Trach Hemorrhage


Bentonville Arkansas
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I am really having a hard time with this one. Some fresh eyes and insight would be most appreciated. Thanks.

Op Note

HISTORY OF PRESENT ILLNESS The patient is a 60-year-old gentleman
who has been in the hospital for about a month with multiple problems
related to his chronic obstructive lung disease with acute
exacerbation, and acute ST segment elevation myocardial infarction
with cardiogenic shock requiring intraaortic balloon pump placement
and cardiac intervention. This morning he had a huge amount of
bright red blood that came around his tracheostomy site and down into
his trachea that caused him to lose his saturations and have a near
arrest and a code blue was called. He had greater than 1500 cc of
blood. It was bright red and appeared to be pulsatile. His
tracheostomy was placed about 10 days ago. The trach was removed and
replaced with an endotracheal tube, and with the tube placed further
down the trachea and the balloon reinflated this seemed to control
the bleeding. He had another episode of bleeding when the
endotracheal tube was moved in the tracheostomy site, but this
stopped with repositioning. Bronchoscopy was performed which showed
a bunch of clotted blood in the tragus and what looked to be a
pulsatile area on the anterior tracheal surface. He is brought into
the operating room at this time because of what appears to be a
sentinel bleed from suspected tracheoinnominate fistula. I have had
the chance to talk with the patient, and he wants everything done.
He understands the risk of stroke associated with this procedure.
The goals, risks, benefits, procedures, and alternatives have been
carefully explained to him. He understands and consents.

OPERATIVE NOTE Under adequate general endotracheal anesthesia, the
patient was prepped and draped in the routine sterile fashion. A
left subclavian Swan-Ganz introducer was placed in the routine
Seldinger fashion for a volume line. A right femoral arterial line
was placed in the routine fashion for monitoring and blood gas draws.
The standard median sternotomy was performed. This did not create
any bleeding at this point. We opened the pericardium and I
encircled the base of the innominate artery with cord tape. Then we
carefully dissected upward and we were able to identify the trachea
and tracheostomy site. There was no great vessel fistula present
that could be identified. I scrubbed out of the case at this time,
took a bronchoscope, and introduced it through the endotracheal tube
which was passed in through the tracheostomy site. The tube was
small. It was only 6.5, but I was able to suction free a lot of
blood and clotted blood from the trachea and bronchus, and could not
find any site of bleeding here. We had removed several large clots
from the trachea around the endotracheal tube from the operative
field. I pulled the endotracheal tube back until the tip was just at
the level of the tracheostomy site, and still could not find any
evidence of active bleeding or bleeding site. The scope was
withdrawn and I rescrubbed in. We removed the endotracheal tube from
the tracheostomy site, and replaced it with an 8 Shiley low pressure
cuff tracheostomy tube that went through the tracheostomy site.
There were a few centimeters of intact skin between the top of our
median sternotomy and the tracheostomy site. The patient ventilated
easily through the trach. A 32-French chest tube was placed
substernally, brought out through a separate stab incision, and
attached to skin using heavy silk suture. The chest was copiously
irrigated using antibiotic saline and normal saline irrigant, and
then closed in the routine fashion using interrupted #1 Vicryl
sutures in a circumcostal fashion to reapproximate the sternum. The
fascia and subcutaneous tissue were closed using running #1 Vicryl
suture in layers. The skin edges were reapproximated using running
4-0 Vicryl in a subcuticular fashion. Dermabond was placed as a
dressing. The flanges of the tracheostomy tube were secured to the
skin using 2-0 silk suture, and trach tape was placed and tied to
further secure the tracheostomy. I repeated the bronchoscopy through
the trach site and was unable to find any source of active bleeding
or suspected bleeding. The scope was withdrawn. The patient was
transferred from the operating room to the ICU.

Once again, thanks for the help.