- Email: [email protected]
Complications of Percutaneous Tracheostomy
Discussion Initial treatment of nifedipine overdose should consist of gastric lavage and administration of activated charcoal to reduce GI absorption. Since nifedipine is highly protein bound, hemofiltration or dialysis is of no value. Although IV calcium is the initial pharmacotherapy for CCB overdose, its clinical efficacy is inconsistent6,7 and the dosage required is unclear. As demonstrated in this case, repeated bolus injection of calcium gluconate failed to reverse the toxicity of massive CCB overdose, and sustained-release preparation of CCB can result in prolonged hemodynamic instability. In animal experiments, doubling the serum calcium level is required for treatment of severe CCB toxicity.8 In this case, continuous and prolonged high-dose IV calcium infusion was administered to provide sustained increases in serum ionic calcium level (approximately 2 mmol/L) and was able to improve the hemodynamic status without any major adverse reaction. However, the risk of extravasation should be minimized by infusion using a central venous line. CaCl is preferable to calcium gluconate as the percentage of calcium ion available is higher (13.6 mEq vs 4.5 mEq in 10 mL of 10% solution). In patients with massive CCB overdose, additional catecholamine infusion may be required to maintain the hemodynamic status.1 Furthermore, glucagon injection may be useful in those who are refractory to other treatment.9 Occasionally, hyperglycemia, bradyarrhythmias, and noncardiogenic pulmonary edema may complicate CCB overdose.1,4,10 In this patient, only noncardiogenic pulmonary edema was observed. The exact mechanism of noncardiogenic pulmonary edema associated with CCB overdose is unclear but may be attributed to selective precapillary vasodilation and excessive fluid resuscitation for treatment of hypotension. Continuous calcium infusion and diuretic therapy can lead to resolution of the noncardiogenic pulmonary edema. In conclusion, massive CCB overdose can be lethal and the adverse effects are significantly prolonged if a sustained-release preparation has been taken. Judicious use of continuous CaCl infusion is a safe and effective treatment for patients with hemodynamic instability due to massive CCB overdose.
References 1 Ramoska EA, Spiller HA, Winter M, et al. A one-year evaluation of calcium channel blocker overdoses: toxicity and treatment. Ann Emerg Med 1993; 22:196 –200 2 MacDonald D, Alguire PC. Case report: fatal overdose with sustained-release verapamil. Am J Med Sci 1992; 303:115–117 3 Cosbey SH, Carson DJ. A fatal case of amlodipine poisoning. J Anal Toxicol 1997; 21:221–222 4 Stanek EJ, Nelson CE, DeNofrio D. Amlodipine overdose. Ann Pharmacother 1997; 31:853– 856 5 Kleinbloesem CH, van Brummelen P, van de Linde JA, et al. Nifedipine: kinetics and dynamics in healthy subjects. Clin Pharmacol Ther 1984; 35:742–749 6 Crump BJ, Holt DW, Vale JA. Lack of response to intravenous calcium in severe verapamil poisoning. Lancet 1982; 2:939 –940 7 Luscher TF, Noll G, Sturmer T, et al. Calcium gluconate in severe verapamil intoxication. N Engl J Med 1994; 330:718 – 719 8 Hariman RJ, Mangiardi LM, McAllister RG, et al. Reversal of the cardiovascular effects of verapamil by calcium and sodium: differences between electrophysiologic and hemodynamic responses. Circulation 1979; 59:797– 804 9 Fant JS, James LP, Fiser RT, et al. The use of glucagon in nifedipine poisoning complicated by clonidine ingestion. Pediatr Emerg Care 1997; 13:417– 419 1282
10 Herrington DM, Insley BM, Weinmann GG. Nifedipine overdose. Am J Med 1986; 81:344 –346
Complications of Percutaneous Tracheostomy* Thierry Briche, MD; Yvon Le Manach, MD; and Bruno Pats, MD
Percutaneous tracheostomy is a technique that, reputedly, is simple to perform and causes few complications. It is routinely used in intensive care. We present two patients with tracheal stenosis. In one patient, we had to perform an anastomotic resection to cure the patient; in the other patient, we had to place an endoluminal conformer. To our knowledge, this complication has not been reported in association with the use of this technique. (CHEST 2001; 119:1282–1283) Key words: complications; percutaneous tracheostomy; tracheal stenosis
tracheostomy is an alternative to surgical P ercutaneous tracheostomy, especially for physicians in ICUs. This
technique has the advantage of being performed at the bedside, with a low incidence of complications. However, most series in the literature do not report medium-term or long-term follow-up. We report two cases of laryngotracheal stenosis that developed following percutaneous tracheostomy.
Case Histories Case 1 A 33-year-old immunocompetent female patient was hospitalized in the emergency department after the rupture of an intracerebral angioma. Percutaneous tracheostomy was performed at 14 days. The endoscopy performed 9 days later showed no abnormality in the trachea. At 30 days, glottic edema developed, but it was difficult to assess the portion below the tracheal tube because the patient was agitated. Extubation was considered at 40 days, as the patient’s neurologic and respiratory condition had improved. Blocking off the tube induced asphyxia. Endoscopy was performed under general anesthesia, showing impassable tracheal stenosis. The MRI showed thin stenosis, and removal of the obstruction with CO2 laser exposed a tracheal ring impacted in the trachea. Surgical tracheostomy was performed with resection of the anterior part of the ring. However, at 9 days, stenosis reformed and a Montgomery T-tube had to be inserted. *From the Departments of Ear, Nose, Throat, Head and Neck Surgery (Dr. Briche) and the Intensive Care Unit (Drs. Le Manach and Pats), Hoˆpital d’Instruction des Arme´es Percy, Clamart Cedex, France. Manuscript received June 1, 2000; revision accepted September 13, 2000. Correspondence to: Thierry Briche, MD, Service ORL et Chirurgie de la Face et du Cou, Hoˆpital d’Instruction des Arme´es Percy, 101, avenue Henri Barbusse, 92141 Clamart Cedex, France; e-mail: [email protected] Selected Reports
It was removed 6 months later, but after 2 weeks stenosis reformed again and tracheal anastomotic resection was performed. Now, the patient has no stenosis and her trachea is normal.
Case 2 A 56-year-old immunocompetent female patient was hospitalized in the emergency department after attempting suicide by ingestion of tricyclic antidepressants. Percutaneous tracheostomy was performed after 5 days of orotracheal intubation. Spontaneous ventilation was possible at 15 days, and findings of nasofibroscopy performed at 40 days were normal. The patient was transferred to the physiotherapy department. Fifteen days later, she exhibited cardiac and respiratory failure. Orotracheal intubation was impossible, which made it an emergency to reopen the pathway of the percutaneous tracheostomy. An examination performed under general anesthesia showed a very tight tracheal stenosis. Laser resection of the stenosis cleared a tracheal ring impacted in the posterior wall of the trachea. A surgical tracheostomy was then performed with insertion of a permanent Montgomery T-tube. The patient is now in a vegetative coma.
Discussion Percutaneous tracheostomy is a technique that seems to be simple to perform and causes fewer complications than conventional tracheostomy. Two techniques are proposed: the Ciaglia method,1 with gradual dilatation of the trachea after puncture (which seems to be the most reliable method); and the less frequently used Fantoni method,2 a translaryngeal method where the tube is placed, through the vocal cords, on the anterior side of the trachea. In our hospital, the ICU department uses the Ciaglia method, for which no serious complication (particularly stenosis) was first reported.3 This technique is only performed by an experienced physician, who has already carried out ⬎ 100 percutaneous tracheostomies. Complications are a recent phenomenon, considering the long experience of this physician, and lack of practice is definitely ruled out. The mechanism underlying these two stenoses seems to be the same: a difficult perforation of the trachea when the dilator and the cannula are inserted, fracturing the tracheal ring and creating a flap that, contrary to the tracheal flap created by surgical tracheostomy, protrudes inside the lumen. Because of the small diameter of the trachea, insertion of the localizing needle used to insert the guidewire can cause damage to the posterior tracheal wall and, with time, the flap becomes impacted against the posterior wall with synechia. Failure of the surgical procedure, laser, and calibration of the trachea by a Montgomery T-tube is explained by the persistence of the inflammatory process, with rapid development of stenosis after removal of the calibration tube. Although it was not necessary in the early phase of treatment, the only surgical method that freed the patient from therapeutic constraints was anastomotic resection of the trachea. In our practice, (1) we cannot say that one technique is better than the other; however, we can say that in all cases complications such as laryngotracheal stenosis may also arise as a result of percutaneous tracheostomy using the Ciaglia method4 – 6; (2) considering the mechanism of this stenosis, it is advised not to damage the posterior wall and, if it is difficult to insert the dilator, it might be preferable
to perform a standard surgical tracheostomy; and (3) nasofibroscopy should always be performed after 6 months and after 1 year to verify the condition of the trachea after decannulation, and to have a better understanding of the incidence of stenotic complications after tracheostomy.
References 1 Ciaglia P, Firsching R, Synec C. Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report. Chest 1985; 87:715–719 2 Fantoni A. Translaryngeal tracheostomie. In: Gullo A, ed. Anaesthesia, pain, intensive care and emergency medicine. Trieste, Italy: A.P.I.C.E., 1993; 465 3 Ciaglia P, Graniero KD. Percutaneous dilatational tracheostomy: results and long-term follow-up. Chest 1992; 101:464 – 467 4 McFarlane C, Denholm SW, Sudlow CL, et al. Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anesthesia 1994; 49:38 – 40 5 Charters P, Mannar R, Jones AS. Laryngotracheal stenosis after percutaneous tracheostomy. Anesthesia 1994; 49:825– 826 6 Ciaglia P, Marx W. Laryngotracheal stenosis after percutaneous tracheostomy [letter]. Anesthesia 1995; 50:261
Minocycline-Induced Pancreatitis in Cystic Fibrosis* Michael P. Boyle, MD
We report two cases of acute pancreatitis secondary to minocycline use in adults with cystic fibrosis (CF). This minocycline complication has not previously been reported. Given the increased use of minocycline in the adult CF population to treat resistant bacteria, awareness of this potential adverse effect is imperative. As both of these individuals with CF had class IV genotypes and pancreatic sufficiency, close observation is warranted in the future to determine if persons with pancreatic-sufficient CF are at an increased risk for minocycline-induced pancreatitis. (CHEST 2001; 119:1283–1285) Key words: cystic fibrosis; cystic fibrosis transmembrane conductance regulator; minocycline; pancreatitis Abbreviations: CF ⫽ cystic fibrosis; CFTR ⫽ cystic fibrosis transmembrane conductance regulator
median survival of adults with cystic fibrosis (CF) A shastheimproved, the frequency of resistant bacteria complicating CF management has increased.1 These or-
*From the Adult Cystic Fibrosis Program, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Manuscript received July 7, 2000; revision accepted September 14, 2000. Correspondence to: Michael P. Boyle, MD, Adult Cystic Fibrosis Program, Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine, 1830 E. Monument St, Suite 301, Baltimore, MD 21205; e-mail: [email protected] CHEST / 119 / 4 / APRIL, 2001
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References 1 Ramoska EA, Spiller HA, Winter M, et al. A one-year evaluation of calcium channel blocker overdoses: toxicity and treatment. Ann Emerg Med 1993; 22:196 –200 2 MacDonald D, Alguire PC. Case report: fatal overdose with sustained-release verapamil. Am J Med Sci 1992; 303:115–117 3 Cosbey SH, Carson DJ. A fatal case of amlodipine poisoning. J Anal Toxicol 1997; 21:221–222 4 Stanek EJ, Nelson CE, DeNofrio D. Amlodipine overdose. Ann Pharmacother 1997; 31:853– 856 5 Kleinbloesem CH, van Brummelen P, van de Linde JA, et al. Nifedipine: kinetics and dynamics in healthy subjects. Clin Pharmacol Ther 1984; 35:742–749 6 Crump BJ, Holt DW, Vale JA. Lack of response to intravenous calcium in severe verapamil poisoning. Lancet 1982; 2:939 –940 7 Luscher TF, Noll G, Sturmer T, et al. Calcium gluconate in severe verapamil intoxication. N Engl J Med 1994; 330:718 – 719 8 Hariman RJ, Mangiardi LM, McAllister RG, et al. Reversal of the cardiovascular effects of verapamil by calcium and sodium: differences between electrophysiologic and hemodynamic responses. Circulation 1979; 59:797– 804 9 Fant JS, James LP, Fiser RT, et al. The use of glucagon in nifedipine poisoning complicated by clonidine ingestion. Pediatr Emerg Care 1997; 13:417– 419 1282
10 Herrington DM, Insley BM, Weinmann GG. Nifedipine overdose. Am J Med 1986; 81:344 –346
Complications of Percutaneous Tracheostomy* Thierry Briche, MD; Yvon Le Manach, MD; and Bruno Pats, MD
Percutaneous tracheostomy is a technique that, reputedly, is simple to perform and causes few complications. It is routinely used in intensive care. We present two patients with tracheal stenosis. In one patient, we had to perform an anastomotic resection to cure the patient; in the other patient, we had to place an endoluminal conformer. To our knowledge, this complication has not been reported in association with the use of this technique. (CHEST 2001; 119:1282–1283) Key words: complications; percutaneous tracheostomy; tracheal stenosis
tracheostomy is an alternative to surgical P ercutaneous tracheostomy, especially for physicians in ICUs. This
technique has the advantage of being performed at the bedside, with a low incidence of complications. However, most series in the literature do not report medium-term or long-term follow-up. We report two cases of laryngotracheal stenosis that developed following percutaneous tracheostomy.
Case Histories Case 1 A 33-year-old immunocompetent female patient was hospitalized in the emergency department after the rupture of an intracerebral angioma. Percutaneous tracheostomy was performed at 14 days. The endoscopy performed 9 days later showed no abnormality in the trachea. At 30 days, glottic edema developed, but it was difficult to assess the portion below the tracheal tube because the patient was agitated. Extubation was considered at 40 days, as the patient’s neurologic and respiratory condition had improved. Blocking off the tube induced asphyxia. Endoscopy was performed under general anesthesia, showing impassable tracheal stenosis. The MRI showed thin stenosis, and removal of the obstruction with CO2 laser exposed a tracheal ring impacted in the trachea. Surgical tracheostomy was performed with resection of the anterior part of the ring. However, at 9 days, stenosis reformed and a Montgomery T-tube had to be inserted. *From the Departments of Ear, Nose, Throat, Head and Neck Surgery (Dr. Briche) and the Intensive Care Unit (Drs. Le Manach and Pats), Hoˆpital d’Instruction des Arme´es Percy, Clamart Cedex, France. Manuscript received June 1, 2000; revision accepted September 13, 2000. Correspondence to: Thierry Briche, MD, Service ORL et Chirurgie de la Face et du Cou, Hoˆpital d’Instruction des Arme´es Percy, 101, avenue Henri Barbusse, 92141 Clamart Cedex, France; e-mail: [email protected] Selected Reports
It was removed 6 months later, but after 2 weeks stenosis reformed again and tracheal anastomotic resection was performed. Now, the patient has no stenosis and her trachea is normal.
Case 2 A 56-year-old immunocompetent female patient was hospitalized in the emergency department after attempting suicide by ingestion of tricyclic antidepressants. Percutaneous tracheostomy was performed after 5 days of orotracheal intubation. Spontaneous ventilation was possible at 15 days, and findings of nasofibroscopy performed at 40 days were normal. The patient was transferred to the physiotherapy department. Fifteen days later, she exhibited cardiac and respiratory failure. Orotracheal intubation was impossible, which made it an emergency to reopen the pathway of the percutaneous tracheostomy. An examination performed under general anesthesia showed a very tight tracheal stenosis. Laser resection of the stenosis cleared a tracheal ring impacted in the posterior wall of the trachea. A surgical tracheostomy was then performed with insertion of a permanent Montgomery T-tube. The patient is now in a vegetative coma.
Discussion Percutaneous tracheostomy is a technique that seems to be simple to perform and causes fewer complications than conventional tracheostomy. Two techniques are proposed: the Ciaglia method,1 with gradual dilatation of the trachea after puncture (which seems to be the most reliable method); and the less frequently used Fantoni method,2 a translaryngeal method where the tube is placed, through the vocal cords, on the anterior side of the trachea. In our hospital, the ICU department uses the Ciaglia method, for which no serious complication (particularly stenosis) was first reported.3 This technique is only performed by an experienced physician, who has already carried out ⬎ 100 percutaneous tracheostomies. Complications are a recent phenomenon, considering the long experience of this physician, and lack of practice is definitely ruled out. The mechanism underlying these two stenoses seems to be the same: a difficult perforation of the trachea when the dilator and the cannula are inserted, fracturing the tracheal ring and creating a flap that, contrary to the tracheal flap created by surgical tracheostomy, protrudes inside the lumen. Because of the small diameter of the trachea, insertion of the localizing needle used to insert the guidewire can cause damage to the posterior tracheal wall and, with time, the flap becomes impacted against the posterior wall with synechia. Failure of the surgical procedure, laser, and calibration of the trachea by a Montgomery T-tube is explained by the persistence of the inflammatory process, with rapid development of stenosis after removal of the calibration tube. Although it was not necessary in the early phase of treatment, the only surgical method that freed the patient from therapeutic constraints was anastomotic resection of the trachea. In our practice, (1) we cannot say that one technique is better than the other; however, we can say that in all cases complications such as laryngotracheal stenosis may also arise as a result of percutaneous tracheostomy using the Ciaglia method4 – 6; (2) considering the mechanism of this stenosis, it is advised not to damage the posterior wall and, if it is difficult to insert the dilator, it might be preferable
to perform a standard surgical tracheostomy; and (3) nasofibroscopy should always be performed after 6 months and after 1 year to verify the condition of the trachea after decannulation, and to have a better understanding of the incidence of stenotic complications after tracheostomy.
References 1 Ciaglia P, Firsching R, Synec C. Elective percutaneous dilatational tracheostomy: a new simple bedside procedure; preliminary report. Chest 1985; 87:715–719 2 Fantoni A. Translaryngeal tracheostomie. In: Gullo A, ed. Anaesthesia, pain, intensive care and emergency medicine. Trieste, Italy: A.P.I.C.E., 1993; 465 3 Ciaglia P, Graniero KD. Percutaneous dilatational tracheostomy: results and long-term follow-up. Chest 1992; 101:464 – 467 4 McFarlane C, Denholm SW, Sudlow CL, et al. Laryngotracheal stenosis: a serious complication of percutaneous tracheostomy. Anesthesia 1994; 49:38 – 40 5 Charters P, Mannar R, Jones AS. Laryngotracheal stenosis after percutaneous tracheostomy. Anesthesia 1994; 49:825– 826 6 Ciaglia P, Marx W. Laryngotracheal stenosis after percutaneous tracheostomy [letter]. Anesthesia 1995; 50:261
Minocycline-Induced Pancreatitis in Cystic Fibrosis* Michael P. Boyle, MD
We report two cases of acute pancreatitis secondary to minocycline use in adults with cystic fibrosis (CF). This minocycline complication has not previously been reported. Given the increased use of minocycline in the adult CF population to treat resistant bacteria, awareness of this potential adverse effect is imperative. As both of these individuals with CF had class IV genotypes and pancreatic sufficiency, close observation is warranted in the future to determine if persons with pancreatic-sufficient CF are at an increased risk for minocycline-induced pancreatitis. (CHEST 2001; 119:1283–1285) Key words: cystic fibrosis; cystic fibrosis transmembrane conductance regulator; minocycline; pancreatitis Abbreviations: CF ⫽ cystic fibrosis; CFTR ⫽ cystic fibrosis transmembrane conductance regulator
median survival of adults with cystic fibrosis (CF) A shastheimproved, the frequency of resistant bacteria complicating CF management has increased.1 These or-
*From the Adult Cystic Fibrosis Program, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Manuscript received July 7, 2000; revision accepted September 14, 2000. Correspondence to: Michael P. Boyle, MD, Adult Cystic Fibrosis Program, Johns Hopkins University School of Medicine, Division of Pulmonary and Critical Care Medicine, 1830 E. Monument St, Suite 301, Baltimore, MD 21205; e-mail: [email protected] CHEST / 119 / 4 / APRIL, 2001
1283