PLEASE COMMENT ON THIS CASE ONLY IF YOU ROUTINELY CREATE AND MANAGE TRACHEOSTOMIES
Surgery completed successfully with no complications:
1. Left hemimandibulectomy
2. Left limited neck dissection
3. Right limited neck dissection
4. Extraction of teeth complex x2 (teeth #21 and 22)
5. Tracheostomy (See “Tracheostomy Placement”)
(4/19) Post-Op: WBC 14.3, RBC 3.49, Hgb 10.6, Hct 32.3, BP 125/65
Patient doing well. Started on Lovenox.
(4/20) POD #1: WBC 14.0, RBC 3.50, Hgb 11.0, Hct 32.1, BP 141/73
Tracheal lavage treatments on average every 4 hours. On tracheal humidifier. Trach site noted to have copious secretions – the secretions were bloody, tan, cream and white. Lungs were clear. MD aware of patients smoking status and added Mucinex. No documentation of tracheostomy tube cuff pressure. Circuit arm was frequently adjusted for offloading.
(4/21) POD #2: WBC 12.8, RBC 3.48, Hgb 10.6, Hct 32.8, BP 132/80
Tracheal lavage treatments on average every 5 hours and still on tracheal humidifier. Trach site noted to have copious tan and cream secretions. Breath sounds became diminished then coarse in both lungs. Patient OOB and ambulating. Only document of tracheostomy tube cuff pressure was 0. Circuit arm was frequently adjusted for offloading.
(4/22) POD #3: WBC 13.0, RBC 3.36, Hgb 10.3, Hct 31.3, BP 136/84
Tracheal lavage treatments on average every 4 hours. A #6 Shiley cuffed trach is in place. Trach site is noted to have copious tan and cream secretions. Breath sounds were coarse. Patient developed a fever of 101.1F. Nursing sent a provider notification about the fever and elevated WBC and there was no response. The plan is to move the patient out of ICU. Only document of tracheostomy tube cuff pressure was 0. Circuit arm was frequently adjusted for offloading.
(4/23) POD #4: WBC 11.6, RBC 3.29, Hgb 10.1, Hct 30.3
Nursing performed tracheal lavage treatments on average every 3 hours. In the morning, the patient had pain post suctioning, and had copious amounts of thick and tan secretions. Later in the day, the patient was noted to have bleeding around the trach site. RN notified physician and approximately an hour later, the physician was bedside and changed the trach size to 4.0 Shiley Trach. The bleeding decreased but was still in the sputum. No documentation of tracheostomy tube cuff pressure. Circuit arm was frequently adjusted for offloading.
Overnight, the patient had no tracheal lavage treatments. Secretions were thick, yellow, and tan.
(4/24) POD #5/POD #0: WBC 11.2, RBC 3.26, Hgb 10.2, Hct 30.0, BP 168/95
In the morning, the patient coughed up a mucus plug and began bleeding around and out of the trach. Suction was provided and pressure was applied. The physician was able to arrive immediately to evaluate. The patient began to bleed out of oral cavity at this time. Patients BP and O2 remained stable during the episode. Patient was transported to OR. (See “Second Op Report”)
Post-op, nursing performed tracheal lavage treatments on average every 3 hours. Secretions were noted to be blood-tinged, cloudy, and mostly thick with mucus plugs.
That afternoon, the patient underwent a bronchoscopy. (See “Bronchoscopy Report”)
(4/25) POD #1: WBC 10.8, RBC 2.84, Hgb 8.6, Hct 26.9, BP 130/70
On the morning after his second surgery, he was seen by a PA. They stated:
“ETT in tracheostomy site secured with suture. Scant mucous secretions w/o blood. No evidence of bleeding circumferential to tracheostomy site. Bilateral neck incision clean, dry, intact. Well-approximated. Right neck Neck is soft and flat w/o erythema, warmth, or dehiscence. Expected post-operative swelling w/o evidence of seroma/hematoma formation. Mild tenderness to palpation.”
Another PA noted in the morning there was a small amount of blood oozing from the site. Nursing performed tracheal lavage treatments on average every 4 hours. No documentation of tracheostomy tube cuff pressure. Circuit arm was adjusted for offloading.
Respiratory therapist, PA, and physician were bedside to remove ETT in the afternoon:
“Dr and pa bedside to remove ett from stoma and place a 6.0 uncuffed shiley. pt tolerated
placement of new trach tube. BBS ,good chest rise. pt is on 30% t/c w/ 10L. sp02 holding @ 95% no distress noted. rn present @ bedside when [sic] change was made.
In the afternoon, an RN sent a provider notification that the patient was trending with higher temp. The response was to continue to monitor and administer scheduled antipyretic.
(4/26) POD #2: WBC 17.9, RBC 2.94, Hgb 9.0, Hct 26.8, BP 153/85
In the morning, patient was noted to be doing well with no recurrence of bleeding, stable Hgb but WBC increased to 17.9. Patient received his last tracheal lavage in the morning. An RN sent a provider notification that the patient had a fever and heavier blood-tinged secretions. The response was to continue to monitor.
RT note in the morning:
“Pt. remain with uncuffed 6.0 Shiley trach. The trach was capped by PA and a Dale trach collar is around the neck with the approval of PA. Dr. also at the bedside. Suctioning to be done PRN only per PA to evaluate the patient's management of secretions with the capped trach.”
One of the surgeons came to evaluate the patient around noon. He noted increased WOB secondary to increased sputum production. Due to elevated WBC, the patient was started on Unasyn.
In the afternoon, two RNs sent provider notifications within 7 minutes for heavier blood-tinged secretions, fever, and tachycardia. The response was to give 1 G IV Tylenol and continue to monitor. Shortly after this, another notification was sent for increase in blood secretions, tachycardia, and febrile. The response was continue to monitor. About an hour later, another notification was sent for EKG abnormality and tachycardia. The response was to draw cardiac labs, continue to monitor, and cleared to change ST elevation parameters.
Labs showed scant growth of E. Coli and Pseudomonas aeruginosa from a respiratory/sputum culture.
CCC-SLP Evaluation in the afternoon:
“Deferred Treatment Adl Info: Attempted dysphagia evaluation, however upon entering room observed pt's tracheostomy was no longer capped and noted bloody secretions. RN reports MD notified and awaiting return call. (AHNA APP) notified and came to patient's bedside. Requests deferral of dysphagia evaluation until tomorrow (04/27).”
In the evening, an RN noted that the patient had a decreased ability to handle secretions.
(4/27) POD #3: WBC 15.5, RBC 2.93, Hgb 8.7, Hct 27.2, BP 178/103
Code Blue called in the AM for hypoxia, marked hemoptysis, and acute respiratory distress.
Notes:
“Patient's overnight ICU course was notable for sudden onset of hypoxia, monitor mopped assist and acute respiratory distress with noted large volume of frank red blood and clots expelling from pt's trach and mouth approximately 4:14 AM. Attempts were made to oxygenate patient with increased O2 supplementation via trach as well as inline suctioning. These efforts were minimally successful due to apparent volume of hemoptysis and large clots in and around tracheostomy tube. Patient became increasingly agitated and hypoxia worsened partially pulling on trach in the presence of ongoing arterial bleeding. Direct pressure was applied by digital manipulation to inferior region of tracheostomy site and further attempts were made to oxygenate the patient with bag-valve-mask and ongoing inline suctioning when the patient was noted to further display bradycardia and eventually lost spontaneous pulsation. CODE BLUE was
initiated. ENT physicians notified. #8 ET tube was placed in trach site and ongoing oxygenation with bag-valve-mask as well as inline intermittent suctioning during chest compressions. Dr. arrived at bedside and began attempting to locally explore tracheostomy site and applying digital pressure to apparent arterial bleed. The patient was intubated from above by critical
care and ongoing resuscitative efforts were continued including multiple rounds of CPR, IV epinephrine, sodium bicarb, atropine, calcium as well as volume resuscitation with isotonic crystalloid (normal saline) and 3 units of crossmatched blood. During resuscitation efforts a right femoral triple-lumen and left femoral arterial line were placed. IV vasopressors were initiated with IV epinephrine, Levophed, Neo-Synephrine and vasopressin. Persistent ROSC was achieved at approximately 4:56 AM. OR team present at bedside to transport of pt to OR (per MDs). MD present at bedside for emergent interventional bronchoscopy. MDs attempting to stabilize bleeding source at bedside via tracheostomy site before proceeding to OR. Pt's wife notified and presented to bedside during resuscitation and updated while resuscitation in progress.”
“I was called emergently this morning at 0406h about bleeding from the tracheostomy site, with significant bright red blood, difficulty maintaining his airway, and changes and decrease in oxygen saturation. I broke several traffic laws on my way to the hospital, during which time I was able to contact my partner, who also urgently came to the bedside. We also prepared the operating room in case we were able to take the patient to the operating room emergently. When I arrived at the bedside at 0417h, the attending anesthesiologist had placed an endotracheal tube through his tracheostomy site as I had requested, but the patient had poor oxygenation, due to clot within the mainstem trachea and bronchi. He had just begun cardiopulmonary resuscitation approximately 1 minute prior to my arrival, and this is documented in the code record. I did not see any active extravasation from the neck. I held pressure in order to ensure that there was not further bleeding into the airway, while a femoral arterial line, central line, and additional IVs were obtained. He was resuscitated with packed red cells and high volumes of fluid. I also requested that the attending anesthesiologist place an endotracheal tube via his mouth, so that I could better assess a area of bleeding, and we could use the balloon to restrict further bleeding into the airway. As he passed this, I can feel that the endotracheal tube was coming out the anterior wall of the trachea, which seemed odd to me, so
I guided it with my finger into the appropriate position. This was confirmed with a bronchoscope upon arrival by MD, and we used frequent use of lavage and suction to remove clot. After some time, we were able to have excellent chest rise, easy ventilation, and resumption of normal 97 to 100% oxygen saturation. This corresponded with blood gases that were drawn. However, it was unclear exactly how bad his perfusion was during a significant portion of this time. At least twice, he was able to regain spontaneous circulation, but due to desaturation, he had difficulty maintaining appropriate pressure and required further resuscitation. Eventually, Dr. was able to remove a clot which was then expelled out through the anterior wall of the trachea, measuring greater than 15 cm in length, and 6 to 8 mm in diameter. This was done right before
Dr. arrived and performed bronchoscopy to confirm that we were not mainstem, and there is no further clot within the main airway to evacuate. We secured the endotracheal tube, confirmed that his pressor requirements came down, and then plan to taken to the operating room, which was delayed due to discovery on chest x-ray that we had ordered of left-sided pneumothorax, so after a pigtail catheter was placed to treat this, we plan to take him to the operating room. During this time, I was able to obtain informed consent from his wife, who was at the bedside for least a portion of this event.”
See “Third Op Reports”.
Evaluation after the operation showed necrosis around anterior trachea. A Dr. assessed the necrosis may have been due to cuff pressure.
After this decline, the patient never recovered and passed away days later.
Files:
Q: Were chest XRays and coagulation profiles obtained during this time?
A: Coagulation profiles were obtained on 4/27 after the Code Blue. X-ray on 4/22 - No evidence of acute cardiopulmonary pathology. Xray on 4/24 showed slight increase in bibasilar pulmonary edema &/or pneumonia. 4/26 showed no acute cardiopulmonary process.
Do you believe there might have been medical error?
The increased work of breathing on post day #2 with increased volume and bloody secretions are concerning. There was already enough bleeding from the tracheostomy that the patient required a second operation. And the reports of removal of tracheostomy and replacement with endotracheal tube at bedside suggest there may have been some local tissue injury that left the tissue friable and at risk for bleeding. I don't know that there is a clear, single error here, but the patient's course was clearly not progressing well (he required a take back to OR, he had fevers, increased secretions, increased work of breathing). The catastrophic complication after tracheostomy is a tracheo-innominate artery fistula, and that at least does not appear to have occurred. But at the final operation it appeared that there was some destruction of several cartilage rings, which the surgeon describes as chronic. Did the patient have a previous tracheotomy? Or is this a marker of the tissue injury from his initial operation? Or is this due to excessively inflated tracheal cuff? Had the patient had previous radiation therapy? That would put him at risk for tissue breakdown and subsequent bleeding. From my reading of the case with the limited information available, it seems the tracheostomy was not likely to be permanent but was placed to allow recovery after the hemimandibulectomy and flap reconstruction. There is not an obvious single error, but it the setting of a patient who is not progressing well, a bronchoscopy or further evaluation in the operating room may have been warranted. The lack of documentation of tracheal cuff pressure is not evidence that the pressure was too high, but it is possible. In the setting of bleeding from the tracheostomy the surgeons may have intentionally wanted the cuff pressures higher to tamponade the bleeding. Furthermore there were multiple tubes in and out of the trachea, that may have also contributed to the tracheal necrosis. It is difficult to say without reviewing the record in more detail.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The failure to intervene earlier to identify and stop the bleeding may have prevented the airway obstruction with clot that led to the cardiac arrest and hypoxemia with anoxic brain injury.
What makes you a good expert for this case?
I am a surgeon practicing trauma surgery and surgical critical care. I perform tracheostomies frequently in the ICU and operating room. I take care of patients with tracheostomies, including complications such as bleeding and tracheal stenosis.
How often do you encounter cases similar to this one in your practice?
I probably see complications of tracheostomy 2-4 times annually. I have performed repeat tracheostomy multiple times and am very cognizant of the risks of bleeding and tracheal necrosis
Do you believe there might have been medical error?
With each tracheostomy placement, it is encumbrance on the treatment team to ensure that appropriate cuff pressure is checked and documented. It seems that in this case, there was an issue with tracheal necrosis as well as what was likely a tracheal innominate fistula where the trachea erodes into the blood vessel most commonly due to high cough pressure. I also feel that when there was an issue with the tracheostomy, it should have been removed and the patient reintegrated orally to give an opportunity to closely examine the area for the source of the bleeding
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Because the cuff pressure was not monitored on a daily basis (as is done in many hospitals, including the hospital where I am on staff), it is difficult to know how much pressure is in the cuff. The pressure needed is only enough to get a seal, and no more due to the pores sure necrosis concern. This apparently we not done and documented
What makes you a good expert for this case?
I have 14 years of experience as a trauma surgeon at a verified level one trauma center. In my hospital, trauma surgeons are tasked with tracheostomies and we do several per month.
How often do you encounter cases similar to this one in your practice?
We see several complex tracheostomy cases per month with head and neck cancer and traumatic wounds. Given the importance of the airway in a resuscitative setting, I am required to do emergent surgical airways and manage patients with complex airway anatomy
Do you believe there might have been medical error?
It seems that this patient had postoperative increase, secretion and potential pneumonia. The cuff pressure and endotracheal position based on the report appear to be appropriate. The initial blood tinged sputum is normal in somebody who has significant facial and upper airway surgery. The later bleeding is concerning for tracheal innominate fistula. This is a dangerous complication. Local control of bleeding is almost impossible. However, it is difficult to ascertain whether this patient had in fact the trachea anomic fistula. It is possible this was a tracheal erosion without the fistula.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
If this was a tracheal innominate fistula, which an autopsy or a CT angiogram would have shown it, then, as long as the two boys placed appropriately, it is a complication that was not preventable. If this was a tracheal erosion, without documentation of high balloon pressure or malplacement, again, it’s difficult to say it was preventable.
What makes you a good expert for this case?
I am a surgical, critical care and trauma surgeon that deals with these issues commonly
How often do you encounter cases similar to this one in your practice?
These are uncommon cases. However, I deal with tracheal complications a lot of times.
Do you believe there might have been medical error?
Based on the above information available, I believe there were multiple opportunities for improvement in this case regarding the management of the tracheostomy and chain of events that ultimately put the patient at risk for development of a tracheo-innominate fistula and the significant bleed seen later in the patient's stay. Please see below in the causation section for my description of what I believe was the ultimate diagnosis and causations/factors that led to the patient's demise based on the information available to me.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient had frequent lavages which required instrumentation of the tracheostomy and trachea which is a risk factor for repeated injuries to the tracheal wall. I would need clarification of what the "circuit arm" is referring to in this case, but if the patient was ever ventilated, if there is pressure on the circuit and therefore the tracheostomy, this is a major preventable risk factor that may lead to development of a tracheo innominate fistula. Additionally, there were multiple instrumentations and exchanges of the tracheostomy and replacement of an endotracheal tube within the tracheostomy stoma throughout the patient's stay, further manipulating the area and increasing the risk of this complication to develop. From the description of the trachea condition in one of the operative reports, it appears that there was necrosis of the anterior tracheal wall and malposition of the tracheostomy tube, both additional risk factors for this complication. Finally, there was a significant change in the character of the bleed (described as bright/arterial) which is known as a herald bleed. This is a type of bleed that is often associated with near full erosion into an artery and subsequently a brisk life threatening bleed. It most often occurs on post-operative day #7 as it takes time to develop, which is exactly when it happened in this case. Further, the patient had a subsequent worse bleed shortly after this bleed that I believe ultimately caused significant intra-tracheal bleeding, aspiration, hypoxia, and cardiac arrest. Once a herald bleed occurs, there must be a high index of suspicion. A CTA is done to rule in or rule out this diagnosis expeditiously as if it is present, it can lead to a life threatening bleed shorty after. Additional risk factors to support this diagnosis included steroid use and infection based on the cultures and gross description of the patient's sputum.
What makes you a good expert for this case?
As an acute care surgeon, I often perform tracheostomies as part of my routine practice. I also have managed complications of these cases, including a tracheo innominate fistula, during my practice. I also have training in critical care, which offers an additional perspective in dealing with tracheostomy complications as often times patients will be managed post-operatively in the intensive care unit especially in situations where there are concerns for bleeding or infectious complications or potential for airway compromise, bronchoscopy need, or temporary airway management while awaiting return to the OR.
How often do you encounter cases similar to this one in your practice?
While my suspected diagnosis of a tracheo innominate fistula is a very rare complication overall, I have seen it 5 times in my career. However, similar cases where there is bleeding in or around tracheostomies, need for tracheostomy exchange, need for return to the OR for bleeding control are all cases that I have seen and managed often in my career.
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