Percutaneous tracheostomy (PCT) is a blind surgical procedure that has a risk of producing tracheal and adjacent tissues injury with possible subsequent complications.
This case report describes a case of posterior tracheal wall injury during PCT, which led to a series of complications, namely mediastinal emphysema, compromised mediastinal pleura, and right tension pneumothorax.
Cardiac arrest, tension pneumothorax and emphysema may be encountered during PCT even with use of bronchoscopy. Adequate local anesthesia and appropriate sedation are essential to prevent injuries caused by unwanted movements.
In bronchoscopy-assisted surgery, even if posterior tracheal wall and anterior esophageal wall damage is inevitable, emergency treatment can be provided immediately.
Percutaneous tracheostomy (PCT) is a blind surgical procedure that may cause traumatic injury to the tracheal wall and surrounding structures. Complications related to injuries include mediastinal or subcutaneous emphysema, tension pneumothorax and cardiac arrest [ ]. In this case report, we describe the clinical presentation and management scenario of a patient who developed cardiac arrest and right tension pneumothorax as a result of injury to the posterior tracheal wall during PCT.
A 61-year-old male was transported to the emergency room (ER) after motor car accident associated with deforming head trauma. Cardiopulmonary resuscitation (CPR) was immediately initiated and the patient was admitted to the intensive care unit (ICU) after securing endotracheal intubation. Brain CT identified signs of cerebral hemorrhage. and low-lying cerebellar tonsil. Right eye imaging showed vitreous hemorrhage. Chest CT identified bilateral basal subpleural pulmonary subsegmental atelectatic changes. No associated contusions or pneumothorax were detected. Pelvi-abdominal CT showed multiple skeletal fractures. No significant soft tissue or visceral injuries were identified.
In the ICU, the patient was kept on invasive mechanical ventilation (MV) and was managed under the supervision of multidisciplinary team including intensivists, neurosurgeons and orthopedic surgeons. After 7 days, the supervising intensivist recommended PCT by fiberoptic bronchoscope (FOB) in the operation room.
After administration of 2.5 mg midazolam, an ENT surgeon commenced PCT using FOB through endotracheal tube (ETT) and tracheostomy kit (Neo Perc™ Percutaneous Tracheostomy Kit, Covidien, Japan). During tracheostomy, additional 0.5 mg boluses of midazolam were administered as needed, up to a total of 4 mg. Penetration of the membrane between first and second trachea rings was achieved by a 22-gauge needle and intra-tracheal 4% lidocaine spray. The primary dilator was inserted alongside a guidewire. Lidocaine spray was re-applied because of contractions of expiratory skeletal muscles during insertion of the secondary dilator and a tracheostomy tube size 8 was inserted.
Because no capnographic waveforms appeared when the tube was connected to the anesthesia circuit, we removed the tube and repeated the same procedure but still observed no capnographic waveforms. During this time, several contractions of expiratory skeletal muscles were observed. FOB revealed right tracheal wall perforation. The patient developed cardiac arrest which requested help from ICU team who started CPR till cardiac rhythm was restored (see Fig. 1 ).
Spontaneous ventilation was continued at a fraction of inspired oxygen of 1.0 and oxygen saturation of around 80–90%. After confirmation of capnographic waveforms, anesthesia was induced by 50 mg propofol and 30 mg rocuronium and maintained by 1–1.5% sevoflurane and 0.2 μg/kg/min. remifentanil. However, even after proper insertion of the tracheostomy tube, oxygen saturation remained low at 96% with fraction of inspired oxygen of 1.0. In addition, auscultation detected no respiratory sound in the right lung and FOB revealed no signs of blood and/or secretions in the airway or mainstem intubation. Chest X-ray performed approximately 15 minutes after insertion of the tracheostomy tube revealed a severely collapsed right lung and dislocation of the right diaphragm, leading to diagnosis of tension pneumothorax. In addition, there was subcutaneous and left side surgical emphysema ( Fig. 2 ). We discontinued surgery and remifentanil administration, and administered 200 mg sugammadex sodium to restore spontaneous ventilation. The intensivist inserted chest tube on the right side using chest tube kit connected to a drain under spontaneous ventilation with 1–1.5% sevoflurane. The total duration of surgery was 1 hour and 15 minutes. Duration of anesthesia was 2 hours and 45 minutes. The patient was discharged from the ICU and no procedure-related long-term sequela were reported.