The use of ultrasound imaging prior to percutaneous ... - JICS

Case reports © The Intensive Care Society 2012The use of ultrasound imaging prior topercutaneous tracheostomyFA Mir, P Hopkins, C Holland, R Ramnarine, MYS WanUltrasound scanning (USS) is commonly used in intensive care units (ICUs) for vascular access procedures, and forpleural and cardiac imaging. However, it is not routine practice to use USS prior to or during percutaneous tracheostomy.We report the case of a patient who was scheduled to have a percutaneous tracheostomy which was abandonedfollowing assessment with ultrasound.Keywords: percutaneous tracheostomy; ultrasound; complications; bleedingIntroductionA 48-year-old lady was admitted to the King’s College HospitalICU following evacuation of a spontaneous intracerebralhaematoma with ventricular extension. She subsequentlyunderwent a decompressive craniectomy for control of highintracranial pressure. On day 10 of her ICU admission, it wasdecided that she would benefit from a tracheostomy as she hada persistently low GCS despite being off all sedation, had aweak cough, no gag reflex and was localising to pain with herleft arm only.A bedside ultrasound scan (USS) of her neck was performedbefore attempting percutaneous tracheostomy (PT). Thisshowed an antero-medial right internal carotid artery and anadditional large artery traversing the trachea at the level of thefirst and second tracheal rings. The procedure was thereforenot considered safe and it was agreed that she should havefurther investigations followed by an elective surgicaltracheostomy. We were concerned by the possibility of directarterial injury during the procedure and by the possibility ofsubsequent erosion of this aberrant artery.A CT-angiogram of the aortic arch and carotids wasperformed the next day. This confirmed the medial course ofthe proximal brachiocephalic trunk, traversing the midlineabout 4 cm above the sternal notch and crossing over thetrachea to the right (shown in the volume-rendered image ofthe neck in Figure 1).The case was discussed with the maxillofacial team whoagreed that the tracheostomy should be performed surgically.This took place uneventfully in theatre on the next day withdirect vision of the at-risk vessels. There was a large artery justbelow the level of the fourth tracheal ring. The tracheostomywas inserted at the 2/3rd tracheal ring level.DiscussionIn the 4th National Audit Project (NAP 4), it was reported thattwo ICU patients had adverse outcomes because of a failure toplace a tracheostomy successfully. 1 There were also two cases ofsignificant haemorrhage, one on tracheostomy insertion andFigure 1 Volume-rendered image of the neck showing the midlineright brachiocephalic artery overlying the ETT.one on removal of a tracheostomy placed 24 hours previously. Itwas also suggested that tracheostomies performed on ICU carrya high risk. 1 There are no national guidelines currently availableregarding the use of USS before attempting PT on ICU.In our unit, we promote the practice of using USS toenhance safe practice before tracheostomies are performed. Wehave incorporated a question as to whether USS of the neckhas been performed in our percutaneous tracheostomyproforma. Over the last six months we have had two caseswhere the procedure was abandoned due to the USS finding ofaberrant vessels in the neck. In one case, USS detection of alarge vein prompted a joint procedure with the maxillofacialteam who tied off the vein prior to proceeding with standardPT insertion.48Volume 13, Number 1, January 2012 JICS

Case reportsPT is considered to be a safer and better alternative tosurgical tracheostomy as shown by several studies. 2 In theEuropean ‘Prevalence of Infection in Intensive Care’ (EPIC)study 3 in 1995, 12.6% of all critically ill patients had atracheostomy. Fatal haemorrhage is a rare complication of PT(0.25% in a series reported in 2005), 4 but is believed to beunder-reported. In one study, bleeding from injury to bloodvessels, which could have possibly been identified if ultrasoundwas used, was considered significant in 24 of 497 (5%) PTsperformed without pre-procedure US evaluation. Six out ofthese 24 patients required conversion to surgical tracheostomy. 5There are case reports which have demonstrated the benefitsof using ultrasound before PT. Bertram et al 6 showed in theirseries of patients that about 15% of patients had the commoncarotid artery less than 10.5 mm from the fourth tracheal ringand anticipated that the neck extension required for PDTwould result in these vessels coming closer to the level of theupper tracheal rings. This was deemed to pose a higher risk ofbleeding complications.Another advantage of the use of USS for PT is the real-timeimaging of the needle path through the anterior neck tissues todefine levels of puncture of the trachea. Studies have been doneon models which show that in subjects with simulatedunidentifiable anterior neck airway anatomy and trachealdeviation, the use of USS improves speed and success of cannulaplacement and reduces the number of attempts required. 7ConclusionThe routine use of USS is of benefit in identifying overlying orvulnerable adjacent structures such as the thyroid gland andisthmus, and blood vessels. Imaging can also guide needles anddilators away from at-risk structures. 8,9 In view of theincreasing availability of USS and expertise in its use, werecommend that it is used routinely for PT.Declaration of interestsNo conflict of interest to declare.References1. Harper J, Rangasami J, Cook T. Major airway events in patients with atracheostomy. In: Report and Findings of the 4th National Audit Project ofThe Royal College of Anaesthetists. RCoA London 2011: p 126-27.2. Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatationaltracheostomy versus surgical tracheostomy in critically ill patients: asystematic review and meta-analysis. Crit Care 2006,10:R55.3. Vincent JL, Bihari DJ, Suter PM et al. The prevalence of nosocomialinfection in intensive care units in Europe. Results of the EuropeanPrevalence of Infection in Intensive Care (EPIC) study. JAMA 1995;274:639-44.4. McCormick B, Manara AR. Mortality from percutaneous dilatationaltracheostomy. A report of three cases. Anaesthesia 2005;60:490-95.5. Muhammad JK, Major E, Wood A, Patton DW. Percutaneous dilatationaltracheostomy: haemorrhagic complications and the vascular anatomy ofthe anterior neck. A review based on 497 cases. Int J Oral Maxillofac Surg2000,29:217-22.6. Bertram S, Emshoff R, Norer B. Ultrasonographic anatomy of theanterior neck. J Oral Maxillofac Surg 1995;53:1420-24.7. Rajajee V, Fletcher JJ, Rochlen LR, Jacobs TL. Real-time ultrasoundguidedpercutaneous dilatational tracheostomy: a feasibility study. CritCare 2011;15:R67.8. Dinsmore J, Heard AMB, Green RJ.The use of ultrasound to guide timecriticalcannula tracheotomy when anterior neck airway anatomy isunidentifiable. Eur J Anaesthesiol 2011;28:506-10.9. Mallick A, Bodenham AR. Tracheostomy in critically ill patients. Eur JAnaesthesiol 2010;27:676-82.Fauzia Ahmad Mir Specialist Registrar Intensive Carefauziamir@nhs.netPhilip Hopkins Consultant Intensive CareChristopher Holland Consultant Intensive CareRaymond Ramnarine Specialist Registrar RadiologyMing Young Simon Wan Specialist Registrar RadiologyKings College Hospital, LondonCommentary: Ultrasound guidance for practical proceduresThis report rightly emphasises the potential value ofultrasound visualisation of pre-tracheal blood vessels priorto percutaneous tracheostomy (Figure 2). Such vessels, ifarterial, may be palpable or visibly pulsatile. The use ofultrasound to guide needles into the trachea at the correct levelis also described. Higher-resolution devices now enable goodvisualisation of individual tracheal cartilages. The true utility ofsuch approaches is still hampered by the probe footprint sizeand shape applied to the root of the neck, and the inability ofultrasound to enable imaging within the air-filled trachea.Clinicians should also consider the use of high-resolutionultrasound prior to other invasive procedures to reduce therisk of bleeding, eg identification of vessels in the chest orabdominal wall in the liver failure patient with portalhypertension prior to ascitic or pleural drain insertion.Andrew Bodenham Director of Intensive Care, Consultant inAnaesthesia, Leeds General InfirmaryFigure 2 Cross-section ultrasound image of the neck showing aplexus of large anterior jugular veins (arrow) in front of thetrachea in a patient with tricuspid regurgitation.JICS Volume 13, Number 1, January 2012 49