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LETTER TO EDITOR
Year : 2019  |  Volume : 20  |  Issue : 2  |  Page : 109-110
 

Intractable bleeding during tracheostomy


1 Department of Anaesthesiologist and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Neuroanaesthesiologist and Critical Care, AIIMS, New Delhi, India
3 Department of Anaesthesiology and Critical Care, Command Hospital, Pune, Maharashtra, India

Date of Web Publication28-Aug-2019

Correspondence Address:
Dr. Sagar Debbarman
Department of Neuroanaesthesiologist and Critical Care, AIIMS, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_21_19

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How to cite this article:
Singh S, Debbarman S, Dwivedi D, Sud S. Intractable bleeding during tracheostomy. Indian Anaesth Forum 2019;20:109-10

How to cite this URL:
Singh S, Debbarman S, Dwivedi D, Sud S. Intractable bleeding during tracheostomy. Indian Anaesth Forum [serial online] 2019 [cited 2019 Nov 13];20:109-10. Available from: http://www.theiaforum.org/text.asp?2019/20/2/109/265641




Sir,

Incidence of major vascular injury during tracheostomy is 0.1%–1.0% with innominate artery being the most common and carotid artery being the rarest.[1] We report a case of the right common carotid artery (RCCA) injury during tracheostomy in a 25-year-old female weighing 62 kg (Body mass index - 24.4 kg/m2). The patient was an operated case of the left frontotemporal parietal subdural hematoma and was on mechanical ventilation. Preoperative investigations were within normal limits. Written informed consent and nil per oral status were confirmed. Standard monitoring was ensued and suctioning of the endotracheal tube (ETT) was done. General anesthesia was administered with injection fentanyl 100 μg, propofol 100 mg, and atracurium 25 mg intravenous (IV). On dissection of pretracheal fascia, there was sudden bleeding which was bright red, projectile and was under high pressure emerging from the incision site. Attempts to identify the bleeder and manual compression to control the bleeding, both were unsuccessful. The ETT cuff was overinflated to prevent aspiration of blood. Blood pressure (BP) dropped from the baseline of 128/68 to 70/46 mm Hg and heart rate increased from 80 to 130/min. Two 16G IV access were secured in both upper limbs and left radial artery was cannulated for invasive BP monitoring. IV fluids were rapidly infused, and norepinephrine IV infusion was started to maintain BP within 20% of the baseline. On extending the transverse incision, a small curvilinear incision on the side wall of RCCA was found which was repaired by clipping proximal and distal end of the artery by the vascular surgeon. In 4-h surgery, blood loss was 3 L. The patient received six units of packed red blood cells, seven units of fresh frozen plasma, seven units of cryoprecipitate, and 4500 mL of crystalloids. The patient was shifted to intensive care unit (ICU) without reversal for elective ventilation. The patient was weaned off ventilator after 3 days and was discharged without any neurological squeal.

Hemorrhage is one of the rarest and most feared complications during surgical tracheostomy with an incidence of 1.9%.[2] Bleeding can happen due to slippage of suture, erosion of vessel, injury to aberrant artery/vein, or direct trauma to a vessel.[3],[4]

In our case, the accidental injury of RCCA could be explained by incomplete neck extension due to short neck making the carotid artery superficial in the carotid sheath. This could have led to inadvertent incision of RCCA. Such an error of judgment can be prevented by the judicious use of preprocedural ultrasound (USG) of the neck to ascertain the position of RCCA in relation to structures of the neck. The inclusion of USG of the neck will definitely help in thwarting such life-threatening complications during tracheostomy especially the ones which are done bedside in an ICU with a suboptimal extension of the neck on a hemodynamically compromised patients in emergency settings.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Allan JS, Wright CD. Tracheoinnominate fistula: Diagnosis and management. Chest Surg Clin N Am 2003;13:331-41.  Back to cited text no. 1
    
2.
Halum SL, Ting JY, Plowman EK, Belafsky PC, Harbarger CF, Postma GN, et al. Amulti-institutional analysis of tracheotomy complications. Laryngoscope 2012;122:38-45.  Back to cited text no. 2
    
3.
Praveen CV, Martin A. A rare case of fatal haemorrhage after tracheostomy. Ann R Coll Surg Engl 2007;89:W6-8.  Back to cited text no. 3
    
4.
Khandelwal A, Kapoor I, Goyal K, Singh S, Jena BR. Pneumothorax during percutaneous tracheostomy – A brief review of literature on attributable causes and preventable strategies. Anaesthesiol Intensive Ther 2017;49:317-9.  Back to cited text no. 4
    




 

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