Question 15

With reference to the performance of percutaneous tracheostomy in the ICU:    
a) List the common complications encountered during the procedure.    (2 marks)
b) Outline the steps that can be taken both prior and during the procedure to prevent or minimize the risk of these complications.     (8 marks)

[Click here to toggle visibility of the answers]

College Answer

Syllabus topic/section:

2.1.19 Intensive Care Procedures.

Aim:

To allow demonstration of knowledge of safety regarding a commonly performed ICU procedure.

Discussion:

A core topic in intensive care practice. Candidates scored high marks for the first part of the question when a comprehensive list was provided. The second part of the question (8/10 marks allocated) asked for steps to prevent or minimise the risk of the identified complications. Some candidates answered with a generic account of how to perform a tracheostomy, rather than referring to the complications previously outlined and addressing each complication in turn (a table format may have been useful to help with this).

Specific oversights: bleeding was usually mentioned as a potential complication however the use of lignocaine with adrenaline to reduce this risk was uncommonly mentioned. Hypoxia was commonly mentioned however performing the procedure on an FiO2 of 100% was uncommonly outlined as a prevention strategy. Use of bronchoscopy and ultrasound were usually outlined, however many candidates did not outline a coagulation status check or withholding of anticoagulants. Fasting or aspiration of gastric content prior to the procedure was uncommonly mentioned, as was aspiration of free air into the syringe when confirming needle placement in the trachea.

Additionally, the most complete answers demonstrated a broad view of strategies (e.g. the requirement for haemodynamic and respiratory optimisation and monitoring during the procedure). Candidates who mentioned team factors, such as role allocation, supervision, checklists gained further marks.

Many candidates addressed their response from the narrow lens of the proceduralist. The second part examination is assessing the ability of the trainee to attain the level of an independent practitioner at the level of a transitional fellow. Broadening your perspective to that of a clinician responsible for the overall conduct and safety of the procedure will both achieve this standard and gain superior marks.
 

Discussion

A tabulated approach sounds like what the examiners were expecting, and the question itself is unusual because these days they usually tell you that they want a table when they want a table. This time it seems they would have preferred  a table, as it would have made the answers easier to mark, and would have established a structure where the candidate does not miss any of the listed items. In general tables are better for everything and the candidates should clearly just get into the mindset of always asking themselves "how is this not a table" when approaching any SAQ. 

Complication Strategy to minimise risk
Bleeding
  • Use lignocaine with adrenaline
  • Ensure good skin tension around the sides of the tube by not dissecting very much
  • Ultrasound the neck before the procedure to identify and avoid nearby vascular structures and the thyroid
  • Correct coagulopathy and temporarily withhold anticoagulants
Subcutaneous emphysema
  • Do not suture the wound around the tube
  • Minimise the ventilation pressure during and after the procedure
  • Bronchoscopic guidance will help prevent "through and through" punctures of the trachea
Hypoxia
  • Use 100% FiO2
  • Use pressure control ventilation to maximise the recruitment in spite of an occasionally "open" airway
Aspiration of gastric content
  • Cease the nasogastric feeds 4-6 hours prior to the procedure
Lateral stoma
  • Use bronchoscopic guidance to site the centre of the trachea, and use the local anaesthetic needle (usually a small 25g needle) to piece the trachea at the intended site, leaving it in place as a guide for the larger needle
False passage
  • Use bronchoscopy to confirm tracheal position of the guidewire
  • Use a saline-filled syringe to observe the aspiration of tracheal air when advancing the needle
Tracheal ring fracture
  • Use gentle pressure and corkscrew-like movement to advance the larger dilator
Oesophageal injury
  • Use bronchoscopy to confirm tracheal position of the needle during the puncture

The 

References