ped tracheostomy airway disaster

[david campbell]

We had a disaster in OR last week. A 20 month old 12kg child had a tracheostomy for severe stridor: subglottic stenosis/ ?superimposed infection.
The shiley size 4 ped tracheostomy tube was only sutured in at each of the wings, no ties at all were placed (active decision that they were not needed).
As the child started waking up the airway was lost, immediate diagnosis of misplacement made, sutures cut and tube removed, anesthesiologist was unable to replace it despite multiple desperate attempts and intubation attempts/oxygenation attempts too until Oto surgeon could be found 2 floors away, returned to OR and was replaced with difficulty after 5 minutes of hypoxia.
Long story cut short.... Child died next day.
Are sutures alone enough? Should all ped tracheostomies have snug tapes or velcro ties AND sutures?
Any other wisdom?
Yes I have read the previous "survey" here on this topic of securing tracheostomies from 2006.
Thanks

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[resxn]

We had a disaster in OR last week. A 20 month old 12kg child had a tracheostomy for severe stridor: subglottic stenosis/ ?superimposed infection.
The shiley size 4 ped tracheostomy tube was only sutured in at each of the wings, no ties at all were placed (active decision that they were not needed).
As the child started waking up the airway was lost, immediate diagnosis of misplacement made, sutures cut and tube removed, anesthesiologist was unable to replace it despite multiple desperate attempts and intubation attempts/oxygenation attempts too until Oto surgeon could be found 2 floors away, returned to OR and was replaced with difficulty after 5 minutes of hypoxia.
Long story cut short.... Child died next day.
Are sutures alone enough? Should all ped tracheostomies have snug tapes or velcro ties AND sutures?
Any other wisdom?
Yes I have read the previous "survey" here on this topic of securing tracheostomies from 2006.
Thanks

Sorry to hear about that tragic case.

Great question to post on Sermo.com where there are some 845 registered ENT's (60k docs registered although much smaller group of active posters). I bet you'll get some really good input from that forum.

There was a recent survery posted from the Archives where they asked some of these very questions to members of ASPO and compared them to non-fellowship-trained ENT's.

The vast majority place stay sutures and consider them necessary. In our program (which I cont to follow) we placed stay sutures, skin sutures, and also placed ties. In cases where immediate decannulation was not expected, we also sutured the inf tracheal flap to the skin to help decrease the risk of false passage.

Accidental decannulation was the #1 cause of mortality in pediatric trachs in that survey.

 

[otopico]

Sorry to hear about this incident. At our program, we take multiple measures to assure that decannulation does not occur. For our pediatric trachs, we make a vertical skin and tracheal incision and suture the trachea to the skin to mature the stoma. There are also two stay sutures along side the trachea as well as a tie wrapped in some foam material to prevent skin breakdown. I don't quite understand why a surgeon would feel a trach tie is not necessary - I understand the concern for skin breakdown, but as this incident proves it is one more level of prevention. I'm suprised that they chose not to secure the trach seeing as a 20 month old can be pretty active and is likely to a)roll around and dislodge the trach or b) pull at it. I'll step down from my pedestal, but bottom line is as with all cases you have to ask yourself what you would do if it was your family member.

 

[Leforte]

Agree with the above posters. Our peds trachs get:

stay sutures
vertical incision
formalization of stoma
duoderm under trach
sutures to secure trach
trach tie (with 1 finger slack) not velcro ties until 1st trach change

We do ~3-4 a month, and haven't seen an accidental decannulation yet (knock on wood).

 

[Fah-Q]

Why was the surgeon 2 floors away when the patient was waking up?

Why was a child with a critical airway allowed to wake up?

 

[david campbell]

Thank you all for your posts. It has been a harrowing time for us all. Thanks for your sympathies.
My researches so far, backed up by your responses, suggests that this tracheostomy tube was indeed inadequately secured, especially for a 20 month old, with sutures only, and even then, just at the distal wing ends. The surgeon maintains that the tube WAS adequately secured, and that he did not want to use ties as they would have forced the tracheostomy tube down to the carina. The tube was a Shiley 4.0 41mm length PED tube; so would a shorter NEO have been a better one to have swapped it for and then gone ahead and used ties? Is it common to use a rigid hard tube as the initial tracheostomy tube anyway? Years ago we always used a soft PVC (Portex) type tube which was swapped 5 - 7 days later for a Shiley tube at first tube change? I don't know if this was intended to help prevent accidental decannulations or for other reasons, but I imagine it would be more 'forgiving'.
A Starplasty surgical technique has been described. Does anyone do this? And do many of you suture an edge of the trachea to the skin? And do any of you suture the central flange of the tube (not just the distal wings) to the skin? Do you use a single or double tube ties?
Why was the surgeon 2 floors away? Well the airway concerns had all been dealt with and he felt the waking and transfer to PICU was the anaesthetists job. There was no reason to suggest to him an imminent displacement. He was talking to the parents. Why was the child woken up? Good question. What is normally done? It was felt that the child should be able to be woken and breathe on her own through the tracheostomy in PICU now the obstruction was overcome. It is common practice to do this locally. It was not felt reasonable to sedate and ventilate her for several days. If you did do this when would you allow her to wake? When the tract had formed? But we would like to know what others do in this situation. In fact in this case the tube became dislodged before she awoke; but after she was already self ventilating quite well on a low concentration of sevoflurane and a couple of minutes after the shoulder roll was removed. With no warning there was a very slight cough and suddenly she was completely obstructed. The cough was probably not the cause of the dislodgement; more likely the result of the end of the tracheostomy perched on the edge of the tracheal stoma. The tracheostomy tube wings had already been noted to be sitting up proud of the neck skin just before the obstruction occurred.

Thanks again

 

[resxn]

I feel a little uncomfortable 2nd guessing a situation like this when I don't have all the details, but you've been so forthcoming, I thought I'd just share the thoughts I've had as I've considered this case and the questions you've posed.

I do not do a starplasty. I do not like the surgical scar and don't really see the benefit for what is going to be a temporary trach.

If I suspect the trach is not going to be decannulated within a week or two (i.e. what you'd do for epiglottitis or other acute but quickly resolving airway obstruction) I almost always suture an inf flap to the skin. I then put lateral stay sutures through the cut ring so that if pulled, they will open the airway--essentially providing the same advantage that a vertical cut provides, but also giving the inf flap to decrease the risk of false passage when a trach tube is being replaced either emergently or routinely.

I do not suture the tube itself or central flange to the skin, only the wings. But I also place ties (NOT velcro) with a snug one to two fingerbreadth give only.

It depends on the reason for the trach and the time of day if I wake the child immediately post-op. If for a painful thing such as a severe infection, I leave them sedated. If for a less distressful reason (prolonged intubation) I often wake them up. I don't know enough about your case to comment.

Two comments about what I have heard. You said "anesthetist" in my neck of the woods that means CRNA and not anesthesiologist. I personally would not feel comfortable with a CRNA managing a newly awaking trach in a young child. There are fantastic CRNA's out there, but I also may not let the anesthesiologist do it on their own depending on how confident I was in them and how many times I've done a case like that with them. If the anesthesiologist was one with whom I was very comfortable, I wouldn't have had a problem leaving the child to go talk to the parents.
2nd comment about the description. Hindsight is 20/20, but given the risk of decannulation, I think the tube being next to the carina is not as big of a deal as the tube being too short. If there's a question, that's why we have flexible scopes. Even if we don't, that's why we have x-rays.

Last comment regarding the events not yet described. I think the series of events that took place after dislodging need to be evaluated, because even under the best of circumstances, tubes become dislodged. Here are my thoughts on that
1 - the attending should be very clear where he/she will be in the immediate post-op period. It should not take 5 mins to track him down. He should have been over-head paged immediately when dislodgement was noted. Or a resident/nurse/med student/janitor/whatever sent to get him.
2 - was the anesthesiologist competently trained in how to reinsert a fresh trach on a young child? If not, he/she should not have been left alone during wake up, IMO.
3 - assuming competency all around. Why was reinsertion difficult? Part of it was no stay sutures, granted. But did the anesthesiologist try a smaller trach? Did he try using a seldinger technique?
4 - what was difficult about reintubation? There was no mention of a difficult intubation to begin with.
5 - was the anesthesiologist closely monitoring the moving of the pt? When my fresh trach's move--even adults--someone is required to always put a finger on the trach and keep it pushed down.

 

[david campbell]

Thanks for your valuable insights. You are asking some pretty key questions. I don't have all the answers, and answering some of them may prejudice the investigations currently proceeding.
It was a indeed a senior experienced pediatric anesthesiologist, however he had no previous experience of fresh ped tracheostomies. Our hospital does very few of these (maybe one per year). He did have some experience of fresh adult tracheostomies and established ped tracheostomies.
The surgeon and anesthesiologist had worked together before over the years, but they were not a regular team and had never done an emergency case together.
A flexible scope wasn't done to check the trach tube position, only a rigid bronchoscope after the trach was placed to assess the larynx. An x-ray would have been done shortly afterwards.
The surgeon's whereabouts weren't known. There is no overhead page system in our place. The only two OR nurses left to find him and to make the crash call, but never returned, leaving the anesthesiologist and his assistant stranded alone in OR with no-one available to fetch needed equipment. There were no residents, janitors or med students. It was evening time.
The intubation and airway HAD initially been difficult. Not a poor view at laryngoscopy, but a very small laryngeal inlet which accepted only a 2.5 tube, and precipitated the decision to proceed to tracheostomy and not just the planned diagnostic evaluation of the upper airway. There had been very significant episodes of stridor over the prior 24 hours or more, where the child had been thought to be at serious risk of complete obstruction. Inhalation induction was achieved with considerable difficulty.
There WERE tracheal stay sutures placed, but the anesthesiologist was unaware of the significance or even presence of these. It does not seem there was any discussion about stay sutures during the surgery.
There was also a fair amount of blood in the neck. The anesthesiologist could not initially locate the trachea. I probably should not say much more.
Thanks for your input. It has been much appreciated.

 

[Fah-Q]

however he had no previous experience of fresh ped tracheostomies. Our hospital does very few of these (maybe one per year)...they were not a regular team and had never done an emergency case together...The surgeon's whereabouts weren't known. There is no overhead page system in our place...It was evening time....The intubation and airway HAD initially been difficult...decision to proceed to tracheostomy and not just the planned diagnostic evaluation of the upper airway. There had been very significant episodes of stridor over the prior 24 hours or more, where the child had been thought to be at serious risk of complete obstruction...There WERE tracheal stay sutures placed, but the anesthesiologist was unaware of the significance or even presence of these.

You are describing a complete and utter disaster that could have been avoided at several stages along the way. That poor kid never had a chance.

 

[resxn]

Thanks for your input. It has been much appreciated.

Best of luck