GuideWire Migrating into Murphy's Eye of Endotracheal Tube: An Unusual Complication of Percutaneous Dilational Tracheostomy.

Percutaneous dilational tracheostomy (PDT) is a frequently carried out bedside procedure in a critical care setting. It is usually performed under fiberoptic endoscopic guidance. Studies with PDT performed with endoscopic guidance have reported lower complication rates than studies performed with "blind" PDT. We report a case where PDT was performed without endoscopic assistance and the j-shaped guidewire got stuck in the Murphy's eye of endotracheal tube causing difficulty in railroading of tracheostomy tube (TT).

INTRODUCTION

Percutaneous dilational tracheostomy (PDT) is a frequently carried out procedure in a critical care setting. It is performed by intensivists as a bedside procedure under endoscopic guidance. Although simple, PDT is not devoid of complications, especially if done without endoscopic guidance. We report a case where PDT was performed without fiberoptic assistance and j-shaped guidewire got stuck in the Murphy's eye of endotracheal tube (ETT) causing difficulty in railroading of tracheostomy tube (TT). A few similar incidents have been reported, but the fact that the complication is immediately detected and corrected without any damage might be the reason for under-reporting.

CASE REPORT

A 60-year-old male got admitted in intensive care unit with intracranial hemorrhage. The patient was intubated and required mechanical ventilation in view of poor neurological status. He was planned for bedside PDT due to the need of prolonged ventilation. The procedure was performed by experienced intensivists under standard monitoring care using standard percutaneous dilation kit with Blue Line Ultra® suctionaid TT, single staged dilation [Figure 1]. Due to some technical issues with the bronchoscope, it was decided to proceed blindly. After obtaining consent, sedation and analgesia were given. The patient was ventilated on pressure control ventilation with 100% oxygen. The patient was placed in supine position with a pillow placed beneath shoulders to extend the neck. Thorough oral and subglottic suction was done and under direct laryngoscopy (DL) the ETT-size-8.5 was pulled out until the partially deflated cuff was just below the vocal cords. An experienced assistant maintained it, in this position. The neck was disinfected and sterile drapes placed. Anatomical landmarks were identified (thyroid cartilage, cricoid cartilage, sternal notch, and tracheal rings) and the area between thyroid cartilage and sternal notch infiltrated with 5 ml of 2% lignocaine with adrenaline. A horizontal incision of around 2 cm was given midway between thyroid prominence and sternal notch which roughly corresponds to the area between second and third tracheal rings. Blunt dissection was done till pretracheal fascia was reached. A 14 gauge needle and cannula (with saline filled syringe attached) was inserted in the midline in a caudal direction through the same incision and air aspirated to confirm placement of needle and cannula in the trachea. Next the needle was taken out leaving cannula in place and air aspirated to re-confirm its correct placement. Through this cannula, the guidewire was inserted in a caudal direction until the first mark was at skin level. After confirming free movement of the guidewire in and out, the cannula was taken out. The tract was dilated using 14 French short dilator over the guidewire. Now the long guiding catheter was inserted till the specified mark and again tract dilated with pre-lubricated “single stage” dilator. We tried to pass lubricated TT loaded over soft tip tube introducer through the stoma but in vain. Thinking that stoma might be small, the tract was again dilated, but the same problem was encountered which raised our suspicion of ETT hindering the tract.

Figure 1

Components of tracheostomy set

ETT was gently withdrawn and inserted by about a centimeter a couple of times. This corresponded to a swing of the guidewire in the sagittal plane which suggested that the guidewire was somehow attached to the ETT. The dilator and the guidewire were removed, and under DL, the ETT was pulled out further two cm. Now, we were able to insert the TT directly as the stoma was well formed. Placement of the TT was confirmed by manual ventilation and auscultation. On inspection of ETT, no rent or rupture of cuff was found which suggested that guidewire along with the guiding catheter and dilator had stuck in the murphy's eye of ETT [Simulated Figure 2]. Posttracheostomy chest X-radiograph confirmed its correct location.

Figure 2

Simulated picture of guidewire along with guiding catheter and tracheostomy tube introducer stuck in murphy's eye

DISCUSSION

Toy and Weinstein first described percutaneous tracheostomy in 1969. The introduction of PDT by Pasquale Ciaglia in 1985 heralded a new era in the airway management of critically ill patients.

Documented common complications of PDT have been mostly malposition, bleeding, and infection.[1] A study involving series of 200 cases reported only one event of knotted guidewire.[2] Studies with PDT performed with endoscopic guidance have reported lower complication rates than studies performed with “blind” PDT.[3]

Similar incidents have been reported where the guidewire migrating into Murphy's eye did not allow dilatation.[456] In another case reported by Howes et al. guidewire punctured the pilot balloon of ETT.[7] In our case, the introducer needle passed the Murphy's eye, causing the guidewire to get entangled which might have occurred due to the short neck of the patient or by slight caudal movement of ETT by assistant. The distance between vocal cords and the sternal notch is likely to increase a bit when the neck is extended by placement of a pillow under the shoulder blades as used for PDT. This should allow the PDT needle to avoid the tip of the ETT during a puncture. However, there is considerable variation in the anatomy of patients and the distance is less in about a third of patients which increases the potential for ETT and cuff impingement.[7] In a study by Ambesh et al., the incidence of cuff rupture and ETT impalement during PDT was reported to be 6.6% each.[8]

The fact that the complication is immediately detected and corrected without any damage might be the reason for under-reporting. These complications may be averted with the use of fiberoptic endoscopy.[9] In the absence of endoscopy one should check the free movement of the ETT and the guide wire in and out of trachea once needle with cannula is placed inside the trachea.

Recently, portable ultrasonography is used to preserve adjacent structures, demonstrate the guide wire location and the correct level of the cannula.[10] It also enables clinicians to assess the space between the anterior tracheal wall and the skin, to evaluate extends the length of the tube, and suitably put the endo-tracheal tube in the correct position. However, there are limited information and data that supports the efficacy and safety of ultrasound-guided PDT.

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Conflicts of interest

There are no conflicts of interest.