Percutaneous Tracheostomy and Murphy’s Law: An Eye for Trouble

Percutaneous tracheostomy (PT) was first described in 1969 and has rapidly found acceptance due to its safety and convenience. Two methods are in popular use; a one-step dilation using a specialized forceps (Griggs) (1) and a serial dilational method (Ciaglia) (2). Both methods share a common first stage—Seldinger guidewire access to the trachea. A similar complication using a dilational method has been described (3), and we report a further case using the one-step technique, which could lead to undue morbidity. Case Report A 70-yr-old woman was admitted to the intensive care unit for postoperative ventilation after surgery for a colonic perforation and subsequent fecal peritonitis. After 10 days, a PT was planned because of repeated inability to wean the patient from ventilatory support. After obtaining informed, written consent from relatives, the patient was sedated with propofol 150 mg IV and midazolam 5 mg IV, and neuromuscular blockade was achieved with vecuronium 6 mg IV. The patient was positioned with an appropriate degree of neck extension, and the surgical site was infiltrated with 10 mL of lidocaine 1% with 1:200,000 epinephrine. Flexible bronchoscopy was not used during this procedure. Under direct vision, the oral tracheal tube was deflated and withdrawn to the level of the glottis, and the cuff was reinflated. An experienced assistant maintained it in this position. A 3-cm incision was made over the second tracheal ring, and a 20-gauge cannula over the needle was used to access the trachea. Position of the needle was confirmed by aspiration of free air into a saline-filled syringe. A guide wire was then easily inserted through the cannula, and the cannula was removed. A small dilator, supplied with the PT kit, was then easily placed over the wire into the trachea. An air leak confirmed correct placement. The trachea was then dilated to an appropriate size with the specialized forceps, and an 8-mm tracheostomy tube with an obturator was introduced over the guidewire into the trachea. Marked resistance was encountered at this stage, and the tracheostomy tube could not be inserted correctly within the airway. The tube was withdrawn, and further dilation of the trachea with the forceps did not improve the situation. At this juncture, the oral tracheal tube was reintroduced and inflated below the stoma. When the tracheal tube was withdrawn to enable a further attempt, the guidewire was observed to move in tandem with the tracheal tube. Suspecting transfixation of the tube with the needle and guidewire, the tracheal tube was withdrawn from the glottis, where it was noted that the wire had passed through the Murphy’s eye of the tracheal tube. The guidewire was removed through the tracheostomy stoma and rapidly replaced. The tracheostomy tube was then positioned over the wire into the trachea without further incident. The procedure took approximately 20 min with interruptions. There were no further complications, and a chest radiograph revealed correct positioning of the tracheostomy tube. Discussion PT is an established and safe intervention for tracheal access in intensive care (4,5). There is a low incidence of complications, and the technique has gained widespread popularity; however, when complications do arise, they are often serious and may be life-threatening (6,7). The above-described complication has been previously reported using the serial dilation method (Griggs) (4). Using this method, the inability to introduce serial dilators through the Murphy’s eye and consequent movement of the tracheal tube quickly alerts the operator performing the procedure. However, using the Griggs one-step dilation method, the delay in recognizing guide wire movement and, hence, misplacement was caused by the flexibility of the wire, which was mistaken for a normal variant. This could lead to inadvertent dilation of the trachea far in excess of that required to place a tracheostomy tube, thus leading to further complications and significant morbidity, although such an event did not occur in our patient. Tracheal tubes with a Murphy’s eye are often used. This previously reported complication of guidewire misplacement with the Ciaglia technique is noteworthy and more difficult to recognize, particularly when using a dilational forceps method. This complication again reinforces the necessity for continuous flexible endoscopy of the trachea when performing a PT (7).