A dangerous percutaneous dilatational tracheostomy

Excerpt

A 60-year-old male underwent emergent coronary artery bypass grafting for acute myocardial infarction. The patient was admitted postoperatively to our Intensive care unit (ICU) with a severe cardiogenic shock. During the first postoperative day he developed renal and severe respiratory failure. On the seventh post-operative day a percutaneous dilatational tracheostomy (PDT) due to difficult respiratory weaning was deemed necessary. Our preferred technique includes the use of a Ciaglia Blue Rhino^® Introducer Kit (Cook Medical Critical Care, Bloomington, Ireland) under bronchoscopic control. In the reported case the needle puncture resulted twice in venous bleeding, leading to abortion of the procedure; the puncture site was manually compressed. Cervical ultrasound showed an atypical huge anterior jugular vein passing just anteriorly of the tracheal midline (Figs. 1, 2). This finding was confirmed by computed tomography-angiography (Fig. 3). Complications of PDT are relatively rare, but can be life-threatening. Ultrasound scanning of the neck is increasingly advocated prior to puncture. This case confirms the usefulness of this diagnostic modality. Continuation of the procedure would have caused severe bleeding due to laceration of this atypical huge vein. Since this event, we routinely perform a cervical ultrasound scan prior to every PDT in our ICU.

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