Novel positioning solution for difficult tracheostomy.

Sir,

Tracheostomies for morbidly obese patients can present significant challenges for both anesthesia and surgical teams. We present a case of a 44-year-old male with a body mass index (BMI) of 90 for whom creative positioning methods were needed for safe tracheostomy placement.

A 44-year-old, 285 kg man (BMI 90) was scheduled for tracheostomy for acute respiratory failure. His medical history was significant for:

Severe untreated obstructive sleep apnea,

Obesity–Hypoventilation syndrome with chronic CO2 retention and home O2 dependency (4 L),

Acute lower extremity and scrotal cellulitis, and

Recent cardiac arrest secondary to acute hypoxemia.

The patient was brought to the operating room and moved to the bariatric table. Head-up positioning was difficult to maintain as, despite the use of footboards, the patient slid caudally with each attempt at sitting or reverse trendelenburg position. When the patient was supine, rapid desaturation would occur. Ninety minutes were spent on attempts to find a position in which adequate oxygenation and surgical exposure could be accomplished simultaneously. When no such positioning was achieved, the procedure was aborted. The patient was transferred back to the Intensive Care Unit with the plan of optimizing his pulmonary status prior to another attempt at tracheostomy.

Ten days later, the patient returned for another attempt at tracheostomy. He was transferred to the bariatric table awake and placed in a modified beach chair position. Numerous straps were utilized to secure the patient and prevent sliding on the table. After 30 min of careful positioning, surgical exposure was still not acceptable. A chest-suspension technique was then proposed to the patient and surgical team. After short deliberation and patient consent, 1% lidocaine was infiltrated subcutaneously above the patient's nipples bilaterally. Penetrating towel clips were then secured to the patient's chest and suspended from the overhead beams [Figure 1]. The patient was then slowly reclined backward while the tension on the towel clips was kept constant. With his chest in suspension, lung expansion was greatly improved as was surgical exposure [Figure 2]. With the suspension, the patient was able to tolerate general anesthesia in near-supine position, and a four-flap epithelial lined tracheotomy was completed without incident. The patient was seen 9 months later and displayed a well-healed tracheostomy with no appreciable scarring from the towel clips.

Figure 1

Chest in suspension from surgical booms

Figure 2

Chest in suspension with excellent surgical exposure

While the technique of chest wall suspension for its ventilatory benefits has been practiced,[12] as has the suspension of limbs from operating room booms for the purposes of surgical preparation, we are unaware of such a technique ever being used to facilitate both pulmonary mechanics and surgical exposure. We present a case in which creative use of a suspension technique resulted in conditions that were satisfactory to both the patient and surgeon when lengthy attempts at other positioning techniques had failed.