Management of Thyroid Isthmus During Tracheostomy

Adil Hadi Salih Al-Azzawi, Wissam Kadhum Abdel Amer,Ahmed Kareem Shiaan Al-Baidhani
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Keywords : Tracheostomt, cautery knife, ENT
Medical Journal of Babylon  13:2 , 2016 doi:1812-156X-13-2
Published :11 September 2016

Abstract

A tracheotomy is a surgical procedure which consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea (windpipe). As with any surgery, there are some risks associated with tracheotomies. Early Complications that may arise during the tracheostomy procedure or soon thereafter include bleeding, pneumothorax, and subcutaneous emphysema.The aim of this study was to evaluate the use of cautery knife instead of artery forceps in management of thyroid isthmus during tracheostomy with regard to time of operation, post-operative bleeding, and surgical emphysema. This study was a cross-sectional research performed on 60 ICU patients in need of tracheostomy through a period started from January 2009 to January 2012. The patients were divided into two groups each formed of 30 patients, one group(group A) dealt with by traditional tracheostomy through clamping of the thyroid by artery forceps and transfixion to expose tracheal rings, and second group (group B) had a new method of management through cautery knife. Time of both procedures and early complications were registered in questionnaires and the data were analyzed for both groups. A tracheostomy was performed in 60 morbidly ICU patients. The two groups had no significant difference in age, sex, and vital signs. Average duration of the procedure was 10-20 minutes in group A patients using the traditional procedure and 5-10 minutes in the second group (group B) using a cautery knife. Three patients out of thirty in group A got post-operative bleeding, while no patient in group B got bleeding. There was a significant difference between the two groups regarding time of procedure and post-operative bleeding, otherwise there was no significant differences between the two groups regarding occurrence of surgical emphysema. The use of cautery knife for thyroid isthmus management during tracheostomy minimize operation time and reduce occurrence of postoperative complication especially bleeding.

Introduction

Tracheotomy has been done since 1500 BC and is one of the first-born conveyed surgical procedures in the medical works. It is a surgical procedure which involves making a vertical or transverse incision on the anterior surface of the neck and opening a direct airway through an incisionin the anterior wall of trachea. The consequential hole, or tracheostomy, can function independently as an airway or as a site for a tracheostomy tube (metallic or portex) to be inserted; this tube allows a person to breathe directly[1,2]. The postoperative care of tracheostomized patients experiencing this procedure is understated.The safety of existing practice patterns in tracheostomy management is poorly distinct[3]. Tracheotomies are indicated for upper airway obstruction(stridor or streator), extended endotracheal intubation and airway protection from aspiration or airway maintenance. The traditional tracheotomy approach has been attended by percutaneous dilatational techniques in nominated patients, particularly in intensive care units (ICUs)[2,4]. Tracheotomies can be performed in the theater or at the bedside in an ICU and can be done by various specialists including ear, nose and throat (ENT) surgeons, fasciomaxillary surgeons, general surgeons and thoracic surgeons [5]. As with any procedure, a tracheostomy can result in complications. Some of them are more likely to occur shortly after the surgery is done. Other complications are more likely to occurlater [6].Complications that can occur shortly after surgery include hemorrhage, pneumothorax, and surgical emphysema [7,8]. There is slight objective comparative evidence about the postoperative complications and morbidity of tracheostomy procedure [9]. Special techniques and operative strategies must be well applied to overcome serious life-threatening complications from traditional tracheostomy [10,11].

Materials and methods

This study was a cross-sectional research performed on 60 ICU patients in need of tracheostomy through a period started from January 2009 to January 2012. Our study population was derived from those attending the ICU of the General Teaching Hospital in Hilla city Babylon Iraq who underwent tracheostomy, the procedures were performed under general anesthesia in the operating room or bedside of ICU. The patients were divided into two groups each formed of 30 patients, one group (group A) dealt with by traditional tracheostomy through clamping of the thyroid by artery forceps and transfixion to expose tracheal rings, and second group (group B) had a new method of management through cautery knife.
Data collected were comprised of age, gender, admission diagnosis, indication of tracheostomy, time of procedure and early complications were registered in questionnaires and the data were analyzed for both groups.




Results

During a three years period of study a tracheostomy was performed in 60 morbidly ICU patients. Study population was divided into two groups matched in number, age and gender regarding the technique used in their tracheostomy. Time of procedure, early post-operative complications including bleeding and emphysema were registered for all patients. In this study it was found that there was a significant difference (P<0.5) between the average time of the two study procedures between the two groups as that the average duration of tracheostomy was 10-20 minutes in group A patients using the traditional procedure of forceps artery for transfixion of thyroid isthmus, while the average time of procedure was 5-10 minutes among group B patients using a cautery knife as illustrated in table (1).

Discussions

During a three years period of study a tracheostomy was performed in 60 morbidly ICU patients. Study population was divided into two groups matched in number, age and gender regarding the technique used in their tracheostomy. Time of procedure, early post-operative complications including bleeding and emphysema were registered for all patients. In this study it was found that there was a significant difference (P<0.5) between the average time of the two study procedures between the two groups as that the average duration of tracheostomy was 10-20 minutes in group A patients using the traditional procedure of forceps artery for transfixion of thyroid isthmus, while the average time of procedure was 5-10 minutes among group B patients using a cautery knife as illustrated in table (1).

Conclusions

Our results conclude that the use of cautery knife for thyroid isthmus management during tracheostomy can minimize operation time and reduce occurrence of postoperative complication especially bleeding.

References

1. William A Johnson, and ZabMosenifar. 2015. Tracheostomy Tube Change. Medscape.
2. Hannah Zhu, Preety Das, Ralph Woodhouse, HaythamKubba. 2014. Improving the quality of tracheostomy care.Breathe articles.Vol 10 Issue 4.
3. National heart lung and blood institute.2016. Internet paper.
4. El Solh AA1, Jaafar W. 2007. A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients.Crit Care.;11(1):R3.
5. Morris LL, Whitmer A, McIntosh E.2013. Tracheostomy care and complications in the intensive care unit. CritCare Nurse, 33(5):18-30.
6. Buglass E1. Tracheostomy care: tracheal suctioning and humidification.Br J Nurs. 1999 Apr 22-Mar 12;8(8):500-4.
7. Ali A El-Sol and WafaaJaafar. A comparative study of the complications of surgical tracheostomy in morbidly obese critically ill patients. Crit Care. 2007; 11(1): R3.
8. David I. Astrachan MD, J. Cameron Kirchner MD and W. Jarrard Goodwin Jr.2009. Prolonged intubation vs. tracheotomy: Complications, practical and psychological considerations. The Laryngoscope, 98 (11): 1165–1169.
9. Rumbak M, Newton M, Truncale T, Schwartz S, Adams J, Hazard P. A prospective, randomized study comparing early percutaneous dilational tracheostomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;32:1689–1693.
10. Heyrosa M, Melniczek D, Rovito P, Nicholas G. Percutaneous tracheostomy: a safe procedure in the morbidly obese. J Am Coll Surg. 2006;202:618–622.
11. Byhahn C, Lischke V, Meininger D, Halbig S, Westphal K. Peri-operative complications during percutaneous tracheostomy in obese patients. Anaesthesia. 2005;60:12–15.
12. Gross ND, Cohen JI, Andersen PE, Wax MK. Defatting tracheotomy in morbidly obese patients. Laryngoscope. 2002;112(11):1940–1944.


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