Netherlands Journal of Critical Care

142 NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020

Submitted November 2019; Accepted December 2020

C L I N I C A L I M A G E

Harm prevented by using ICU ultrasound prior to percutaneous dilatational tracheostomy

M.E. Seubert, M. de Mos Department of Intensive Care, het LangeLand Ziekenhuis, Zoetermeer, the Netherlands

Correspondence

M.E. Seubert – m.seubert@llz.nl

Keywords - percutaneous dilatational tracheostomy (PDT), vein, ultrasound neck imaging

A tracheostomy was indicated in a 32-year-old female ICU patient with normal habitus and no significant medical history. She had been on and off mechanical ventilation for 11 days because of acute respiratory distress syndrome after ditch water aspiration and was deemed to require a tracheostomy for further ventilator weaning.Informed consent was obtained from the patient and her family to perform a percutaneous dilatational tracheostomy (PDT). In preparation for this, an ultrasound of the trachea was carried out to locate the optimal insertion site and to determine if there where possible complicating factors. As the images show, there appeared to be an overlying vein covering at least the third and fourth tracheal ring, the usual insertion site for a tracheostomy.

With this information an increased risk for bleeding related to the PDT procedure was anticipated. Therefore it was decided to perform the tracheostomy in the operating theatre, safeguarding the vein. The surgeon tied up the vein and an uneventful tracheostomy under bronchoscopic control followed.

Ultrasound screening prior to percutaneous tracheostomy proceduresPerforming ultrasound prior to or during a percutaneous tracheostomy has previously been recommended.[1,2] In a retrospective, observational study of 343 adults, 41% of patients demonstrated a vessel overlying percutaneous tracheostomy insertion sites on computed tomography angiograms. Veins were more common than arteries.[3] This number does not fit the low number of haemorrhagic complications experienced. Possibly tamponade of bleeding from smaller vessels may account for this. On the other hand, mortality as a result of PDT has been described, with one report demonstrating three deaths in 1187 procedures (0.25%) over a 13-year period due to severe haemorrhage.[4] A randomised controlled trial has demonstrated reduced bleeding with the use of ultrasound guidance.[5]

Severe haemorrhage related to PDT may be caused by puncture or distortion of an nearby artery, vein, or a tracheal-vascular fistula. Risk factors are previous neck surgery or radiotherapy, leading to altered vascular anatomy, and obesity, making it difficult to identify the classic landmarks for cannula insertion. However, congenital variants of normal vascularisation are also possible, such as the presence of an anterior jugular vein overlying the trachea in this case. CT scanning is probably unsuitable to detect such abnormalities and although MRI would provide useful information, this is a ponderous exercise with an ICU patient on ventilator support. Ultrasound of the trachea provides a simple and safe method to visualise the vascularisation around the cannula insertion site. It allows for identification of nearby vascular structures and for localisation

Figure 1. Midline transverse view showing cricoid cartilage (lower

arrow) and a vein measuring a diameter of 0.31 cm above (top arrow)

Netherlands Journal of Critical Care

NETH J CRIT CARE - VOLUME 28 - NO 3 - MAY 2020 143

Ultrasound prior to tracheostomy

of the correct insertion site above the fourth tracheal ring. Performing a PDT below this level may increase the risk of severe bleeding by puncture of the right innominate artery.

Transducer selection is important when evaluating the anatomy surrounding the trachea. Higher-frequency linear probes (7.5 MHz) provide the best resolution of superficial structures. Importantly, one should be aware not to use any pressure with the probe on the underlying area because venous structures may collapse and thus become invisible (video link).

In line with results of observational studies, precautions should be taken when an overlying vessel is seen. Therefore, we suggest performing an ultrasound of the trachea as a standard part of the preparation for PDT.

Figure 2. Sagittal view of the trachea showing four tracheal cartilages

(T1-4) with a vein above (longer arrow) and above this the infrahyoid

muscle (short arrow)

T1 T2 T3 T4

DisclosuresThe authors declare no conflict of interest. No funding or financial support was received but the first author (M.E.S) does receive compensation for being an ICU ultrasound instructor at the Dutch Society of Intensive Care (NVIC). References

1. Alansari M, Alotair H, Al Aseri Z, A Elhoseny M. Use of ultrasound guidance to improve the safety of percutaneous dilatational tracheostomy: a literature review. Crit Care. 2015;19:229.

2. Lopez Matta JE, Elzo Kraemer CV, van Westerloo DJ. To see or not to see: ultrasound-guided percutaneous tracheostomy. Neth J Crit Care. 2018;26:66-9.

3. Rees J, Haroon Y, Hogan C, Saha S, Derekshani S. The ultrasound neck imaging for tracheostomy study: A study prompting ultrasound screening prior to percutaneous tracheostomy procedures to improve patient outcomes. J Intensive Care Soc. 2018;19:107-13.

4. McCormick B, Manara AR. Mortality from percutaneous dilatational tracheostomy. A report of three cases. Anaesthesia. 2005;60:490-5.

5. Sarıtas A, Kurnaz MM. Comparison of Bronchoscopy-Guided and Real-Time Ultrasound-Guided Percutaneous Dilatational Tracheostomy: Safety, Complications, and Effectiveness in Critically Ill Patients. J Intensive Care Med. 2019;34:191-6.

Video link to sagittal view of collapsing overlying vein due to slight pressure with probe

https://njcc.nl/sites/nvic.nl/files/19-87%20Seubert%20Collapsvene.mp4

Video 1.

https://njcc.nl/sites/nvic.nl/files/19-87%20Seubert%20Collapsvene.mp4https://njcc.nl/sites/nvic.nl/files/19-87%20Seubert%20Collapsvene.mp4