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Thread: Trach Hemorrhage

  1. #1
    Join Date
    Apr 2007
    Bentonville Arkansas

    Question Trach Hemorrhage

    AAPC: Back to School
    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.
    Leah Graham, CPC

  2. #2
    Join Date
    Apr 2007
    Bentonville Arkansas


    I am thinking 35820, 31603-51, and 31615-51. Any thoughts?
    Leah Graham, CPC

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