Indications

The indications for tracheostomy include (1) prolonged mechanical ventilation (>7 days); (2) an inability to protect airway such as in severe traumatic brain injury, severe maxillofacial trauma, extensive neck, or vocal cord edema/trauma/injury; (3) complex tracheal repair; (4) cervical spinal cord injuries; and (5) respiratory failure and the need for multiple and frequent trips to the OR.

Procedure Options, Contraindications, and Preparation

Bedside tracheostomy can be performed via an open or percutaneous technique based on the surgeon’s preference. Tracheostomy is not recommended at times when respiratory complications related to the procedure will be poorly tolerated by the patient. These include situations such as severe hypoxemia, severe hypercarbia, or respiratory acidosis. Redo tracheostomies in patients with difficult anatomy (short neck, goiter) should preferably be performed in the OR under more favorable conditions with optimal lighting. Specific relative contraindications to the percutaneous tracheostomy include a redo tracheostomy, moderate to severe coagulopathy, and unstable cervical spine injuries or an inability to extend the neck.

Adequate preparation for this procedure is critical, as errors can quickly lead to major complications. A complete surgical tracheostomy set and percutaneous tracheostomy kit are present at the bedside (Table 1). Lighting in the SICU should be optimized or surgeons may prefer using a headlight. Assisting personnel include a surgical team with an operating surgeon attending and one or two assistant surgeons, one respiratory therapist, one anesthesiologist, and a nurse. All personnel in the room have protective headwear, masks, and gloves, and the surgeons also wear sterile gowns and gloves.

Table 1 Equipment Required for Bedside Tracheostomy

Open Tracheostomy Technique

Once the patient is paralyzed and sedated, the neck is prepped and draped. Local anesthetic is injected at the surgical site, and then a 2-cm vertical midline incision is made below the cricoid. The platysma is divided and the strap muscles are retracted laterally. The second to fourth tracheal rings are exposed by retracting the isthmus of thyroid superiorly (using a vein retractor) or by dividing the isthmus of the thyroid. Stay sutures can be placed at the lateral aspect of trachea; note that the balloon of endotracheal tube should be deflated while placing stay sutures. Before the procedure begins, the surgeon should test the balloon of the tracheostomy, and ensure that the anesthesiologist suctions the endotracheal tube and mouth and that all equipment works and is within reach. A tracheotomy is performed using an 11-blade scalpel, the opening is dilated, and under direct vision the endotracheal tube is pulled back to just above the tracheotomy site. The tracheostomy is inserted, the inner cannula is placed, and the balloon is inflated. Then capnography is performed, adequate return of tidal volume is assessed, and chest wall movement is visualized. When placement is confirmed, the tracheostomy is sutured to the skin and secured with tracheal ties, and then the endotracheal tube is removed (Figure 1).

Figure 1 Tracheostomy tube insertion.

(From Velmahos GC: Bedside tracheostomy. In Shoemaker WC, Velmahos GC, Demetriades D, editors: Procedures and Monitoring in the Critically Ill. Philadelphia, WB Saunders, 2001, figure 5-4, p. 34.)

Percutaneous Dilatation Technique

There are several kits available today with various modifications for the percutaneous tracheostomy using the Ciaglia technique. The authors recommend the following percutaneous technique, which includes making a 2-cm vertical midline incision below the cricoid, and gentle dissection and retraction of the strap muscles with the ability to identify the thyroid and palpate the tracheal rings. With or without the use of a bronchoscope in the endotracheal tube, the endotracheal tube is pulled back superiorly so that a 10-ml saline-filled syringe is inserted into the trachea just below the endotracheal tube at about the second or third tracheal ring. Once air bubbles enter the syringe, the syringe is removed and a guidewire is advanced into the tracheal lumen. The needle is removed and the tract is dilated with the short dilator. With the use of a guiding catheter, either serial dilation (12–36 Fr) or a single tapered dilation is performed. The 28-Fr dilator within a #8 tracheostomy tube is placed over the guiding catheter and the entire unit is inserted into the trachea (Figure 2). Once in place, the guidewire, the guiding catheter, and the 28-Fr dilator are removed; the inner cannula is placed; and the balloon is inflated. Placement is confirmed and securing of the tracheostomy is performed as previously explained.

Figure 2 Percutaneous dilation technique (up to 36FR). FR, French.

(From Velmahos GC: Bedside tracheostomy. In Shoemaker WC, Velmahos GC, Demetriades D, editors: Procedures and Monitoring in the Critically Ill. Philadelphia, WB Saunders, 2001, figure 5-9, p. 37.)

Mortality, Morbidity, and Complications

Bedside tracheostomy is considered a safe procedure when performed meticulously and using the suggestions stated above. It has a low mortality rate (0.1%–1%) and minimal morbidity (up to 3%).³ Complications related to tracheostomy occur intraoperatively, early postoperatively, and late postoperatively. Intraoperative complications include bleeding, perforation of posterior wall of the trachea or anterior wall of esophagus, hypoxia, and loss of the airway. Early postoperative complications include bleeding, hematoma, pneumothorax, and tracheoesophageal fistula. Late postoperative complications include subglottic stenosis, laryngeal nerve injury, tracheal granulation, and tracheoinnominate fistula.

A meta-analysis comparing open surgical and percutaneous tracheostomies found that the rate of serious complication was similar in the two groups.⁴ The authors also noted that perioperative complications occurred more often with the percutaneous technique, but that postoperative complications were more frequent with the open surgical tracheotomy. However, most of the differences in complication rates were attributed to minor complications. Another meta-analysis by Freeman et al.⁵ found no difference in overall operative complication rates, but found lower postoperative complications and bleeding in the percutaneous technique. Currently, there are no prospective data to support the use of bronchoscopy to reduce complications related to percutaneous tracheostomy, but using it is advocated during the learning curve.

Indications

Many patients undergoing major surgery for trauma will have a jejunostomy tube or gastrostomy tube inserted at the time of surgery. In the SICU setting, patients needing access to the gastrointestinal tract are those who remain ill and are unable to eat. Any organ failure may cause inability to tolerate oral feedings, especially failure resulting from prolonged ventilatory dependency, traumatic brain injury, or prolonged sepsis. If the duration of injury is expected to be 1–2 weeks, feeding can be given by naso- or oro-gastric tube. Longer periods of naso- or oro-gastric intubation are associated with sinusitis, increased reflux, aspiration, and rarely esophageal stricture. Other indications for PEG include facial trauma and dysphagia.

Procedure Options, Contraindications, and Preparation

If there is no access to the stomach via the mouth, an open procedure is indicated. If a special situation exists in which the stomach is needed for subsequent reconstruction after esophageal injury, it is better to perform an open jejunostomy tube. If there is no barrier to the upper gastrointestinal endoscopy, PEG is indicated unless the stomach is nonfunctional. An absolute contraindication to PEG is an inability to bring the anterior gastric wall in apposition to the anterior abdominal wall. In patients with prior subtotal gastrectomy, ascites or marked hepatomegaly require special consideration. Relative contraindications to PEG include proximal small bowel fistula, gastric varices, obstructive gastrointestinal lesions, and coagulation defects that are not correctable.

The stomach is the most accessible part of the gastrointestinal tract for percutaneous cannulation and the stomach should be empty prior to cannulation. The patient should also receive one dose of antibiotic prophylaxis. In the SICU, sedation is easy to administer.

Technique

The basic elements of all PEG techniques include gastric insufflation to bring the stomach into apposition with the abdominal wall, percutaneous placement of a cannula into the stomach, passage of a guidewire into the stomach, placement of the gastrostomy tube by “push” or “pull” techniques, and verification of the proper position of the gastrostomy button (see Figure 1).

In an intubated patient, the easiest way to introduce the gastroscope is to stand at the patient’s head and elevate the tongue and the endotracheal tube. This may be facilitated with the use of a laryngoscope. Gently using the inflation button, the scope is passed down through the esophagus into the stomach under direct visualization. With the stomach insufflated, a place in the antrum is selected for cannulation. This location is generally two fingerbreadths below the xiphoid and two finger-breadths below the left costal margin in most patients. After placing the needle, a guidewire is thread through the needle and with the gastroscope a snare is used to secure the guidewire (Figure 3). The endoscope is removed from the mouth with snare secured to the guidewire.

Figure 3 Basic elements of PEG technique.

(From Crookes P: Percutaneocus feeding catheters. In Shoemaker WC, Velmahos GC, Demetriades D, editors: Procedures and Monitoring in the Critically Ill. Philadelphia, WB Saunders, 2001, figure 9–7, p. 65.)

In the “push” method, a gastrostomy tube is placed over the guidewire and the assistant pulls the wire and gastroscope out through the anterior abdominal wall after making a 1-cm incision. Typically, the gastrostomy tube can be pulled until the 3-cm mark appears at the skin. The gastroscope is replaced in the stomach and the position of the gastrostomy button is confirmed. In the “pull” method, when brought out of the mouth with the snare, a looped guidewire attaches to the end of the gastrostomy tube and pulled through the anterior abdominal wall.

Mortality, Morbidity, and Complications Management

This procedure is safe and effective with a mortality rate of 0.3%–1% and a morbidity rate of 3%–6%.^10–12 Complications are often related to the initial endoscopic procedure, the puncturing of the stomach, and the administering of feedings. There are no specific complications related to performing the procedure at bedside in the SICU, in the endoscopy suite, or in the OR. Specifically, aspiration is an important risk in all SICU patients, and gastroparesis, esophageal trauma, retention of tube feeds, and bacterial overgrowth in an acid-suppressed stomach all contribute to the risk. This risk is minimized by keeping the stomach empty, minimizing air insufflation, and carefully inserting the endoscope. Perforation with the gastroscope is rare if the gastrointestinal tract is anatomically normal. Other structures can be punctured including the colon and liver; however, if the stomach is distended enough and there is clear transillumination of the skin, this complication is rare.

Early dislodgment of feeding access can lead to gastric perforation with the infusion of feedings into the peritoneal cavity leading to peritonitis. This diagnosis may be difficult to make in obtunded SICU patients, but must be considered during a fever work-up. It is therefore important to note the level of the PEG at the time of initial placement so that it may be noted during a daily physical exam. This complication has the highest associated mortality rate.

Wound infection is the most common complication and occurs in 5% of patintents.¹³ This complication may be reduced by avoidance of overtight placement of silastic cuff, and adequate skin incision surrounding PEG and possibly prophylactic antibiotics. A rare but potentially life-threatening complication is the development of necrotizing fasciitis. The area of cellulites should be assessed for crepitance as the treatment includes wide surgical debridement and broad-spectrum antibiotics.

Buried bumper syndrome refers to the clinical picture resulting from partial or complete growth of the gastric mucosa over the internal bolster and occurs in 0.3%–2.4% of patients.^14,15 The bumper may migrate through the gastric wall. The buried bumper syndrome presents with leakage or infection around the gastrostomy and is usually caused by excessive tension on the bolsters.

Indications

High-risk trauma patients who have IVC filter insertion are often in the SICU and require mechanical ventilation, intracranial pressure monitoring, multiple intravenous infusions, and other invasive monitoring modalities, which puts them at risk when transported from the SICU. Absolute indications for IVC filter placement include the presence of a contraindication to anticoagulation in patients with a known PE or DVT and recurrent PE despite adequate anticoagulation. The relative indications for IVC filters include a chronic PE in a patient with pulmonary hypertension and a large free-floating iliofemoral thrombus. Prophylactic indications for IVC filter placement include spinal cord injury with paralysis, spinal trauma without paralysis, severe closed head injury, severe pelvic trauma, extensive lower extremity trauma, and prolonged immobilization. The indications for IVC filter placement are no different if the IVC filter is placed in the OR or interventional radiology suite. The secondary benefits of bedside IVC filter insertion include avoiding the hazards of intrahospital transport as well as cost-effectiveness due to less resource use.¹⁹

Procedure Options, Contraindications, and Preparation

All patients should have an initial duplex ultrasound of both lower extremities to confirm femoral vein patency and the presence or absence of DVT. This will help to determine the proper access site. Preoperative antibiotics are not routinely indicated. Bedside IVC filter placement can be done with either ultrasound or fluoroscopic assistance. Portable fluoroscopy is very difficult at the bedside and most SICUs are not equipped for the radiation exposure. Therefore, ultrasound-assisted bedside IVC filter placement is more easily performed. An absolute contraindication is inability to visualize the renal veins as well as IVC size greater than 2.8 cm. The right groin is the preferred site for insertion due to the ease of cannulation.

Technique

The IVC and the right renal vein are imaged first. The diameter of the IVC was measured, and ensured that the maximal size limitation of 2.8 cm was not exceeded. After cannulation of the femoral vessel, a guidewire is placed with ultrasound guidance. The dilator-introducing system is then placed with the aid of ultrasound, and the guidewire and dilator are then removed. The tip of the IVC filter is deployed caudal to the confluence of the IVC and the right renal vein. After deployment, the sheath is removed and digital pressure is placed at the puncture site.

Mortality, Morbidity, and Complications Management

Failure of bedside placement is a common complication. Placement may fail if the renal vein is inadequately visualized, which may occur due to morbid obesity or intraluminal bowel gas. Inexperience recognizing landmarks can lead to delay in placement. Another common complication is bleeding at the placement site. To avoid this complication, adequate digital pressure should be applied. There is 5% incidence of filter tilting, either at the time of placement or over a follow-up period.²⁰ The change in position may be due to migration of the filter or fracture of a strut. Penetration of the IVC can occur during any step of insertion and its incidence is 0.1%–9%.²⁰

Insertion site complications include local thrombosis of the femoral vessel, arterial-venous fistula, and pseudoaneurysm formation.²⁰ Long-term caval thrombosis is reported in 3%–9% of IVC filter placements. The incidence of PE with an IVC filter in position has been reported to occur in 0.1%–10% of patients.²⁰

Indications

Diagnostic peritoneal lavage is used in hemodynamically unstable patients in whom clinical examination of the abdomen is unreliable due to intoxication, spinal cord injury, traumatic brain injury, or multiple associated injuries. Both DPL and bedside laparoscopy may be used in SICU patients who have clinical deterioration after an initial diagnostic evaluation with either no CT scan or an equivocal initial CT scan result as well as in patients with multiple organ failure and sepsis with no clear etiology.

Procedure Options, Contraindications, and Preparation

Both DPL and laparoscopy are diagnostic options. DPL is accurate in diagnosing the presence of bleeding and peritonitis. It can also be completed in less than 15 minutes, and results are obtained from the laboratory rather quickly. The disadvantage of DPL is its lack of specificity. Laparoscopy has the advantage of directly visualizing the peritoneal cavity and diagnosing intra-abdominal pathology. Its disadvantages include the transport of the equipment to the SICU as well as the use of pneumoperitoneum. The brevity of the procedure should result in minimal hemodynamic instability related to the pneumoperitoneum. Also, significant respiratory acidosis and hypercarbia can occur in these patients. Hypercarbia occurs due to the peritoneal absorption of CO₂. Changes in airway pressures directly correlate with intra-abdominal pressures and should encourage low-pressure insufflation for the procedure.

Relative contraindications to both DPL and laparoscopy include the presence of abdominal scars from previous surgery, advanced pregnancy, and pelvic fracture with suspicion of a large pelvic hematoma. These relative contraindications can be surpassed if the incision is moved to a supraumbilical location. Prior to performing a DPL or laparoscopy, the stomach and the bladder should be empty, and most patients in the SICU have a Foley catheter and naso- or oro-gastric tube for decompression.

Technique

After preparation of the skin, an incision is made and dissection proceeds through the anterior and posterior fascia until the peritoneum is encountered. Under direct visualization, the peritoneal cavity is entered, the catheter is placed toward the pelvis, and an initial aspiration is performed. If no fluid is encountered, 1000 ml of lactated Ringer’s are instilled into the peritoneal cavity, and then the bag of fluid is placed on the floor and through passive drainage the saline instilled is recovered in the crystalloid bag.

The results of DPL are considered positive in blunt trauma if gross blood is found on aspiration; there are more than 100,000 red blood cells/ml; there are more than 500 white blood cells/ml; amylase, urea, or bilirubin levels are higher than that of blood; and/or food particles or feces are encountered. For penetrating trauma, the threshold for the red blood cell count is lowered to 1000–10,000 cells/ml. DPL is a sensitive technique for the presence of blood, and as little as 50 ml of blood will cause the red blood cell count to be more than 100,000 cells/ml.

A 10–11-mm trochar is placed in the infra- or supra-umbilical position. The abdomen is insufflated with CO₂ to 15 mm Hg. A camera is then introduced through this trochar. Additional 5-mm trochars are placed under direct visualization in the location needed to completely visualize the stomach, small intestine, colon, gallbladder, liver, spleen, and bladder. Other procedure options include the use of a 3.3- or 5-mm laparoscope if available.

Mortality, Morbidity, and Complications Management

The most worrisome complication for both DPL and laparoscopy is injury to the underlying viscera. Although the incidence of this complication is only 1%–2%, this complication is easily avoided by use of the open technique. Proponents of the closed technique cite a shorter procedure time as its greatest advantage. Another potential complication of DPL is the subcutaneous placement of the DPL catheter, which may provide a false negative result. While no deaths have been reported during these bedside procedures, this high-risk group is difficult to compare.

Indications

Currently indirect measurements of intra-abdominal pressure are performed. This assessment can be performed by assessing gastric or urinary bladder pressure. Less is currently known about the value of rectal pressure. Measurement of intra-abdominal pressure is critical when the diagnosis of abdominal compartment syndrome is suspected or cannot be excluded. In addition, it is recommended in postoperative patients with a tense abdomen and/or signs of organ failure.

Decompressive laparotomy is indicated in patients with elevated intra-abdominal pressures of 25–35 cm of water and signs of compromised organ function, such as oliguria, hypoxemia with elevated peak airway pressure, or hemodynamic instability. Emergent decompressive laparotomy is indicated with intra-abdominal pressures exceeding 35 cm of water due to risk of severe hemodynamic compromise. Decompressive laparotomy is an emergency procedure, and is the only current treatment for abdominal compartment syndrome. It can easily be performed in the SICU, which is often the case because the patient is too critical to be safely transported to the OR.

Procedure Options, Contraindications, and Preparation

The options for intra-abdominal pressure measurement include the direct measurement of pressure in the inferior vena cava. This method is invasive and not currently recommended because of the risk of complications. Indirect measurement of intra-abdominal pressure can be performed via the stomach or the urinary bladder.

Technique

Gastric intra-abdominal pressure can be transmitted to the stomach when it is partially filled. The patient is placed in a supine position, and then 50–100 ml of saline is infused via a nasogastric tube to fill the stomach. A pressure transducer, calibrated at the midaxillary line, is used to measure the pressure at the end of expiration. A ruler can also be used to measure the height of the column of fluid in the NG tube.

Urinary bladder pressures are the preferred and most commonly performed measurement. There are two techniques. The standard technique involves emptying the bladder and placing the patient in a supine position. The Foley is then double-clamped and 50–100 ml of saline are infused into the bladder via the aspiration port. A transducer attached to an 18-gauge needle is set to zero at the level of the symphysis pubis and then inserted into the aspiration port to measure bladder pressure. The U-tube technique involves raising the Foley catheter above the patient, allowing for a U-shaped loop to develop, and then measuring the height of the urine column from the symphysis pubis to the meniscus. The main advantage of this technique is that it does not require violation of the Foley catheter continuity, which can increase the risk of infection; however, the pressure measurement is less accurate.

Decompressive laparotomy is performed with a midline incision and opening of the peritoneal cavity. Temporary abdominal closure of the open abdomen is done with the use of the Bogota bag or prosthetic mesh. Continued urinary bladder pressure measurement should be performed with an open abdomen.

Mortality, Morbidity, and Complications Management

Although complications related to this procedure are rare, there are pitfalls worth noting. Falsely elevated intra-abdominal pressures occur in agitated or straining patients. Measurements are most accurate in sedated or chemically paralyzed patients. Abnormal values may occur in patients who are not supine, or if a transducer is not set to zero at the symphysis pubis.