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Safety of semi-open percutaneous tracheotomy when performed in critically ill burn patients
Critical Care volume 11, Article number: P216 (2007)
Lung injury and generalized edema from a burn and resuscitation complicates airway management and patient care. The need for long-term ventilation and multiple surgeries warrant early tracheostomy. Percutaneous techniques are well described; however, the burned and swollen neck increases all of its recognized complications. We report a modified semi-open technique for performing percutaneous tracheotomies (PT) in acutely burned patients, which we consider safer.
We reviewed the medical records of 20 patients admitted to a regional burn center requiring tracheostomy for prolonged mechanical ventilation. The procedure took place in the OR if burn excision was planned; otherwise it was performed at the bedside. The Blue Rhino tracheostomy kit was used for all PT. Major differences from other approaches included dissecting down to the pretracheal fascia, allowing the trachea to be seen and palpated; bleeding was controlled using an electrocautery, and blood vessels were retracted from the field or ligated. The trachea was palpated as the endotracheal tube was withdrawn into the proximal trachea and a flexible bronchoscope was used only to confirm the proper placement of the guidewire. Proper placement of the tracheal tube was confirmed by capnography. In patients with a deep trachea due to severe neck swelling, a proximal-long tracheostomy tube was substituted for the standard one. In the event that the airway or ventilation became compromised, this technique could be converted rapidly to an open procedure.
Of 350 patients admitted to the burn center from July 2005 to December 2006, 20 (6%) required a tracheostomy. Eighteen were performed percutaneously, 13 at the bedside. The total burn surface area averaged 46% (range 2–95%). PT were performed within an average of 10 days from admission (range 0–32 days). Overall mortality in the tracheostomy group was 35%. There were no short-term complications associated with this method.
PT can be performed safely in severely burned patients using a semi-open percutaneous technique. Exposing the trachea and palpating the trachea avoids the risk of losing the airway and permits immediate access to the trachea in the event of an untoward loss of the airway. We believe that this method is safer than the more commonly used technique requiring bronchoscopic visualization.
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Gerold, K., Dhanjani, K., Price, L. et al. Safety of semi-open percutaneous tracheotomy when performed in critically ill burn patients. Crit Care 11 (Suppl 2), P216 (2007). https://doi.org/10.1186/cc5376