Repeat bedside percutaneous tracheostomy: still a contraindication?

Introduction

Percutaneous tracheostomy has become an established procedure in airway management of critically ill patients. Repeat PDT is considered a (relative) contraindication as a result of distorted anatomy.

Methods

A retrospective review of all repeat bedside percutaneous dilatational tracheostomies (Ciaglia technique with direct bronchoscopic guidance) performed on our cardiothoracic critical care unit from January 2004 to February 2013 was conducted.

Results

From a total of 1,001 patients undergoing PDT, we identified 36 patients with repeat PDT. Patients' previous tracheostomies dated back between 5 days and 2.7 years (mean 122 days). Mean age was 60.3 ± 14.3 years, 42% of patients were female. The mean time from intubation to PDT was 3.7 ± 3.9 days. There were no deaths associated with PDT but one major procedure-related complication: one patient suffered from a periprocedural laceration of the brachiocephalic trunk. After emergency surgery and surgical tracheotomy (ST), the patient recovered completely. In all other patients, no conversion to ST, no loss of airway, no paratracheal insertion, and no accidental tracheal extubation was observed. No pneumothorax, pneumomediastinum, hypotension, hypoxemia, or arrhythmias were recorded. A mild bleeding was observed in 13 patients (36%). A moderate but not significant bleeding was observed in only one patient (2.8%). A tracheal ring fracture occurred in six patients (16.7%). Fourteen patients (38.9%) could be weaned successfully from the respirator and the tracheostomy could be removed. Thirteen patients (36.1%) were transferred to another ICU with the tracheostomy in place. The functional and cosmetic outcomes of PDT were excellent.

Conclusion

Repeat PDT is a safe procedure in experienced hands and should not be generally considered a contraindication. However, special attention should be paid to the anatomical situation with an increased risk of vascular complications.