Andrew Cohen

Neck Ultrasound Prior to Percutaneous Tracheostomy: Should this Now be a Standard of Practice?

On our intensive care unit we routinely perform 2D ultrasound on the anterior neck prior to percutaneous tracheostomy insertion, in order to identify the vascular anatomy. This enables us to identify patients who may be at risk of vascular complications during the insertion. Haemorrhage is a rare but potentially fatal complication of percutaneous tracheostomy1-3 and is reported to occur in 5.7% of cases.4 Erosion into adjacent blood vessels is a later, but no less serious, complication. We would like to report one of a number of similar cases we have encountered in our unit where this practice was invaluable in preventing potential haemorrhage. On routine ultrasound of the neck prior to tracheostomy, large anterior vessels were visualised sitting very close to the midline (Figure 1). The risk of primary haemorrhage from one of these vessels, or erosion into them at a later date was considered substantial, so we arranged for one of our maxillofacial surgeons to perform a surgical tracheostomy in theatre. Large blood vessels were encountered anteriorly and were ligated, with some difficulty, prior to successful insertion of a tracheostomy. We believe that identification of the blood vessels by using portable ultrasonography (Figure 1) enabled us to formulate a sensible plan to minimise risk to our patient. We have no doubt that had this procedure been performed on the intensive care unit there may have been significant bleeding which may have been difficult to control. With lack of immediately available ENT support, a position becoming more common as specialist services are centralised, this could have resulted in serious morbidity or even mortality. In addition to identifying abnormal vessels, ultrasound can also be used to measure tracheal depth, location of the thyroid isthmus and identification of the tracheal rings. Indeed, some physicians are now advocating tracheostomy insertion using real-time ultrasound guidance.5 We are aware that such recommendations have been made before;6,7 however, we are concerned that this practice does not appear to have had significant take-up within the intensive care community. We are convinced that ultrasound of the neck on our patient prevented significant morbidity and believe that this simple and effective procedure should now be a standard of practice on all intensive care units that perform percutaneous tracheostomy. References

JICS and ethics

Graduating from medical school before the CT scanner had been invented, I can confirm that there was no time set aside for the discussion of ethics in those days. We were able to witness first-hand patients denied coronary care beds because they were women or over 65 years of age, patients arriving for surgery having no idea what was being done to them and some doctors treating patients as an inconvenience, let alone listening to their views on their own health care. Students were told that the role of the General Medical Council was to make sure that they did not indulge in recreational drugs, have inappropriate liaisons with patients, advertise their services or get caught driving under the influence of alcohol on too many occasions. Times have changed; ethics is now a subject that is routinely studied at medical school, is in the mainstream and young doctors understand the importance of considering such issues. This does not mean to say they know the answers but that they have been educated to understand the importance of asking the questions and to consider the needs and rights of their patient and society as a whole. I doubt whether many people choose a career in critical care medicine because they are closet ethicists and yet we find ourselves dealing with important ethical questions on a daily basis, such as consent, patient autonomy, rationing, triage and the subtleties of what is and is not acceptable in the process of organ donation.