Available from: http://www.ijaweb.org/text.asp?2011/55/2/215/79888

Sir,

Percutaneous dilatational tracheostomy (PDT) is a frequently carried out procedure in a critical care setting. It is performed in majority of patients by intensivists bedside under endoscopic guidance. Though simple PDT is not devoid of complications, especially if done without endoscopic guidance. We discuss an unusual complication during PDT. A PDT was planned in a 45-year-old male patient with head injury. The patient was placed on a regimen of 1.0 FiO 2 (Fraction of inspired oxygen). Blood pressure, cardiac rhythm and oxygen saturation were continuously monitored. Analgesia, sedation and neuromuscular blockade were administered. The neck was extended and antiseptic solution on the surgical field was applied. The endotracheal tube was repositioned above the site of the proposed tracheostomy under bronchoscopic guidance. The endotracheal tube cuff was deflated and it was withdrawn to just below the vocal cords. During the insertion of the introducer needle, the lamp of the fibrescope stopped functioning. We decided to proceed without endoscopic guidance since the needle was introduced. Griggs technique was performed using the percutaneous tracheostomy kit. At the end of the procedure, we were unable to pull out the guidewire through the tracheostomy tube. When the endotracheal tube was pulled out, the guidewire also came along with it [Figure 1].
Figure 1: Guidewire coming out through oral route along with endotracheal tube

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Griggs et al. [1] reported the guide wire dilatation forceps (GWDF) technique in 1990. Van Heerden et al., [2] published a series of 54 patients of PDT. They used a bronchoscope for the first 15 cases and found that bleeding and damage to the endotracheal tube were the most common complications. In our case, the introducer needle must have pierced the Murphy's eye, causing the guidewire to get entangled. Studies with PDT performed with endoscopic guidance [3],[4],[5],[6] have reported lower complication rates than studies performed with 'blind' PDT. Perioperative and late complication rates for endoscopic and non-endoscopic PDT have been reported to be: 7.2% versus 8.2%, 3.9% versus 6.1% and 1% versus 2.2%, respectively. The mortality rates were 0.65% and 0.52%, respectively, for endoscopically guided and 'blind' PDT. [7] Although bronchoscope-guided PDT is advisable, there are still many centres where bronchoscope is not available and blind PDT is done.

This complication re-emphasises the use of bronchoscope during all PDT procedures.

 
   References Top

1.Griggs WM, Worthley LI, Gilligan JE, Thomas PD, Myburg JA.A simple percutaneous tracheostomy technique. Surgery 1990;170:543-5.  Back to cited text no. 1
    
2.Van Heerden PV, Webb SA, Power BM, Thompson WR. Percutaneous dilational tracheostomy.A clinical study evaluating two systems. Anaesth Intensive Care 1996;24:56-9.  Back to cited text no. 2
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3.Marelli D, Paul A, Manolidis S. Endoscopic guided percutaneous tracheostomy: Early results of a consecutive trial. J Trauma 1990;30:433-5.  Back to cited text no. 3
    
4.Manara AR. Experience with percutaneous tracheostomy in intensive care: The technique of choice? Br J Oral Maxillofac Surg 1994;32:155-60.  Back to cited text no. 4
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5.Winkler WB, Karnik R, Seelmann O, Havlicek J, Slany J. Bedside percutaneous dilational tracheostomy with endoscopic guidance: Experience with 71 ICU patients. Intensive Care Med 1994;20:476-9.  Back to cited text no. 5
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6.Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy/gastrostomy in brain-injured patients: A minimally invasive alteranative. J Trauma 1992;33:435-9.  Back to cited text no. 6
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7.Powell DM, Price PD, Forrest LA. Review of percutaneous tracheostomy. Laryngoscope 1998;108:170-7.  Back to cited text no. 7
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