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Safety of percutaneous tracheotomy in patients with cricoid cartilage not identified: report of 122 cases
Critical Carevolume 13, Article number: P18 (2009)
Percutaneous tracheotomy (PT) is one of the most frequent procedures carried out in critically ill patients. However, it carries contraindications in the patient group younger than 16 years of age, in cases with known or anticipated difficult endotracheal intubations, in infection of surgical areas and in cases with cricoid cartilage not identified. In this retrospective study, we evaluated the safety of performing the PT-associated blunt dilatational exploration with a right-angle clamp in patients having cricoid cartilage not identified.
We reviewed retrospectively the data of 122 PTs in patients having cricoid cartilage not identified due to obesity or postural deformity, between January 2006 and October 2008. The data obtained from charts included age, sex, timing of PT, duration of the procedure, minor or major complications and mortality. All of the procedures were performed at the bedside in the ICU. After as maximal a positioning of the patient as could be performed, local anesthetic infiltration was applied to 1 to 2 cm superior of the jugular notch of manibrium sterni (according to the structure of patient's neck). After incision (~2 cm) of skin and subcutaneous tissue, all layers of subcutaneous tissue were passed through until feeling the trachea by finger using a right-angle clamp (blunt dilatational exploration). So, cricoid cartilage was directly palpated by the tip of the finger, and the attempt (Griggs technique) was performed between the first and second tracheal cartilages below the cricoid cartilage.
The patients were mechanically ventilated for an average of 12.9 ± 2.6 days. They were 57 ± 14 (26 to 86) years old, and 64 of them were female, 58 of them were male. The duration of the technique was 2.5 to 5 minutes. There was no death or cardiac arrest related to tracheotomy. There were 113 PTs (92.6%) documented as uncomplicated. There was no technically difficult procedure, and none of the patients changed into a surgical approach during the procedure. However, major hemorrhage developed during first 24 hours in eight patients. In one patient, pneumomediastinum was determined in the 48th hour after the procedure. The overall complication ratio was established as 7.4%.
PT associated with using a right-angle clamp seems to be safe; it could be performed in the patients having cricoid cartilage not identified.