The World Health Organization published a checklist for surgical safety in 2008. Since that time, enhanced communication and awareness of operating room processes has resulted in improved patient outcomes.[1],[2]
A checklist has been proposed for percutaneous dilational tracheostomy (PDT)[3]. Mortality in PDT is associated most commonly with hemorrhage and loss of airway. Abnormal anatomy and abnormal tube placement are cited as the most common reasons for mortality. While the popularity of PDT has increased since Ciaglia first introduced the technique in 1985, contraindications to PDT may necessitate an open tracheostomy.
An open tracheostomy remains a commonly performed procedure. Complications associated with tracheostomy include death, stoma site hemorrhage, hypoxic brain injury, tracheoinnominate fistula, nerve damage, tracheal stenosis, infection, sepsis, cardiac arrest, pneumothorax, esophageal perforation, or bronchospasm. This checklist may serve to mitigate or eliminate the incidence of some of these complications when implemented. Specifically, the incidence of arterial or venous injury, delayed stoma site bleeding, pneumothorax, and hypoxic brain injury may be reduced through consideration of this checklist.
Arterial or venous injury may be reduced through a detailed preoperative assessment of relevant imaging noting the location of large vessels in the path of the intended procedure. Physical examination of the neck length, depth and palpation of pulsatile vessels near the midline may reveal the presence of large vessels in patients without prior neck imaging. Preoperative or intraoperative ultrasound may be used to assess large vessels in the anterior neck. Delayed stoma site bleeding is a common reason for postoperative surgeon communication by the nursing staff. This may be reduced through the use of a flowable hemostatic matrix injected around the wound after securing the tracheostomy tube. Alternatively, oxidized cellulose may be used to provide a physical tamponade as well as hemostasis in the immediate postoperative period.
A pneumothorax may be avoided by a detailed analysis of the preoperative computed tomograph imaging as well as knowledge of pre-existing conditions affecting the lungs.
Many patients who undergo elective and emergent tracheostomy are an ASA 4 or greater. Patients often present with high FiO2 requirements and do not tolerate prolonged periods of reduced oxygenation and ventilation. It is common practice to reduce the FiO2 prior to entering the trachea due to the risk of fire hazard with flammable gases. While the trachea should not be entered with an electrocautery device, maintenance of 100% FiO2 throughout the procedure may be done safely through careful surgical technique. Intraoperative desaturation during tracheostomy is not essential
Prior checklists for open tracheostomy describe the surgical procedure without identifying perioperative risk factors.[4] The following checklist provides perioperative risk factors which are not absolute contraindications to open tracheostomy placement but rather makes the operating surgeons cognizant of the need for modification of preoperative medical or interoperative surgical management. Formal clinical validation through a prospective analysis may further enhance patient safety and validate the utility of this surgical checklist.
Jonathon Jundt MD,DDS,FACS
Jason Jundt MD, FACS
References
[1] Do safety checklists improve teamwork and communication in the Operating Room? A systematic review. Russ, Stephanie PhD, Rout, Shantanu, MRCS, et al Annals of Surgery: 2013 Dec; 258 (6): 856-871. [2] Surgical checklists: a systematic review of impacts and implementation. Treadwell J, Lucas S, Tsou A. BMJ Qual Saf. 2014 Apr; 23(4):299-318. [3] Checklist for percutaneous tracheostomy in critical care. Rajendran G, Hutchinson S. Critical Care. 2014 18(2):425. [4] The Parkland 12-Minute Checklist Tracheostomy. Panchal N, Zide M. Journal of Oral and Maxillofacial Surgery: 2015 Mar; 74(3):556-561