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Case Example Percutaneous Tracheotomy

last modified on: Mon, 09/11/2017 - 12:53

Case Example Percutaneous Tracheotomy

 return to: Percutaneous Tracheotomy - Dilation

Modified/edited operative note:

Securing the airway: The patient was brought into the main OR by Anesthesia and placed in a supine padded position with the head positioned toward anesthesia. Due to concerns about potential airway difficulties, the neck was injected with 1% lidocaine with 1:100,000 epinephrine (10 cc) to the upper trachea and cricoid in preparation for possible urgent tracheotomy or cricothyrotomy. Additionally, the bovie monopolar cautery was connected and tested after placement of a grounding pad. Instrumentation for tracheotomy were opened and identified as adequate for possible urgent surgery. The patient then underwent mask ventilation followed by an effort by anesthesia to intubate using MAC blade showing only a grade 4 view. Mask anesthesia was resumed with the Otolaryngology evaluating the airway with a Dedo laryngoscope and suspended (employing a Lewy suspension placed on a pillow over the chest) with fulcrum laryngoscopy permitting intubation with a 5-0 MLT endotracheal tube through the laryngoscope. Ventilation was reestablished and confirmed with return of CO2 identified on the monitor. There were no desaturations.  The superior attachment to the ET tube was removed and the end of the ETT grasped with straight forceps. The cuff of the endotracheal tube was deflated and the ETT was advanced (pushing it into the right mainstem with the straight forceps through the Dedo laryngoscope) as the Dedo scope was withdrawn.  The tube was then digitally palpated intraorally at its exit from the tip of the Dedo laryngoscopy. It was secured in this position by by trapping it with digital pressure against the tongue as the straight forceps were released and the Dedo laryngoscope was removed. The ETT was then repositioned as it was pulled back to ~ 23 cm marking with the cuff reinflated auscultation of the lungs revealed bilateral breath sounds and it was secured with tape to the corner of the mouth.

Performing the Percutaneous Tracheotomy: The patient was rotated, 90 degrees, and repositioned.  The Lindholm laryngoscope was inserted with poor visualization of the glottis. Next, the Dedo laryngoscope was inserted with good visualization of the vocal cords employing suspension laryngoscopy with the Lewy apparatus. The percutaneous tracheotomy was done with the patient in suspension. The neck was prepped and draped in a sterile fashion. 1% lidocaine with epinephrine had previously been injected into the tracheostomy site. A long 0 degree Storz telescope was used to image the glottic larynx, subglottis and upper trachea. Next the percutaneous kit was opened. A stab incision was initiated through the skin and through some subcutaneous tissue. Next a series of hemostats were used to dilate the skin and subcutaneous tissue. The introducer was then inserted through the anterior tracheal wall and visualized with the 0 degree scope. Next, a series of dilators were used to dilate the tracheostomy opening. After the opening had been appropriately dilated, a #6 percutaneous Shiley trach was inserted. The cuff was then removed from the ET tube and that was removed from the airway. The cuff was inflated on the tracheostomy tube and connected to the ventilator. The tracheostomy tube was then secured with 3-0 nylon and trach straps. Patient was taken out of suspension and returned to anesthesia.