- Email: [email protected]
The Parkland 12-Minute Checklist Tracheotomy
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CRANIOMAXILLOFACIAL TRAUMA
The Parkland 12-Minute Checklist Tracheotomy Neeraj Panchal, DDS, MD, MA,* and Michael Zide, DMDy
Q7
Purpose:
To validate the surgical time and propose a new checklist or algorithm to execute a tracheotomy within 12 minutes with optimal outcomes.
Materials and Methods:
The authors designed and implemented a checklist method for tracheotomy based on 6 consecutive patients with respiratory failure and prolonged intubation in a medical intensive care unit. The primary outcome variable was surgical time for a tracheotomy performed by a fifth- or sixthyear resident under the supervision of the senior author (M.Z.).
Results:
Six consecutive patients undergoing tracheotomy (mean, 48 yr; range, 24 to 55 yr; 4 men and 2 women) were included in the study. The average time recorded from the incision to correct insertion of the tracheotomy tube and confirmation of carbon dioxide return by the anesthesiologist was 10.66 minutes (range, 8 to 12 minutes).
Conclusion:
This checklist facilitates the execution of a time-efficient and safe tracheotomy in less than 12 minutes. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-6, 2015
Surgeons perform approximately 100,000 tracheotomies each year in the United States.1 Tracheotomy is not a simple procedure. The patient might be obese or have obstruction, infection, or medical or structural compromise, each of which can complicate the tracheotomy. In a teaching institution, the staff surgeon faces a conflict between the desire to teach a procedure to trainees and the responsibility to obtain a secure airway without complications. Unfortunately, human fallibility can yield untoward and unexpected results. Complications during and after tracheotomy have been tallied for decades. Fallibility can be limited by experience or rote procedural training. Gawande2 recounted that perhaps 10,000 hours is required to produce an accomplished pilot, musician, or surgeon. Gawande recalled that passengers survived Mr Sullenberger’s landing in the Hudson River because of this experience and the compulsory checklist pilots must follow. The checklist Q2
critically offsets some carelessness and inexperience, especially under stress. The introduction of the World Health Organization Surgical Safety Checklist into operating rooms in 8 hospitals resulted in a decreased complication rate from 11.0 to 7.0%.3 Complex technologic advances and checklists have limited negative outcomes in the realms of stroke, heart attack, and asthma. As Gawande pointed out, ‘‘under duress getting the right steps is brutally hard, even if you know them.’’ Three sequential stages of learning have been described to generate expertise in a procedure4,5; these stages are applicable to the performance of tracheotomy. During the first stage (cognitive stage), information is acquired in a propositional form. The surgeon processes with fact memorization and rehearsal by active thinking but develops only a basic understanding of 2tasks and strategies. This propositional method
*Former Chief Resident, University of Texas Southwestern,
Address correspondence and reprint requests to Dr Panchal:
Parkland Memorial Hospital, Dallas, TX; Clinical Instructor,
3400 Spruce Street, 5 White Building, Philadelphia, PA 19104;
Department of Oral and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA; Chief, Department of Oral and
e-mail: [email protected] Received September 29 2015
Maxillofacial Surgery, Philadelphia Veteran’s Affairs Medical Center,
Accepted October 26 2015
Philadelphia, PA.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
yClinical Assistant Professor, Division of Oral and Maxillofacial
0278-2391/15/01424-X
Surgery, University of Texas Southwestern Medical Center,
http://dx.doi.org/10.1016/j.joms.2015.10.022
Parkland Memorial Hospital, Dallas, TX.
1 FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
PARKLAND 12-MINUTE CHECKLIST TRACHEOTOMY
(step-by-step) can produce an uncertain, faltering, and error-prone procedure. During the second stage (associative stage), the surgeon masters procedural skills, but the execution is plodding, variable, and susceptible to errors. However, in this stage, the cognitive information from stage 1 is enhanced through contexts, goals, and circumstances. Repetitive practice teaches what specific conditions result in a positive outcome and where errors are most likely to occur. ‘‘Smoothing out’’ errors contribute to competence. In the third stage (autonomous stage), surgical performances are smooth and fast and the surgeon is proficient. Actions can be executed unconsciously and autonomously with high accuracy and precision.6 A checklist was designed to decrease the anxiety associated with a tracheotomy and to decrease associated bleeding complications. This tracheotomy checklist also serves as an algorithm for surgeons with different experiences to learn to perform a tracheotomy in a straightforward and safe manner. As an algorithm, it not only directs the novice surgeon with a road map but also provides the staff surgeon with execution parameters. Therefore, a checklist or algorithm was developed to execute a tracheotomy within 12 minutes with optimal outcomes. Each step was explained until understood and the process was reviewed the night before surgery. During surgery, the straightforward steps were checked sequentially. The introduction of the checklist and validation of the surgical time were evaluated in this study.
Q1
such was not formally supervised by the institutional review board. CHECKLIST FOR TRACHEOTOMY
, Position the patient using a shoulder roll to extend the neck and mark the cricoid cartilage, the sternal notch, and the incision midway between these landmarks (Fig 1). , Remove a plug of fat down to the strap muscles through the 4- to 5-cm access incision (Fig 2). , Open the strap muscles vertically in the midline with Metzenbaum scissors from the above the cricoid cartilage to the suprasternal notch (Fig 3). , Grasp the strap muscles with Allis clamps and bluntly dissect the full incision to allow easy visualization of the thyroid. Retract the strap muscles with Army-Navy retractors and digitally palpate the cricoid cartilage (Fig 4). , Ensure the anesthesiologist has decreased oxygen delivery and then use a Bovie electrosurgical device to make an 8-mm horizontal nick incision Q3
Materials and Methods After developing the checklist, 6 sequential patients were treated with the checklist protocol as a quality improvement initiative. The checklist method was not used for patients with emergency airway obstruction. All patients were referred by the medical intensive care team for tracheotomy because of prolonged intubation. All tracheotomies were performed in the operating room setting under the supervision of the senior author (M.Z.). The resident surgeon was a fifthor sixth-year resident assigned to the case. Each resident previously had performed a tracheotomy with an approximate time of 20 minutes. Each resident had been talked and walked through the checklist tracheotomy at least once. After evaluation of the patient’s condition and rationale for the procedure, the resident surgeon followed the checklist explicitly. The times recorded were 1) the neck incision and 2) correct insertion of the tracheotomy tube. This project was undertaken as a quality improvement initiative at the Parkland Health and Hospital System (Dallas, TX) and as
print & web 4C=FPO
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
2
FIGURE 1. The cricoid cartilage, tracheotomy incision, and sternal notch are marked. The blue marking indicates the cautery cut Q6 through the fascia into the pretracheal space. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
3
FIGURE 2. A plug of subcutaneous fat down to the strap muscles is removed. print & web 4C=FPO
Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
FIGURE 4. The thyroid gland is exposed by blunt dissection and the bottom fourth of the cricoid cartilage is marked. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
print & web 4C=FPO
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
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PANCHAL AND ZIDE
FIGURE 3. The strap muscles are opened vertically. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
on the bottom fourth of the cricoid cartilage (on top of, but not through, the cartilage). Insert a tracheotomy hook within the nick to grasp the underside of the cricoid and pull the cricoid cartilage superiorly (Fig 5). , Dissect with a mosquito hemostat from the nick inferiorly under the thyroid isthmus and on top of the trachea (Fig 6) and have an assistant move the Bovie device on the mosquito hemostat through the thyroid gland using a blend of cutting and cautery (ensure absolute hemostasis; Fig 7). , Retract the thyroid segments laterally with the Army-Navy retractors. Incise sharply above the second tracheal ring with a number 15 blade from the sides to the middle and complete the inverted ‘‘U’’-shaped flap with scissors. Suture through the U-shaped flap for subsequent attachment to the chest wall (Fig 8). , Insert a pretested tracheotomy device and connect it to the anesthesia circuit (confirm carbon dioxide return).
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
PARKLAND 12-MINUTE CHECKLIST TRACHEOTOMY
FIGURE 5. Using a Bovie device, a nick incision is made on the bottom fourth of the cricoid cartilage and a tracheotomy hook is inserted by pulling the cricoid superiorly. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
, Suture the plastic wings of the tracheotomy device with 2-0 sutures (Fig 9), secure the U-shaped flap suture to the chest, and place a tracheotomy tie around the neck.
Results Six consecutive patients undergoing tracheotomy (mean, 48 yr; range, 24 to 55 yr; 4 men and 2 women) were included in the study. The average time recorded from the incision to correct insertion of the tracheotomy tube and confirmation of carbon dioxide return by the anesthesiologist was 10.66 minutes (range, 8 to 12 minutes).
Discussion The checklist tracheotomy ensures a safe and reliable outcome. The checklist methodology was introduced to increase the culture of safety in the operating room. This checklist has an additional value as an
print & web 4C=FPO
print & web 4C=FPO
337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
4
FIGURE 6. The area under the thyroid isthmus is dissected bluntly. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
algorithm or educational tool for surgical residents. It is important for the resident surgeon to understand the underlying reason for each step on the checklist. The appropriate placement of a shoulder roll shifts the airway in a more ventral position. Neck extension facilitates palpation and visualization of anatomic reference points. Cervical injuries that preclude neck extension complicate the ease of tracheotomy. Despite this difficulty, patients with cervical injury underwent tracheotomies with this technique using a vertical neck incision, requiring an additional 5 minutes in surgical time. The 4- to 5-cm horizontal neck incision is midway between the cricoid cartilage and the sternal notch. If the surgeon elects a vertical neck incision, then the incision is drawn between these 2 anatomic references. Grasping the adipose tissue in the midline with an Allis clamp and removing a plug of fat to the level of the strap muscles minimizes the amount of tissue between the skin and the tracheal wall, easing the identification of the midline raphe of the strap
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448
5
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449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
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PANCHAL AND ZIDE
FIGURE 7. The trachea is exposed after division of the thyroid using a blend of cutting and cautery. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
Q4
muscles and subsequent retraction. Wide exposure under the strap muscles ensures easy visualization and palpation of critical anatomic landmarks. The authors commonly use Metzenbaum scissors to divide the strap muscles; however, electrocautery is an alternative option. The nick incision on the bottom fourth of the cricoid cartilage allows for clean dissection between the thyroid gland and the trachea. A literature review showed that this specific access incision through the pretracheal fascia has not been suggested. The nick incision on the bottom fourth of the cricoid cartilage allows for clean dissection between the thyroid cartilage and the trachea. Blunt dissection under the thyroid isthmus and on top of the trachea ensures that when the thyroid is divided using cutting and cautery blend, there is no accidental entry into the trachea. This additional safeguard permits the surgeon
FIGURE 8. A U-shaped flap is created in the trachea. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
to achieve adequate hemostasis through the vascular thyroid gland. The tracheal airway should be incised from the sides to the middle to hinder accidental risk of cutting adjacent vessels to the trachea. By pulling on the U-shaped flap, the surgeon can easily insert the tracheotomy tube without a dilator. Four permanent sutures through the tracheotomy base and the skin of the neck firmly secure the tracheotomy, preventing accidental decannulation.7 This checklist facilitates the execution of a timeefficient tracheotomy. Each step must be followed in succession. This technique can be applied to almost all tracheotomies. Even for complex cases, surgical time can be shortened. Residents have noted that this checklist method fosters a relatively bloodless, fearless, safe, and reliable 12-minute tracheotomy.
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
PARKLAND 12-MINUTE CHECKLIST TRACHEOTOMY
Future studies will evaluate the authors’ primary objective of formulating the checklist, namely decreasing a surgeon’s anxiety, blood loss, and complications. Q5 Acknowledgments The authors thank Dr Atul Gawande for his editorial assistance in the submission of this article.
References
print & web 4C=FPO
561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587
6
FIGURE 9. The tracheotomy tube is inserted and secured by sutures on the skin. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
1. Yu M: Tracheostomy patients on the ward: Multiple benefits from a multidisciplinary team? Crit Care 14:109T, 2010 2. Gawande A: The Checklist Manifesto. New York, NY, Picador, Henry Holt and Company, 2010 3. Haynes AB, Weiser TG, Berry WR, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360:491, 2009 4. Fitts PM, Posner MI: Human Performance. Belmont, CA, Brooks Cole, 1967 5. Anderson JR: The Architecture of Cognition. Cambridge, MA, Harvard University Press, 1983 6. Anderson JR: Cognitive Psychology and Its Implications. New York, NY, Worth Publishers, 2005 7. Halum SL, Ting JY, Plowman EK, et al: A multi-institutional analysis of tracheotomy complications. Laryngoscope 122:38, 2012
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
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CRANIOMAXILLOFACIAL TRAUMA
The Parkland 12-Minute Checklist Tracheotomy Neeraj Panchal, DDS, MD, MA,* and Michael Zide, DMDy
Q7
Purpose:
To validate the surgical time and propose a new checklist or algorithm to execute a tracheotomy within 12 minutes with optimal outcomes.
Materials and Methods:
The authors designed and implemented a checklist method for tracheotomy based on 6 consecutive patients with respiratory failure and prolonged intubation in a medical intensive care unit. The primary outcome variable was surgical time for a tracheotomy performed by a fifth- or sixthyear resident under the supervision of the senior author (M.Z.).
Results:
Six consecutive patients undergoing tracheotomy (mean, 48 yr; range, 24 to 55 yr; 4 men and 2 women) were included in the study. The average time recorded from the incision to correct insertion of the tracheotomy tube and confirmation of carbon dioxide return by the anesthesiologist was 10.66 minutes (range, 8 to 12 minutes).
Conclusion:
This checklist facilitates the execution of a time-efficient and safe tracheotomy in less than 12 minutes. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-6, 2015
Surgeons perform approximately 100,000 tracheotomies each year in the United States.1 Tracheotomy is not a simple procedure. The patient might be obese or have obstruction, infection, or medical or structural compromise, each of which can complicate the tracheotomy. In a teaching institution, the staff surgeon faces a conflict between the desire to teach a procedure to trainees and the responsibility to obtain a secure airway without complications. Unfortunately, human fallibility can yield untoward and unexpected results. Complications during and after tracheotomy have been tallied for decades. Fallibility can be limited by experience or rote procedural training. Gawande2 recounted that perhaps 10,000 hours is required to produce an accomplished pilot, musician, or surgeon. Gawande recalled that passengers survived Mr Sullenberger’s landing in the Hudson River because of this experience and the compulsory checklist pilots must follow. The checklist Q2
critically offsets some carelessness and inexperience, especially under stress. The introduction of the World Health Organization Surgical Safety Checklist into operating rooms in 8 hospitals resulted in a decreased complication rate from 11.0 to 7.0%.3 Complex technologic advances and checklists have limited negative outcomes in the realms of stroke, heart attack, and asthma. As Gawande pointed out, ‘‘under duress getting the right steps is brutally hard, even if you know them.’’ Three sequential stages of learning have been described to generate expertise in a procedure4,5; these stages are applicable to the performance of tracheotomy. During the first stage (cognitive stage), information is acquired in a propositional form. The surgeon processes with fact memorization and rehearsal by active thinking but develops only a basic understanding of 2tasks and strategies. This propositional method
*Former Chief Resident, University of Texas Southwestern,
Address correspondence and reprint requests to Dr Panchal:
Parkland Memorial Hospital, Dallas, TX; Clinical Instructor,
3400 Spruce Street, 5 White Building, Philadelphia, PA 19104;
Department of Oral and Maxillofacial Surgery, University of Pennsylvania, Philadelphia, PA; Chief, Department of Oral and
e-mail: [email protected] Received September 29 2015
Maxillofacial Surgery, Philadelphia Veteran’s Affairs Medical Center,
Accepted October 26 2015
Philadelphia, PA.
Ó 2015 American Association of Oral and Maxillofacial Surgeons
yClinical Assistant Professor, Division of Oral and Maxillofacial
0278-2391/15/01424-X
Surgery, University of Texas Southwestern Medical Center,
http://dx.doi.org/10.1016/j.joms.2015.10.022
Parkland Memorial Hospital, Dallas, TX.
1 FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
PARKLAND 12-MINUTE CHECKLIST TRACHEOTOMY
(step-by-step) can produce an uncertain, faltering, and error-prone procedure. During the second stage (associative stage), the surgeon masters procedural skills, but the execution is plodding, variable, and susceptible to errors. However, in this stage, the cognitive information from stage 1 is enhanced through contexts, goals, and circumstances. Repetitive practice teaches what specific conditions result in a positive outcome and where errors are most likely to occur. ‘‘Smoothing out’’ errors contribute to competence. In the third stage (autonomous stage), surgical performances are smooth and fast and the surgeon is proficient. Actions can be executed unconsciously and autonomously with high accuracy and precision.6 A checklist was designed to decrease the anxiety associated with a tracheotomy and to decrease associated bleeding complications. This tracheotomy checklist also serves as an algorithm for surgeons with different experiences to learn to perform a tracheotomy in a straightforward and safe manner. As an algorithm, it not only directs the novice surgeon with a road map but also provides the staff surgeon with execution parameters. Therefore, a checklist or algorithm was developed to execute a tracheotomy within 12 minutes with optimal outcomes. Each step was explained until understood and the process was reviewed the night before surgery. During surgery, the straightforward steps were checked sequentially. The introduction of the checklist and validation of the surgical time were evaluated in this study.
Q1
such was not formally supervised by the institutional review board. CHECKLIST FOR TRACHEOTOMY
, Position the patient using a shoulder roll to extend the neck and mark the cricoid cartilage, the sternal notch, and the incision midway between these landmarks (Fig 1). , Remove a plug of fat down to the strap muscles through the 4- to 5-cm access incision (Fig 2). , Open the strap muscles vertically in the midline with Metzenbaum scissors from the above the cricoid cartilage to the suprasternal notch (Fig 3). , Grasp the strap muscles with Allis clamps and bluntly dissect the full incision to allow easy visualization of the thyroid. Retract the strap muscles with Army-Navy retractors and digitally palpate the cricoid cartilage (Fig 4). , Ensure the anesthesiologist has decreased oxygen delivery and then use a Bovie electrosurgical device to make an 8-mm horizontal nick incision Q3
Materials and Methods After developing the checklist, 6 sequential patients were treated with the checklist protocol as a quality improvement initiative. The checklist method was not used for patients with emergency airway obstruction. All patients were referred by the medical intensive care team for tracheotomy because of prolonged intubation. All tracheotomies were performed in the operating room setting under the supervision of the senior author (M.Z.). The resident surgeon was a fifthor sixth-year resident assigned to the case. Each resident previously had performed a tracheotomy with an approximate time of 20 minutes. Each resident had been talked and walked through the checklist tracheotomy at least once. After evaluation of the patient’s condition and rationale for the procedure, the resident surgeon followed the checklist explicitly. The times recorded were 1) the neck incision and 2) correct insertion of the tracheotomy tube. This project was undertaken as a quality improvement initiative at the Parkland Health and Hospital System (Dallas, TX) and as
print & web 4C=FPO
113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168
2
FIGURE 1. The cricoid cartilage, tracheotomy incision, and sternal notch are marked. The blue marking indicates the cautery cut Q6 through the fascia into the pretracheal space. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224
3
FIGURE 2. A plug of subcutaneous fat down to the strap muscles is removed. print & web 4C=FPO
Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
FIGURE 4. The thyroid gland is exposed by blunt dissection and the bottom fourth of the cricoid cartilage is marked. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
print & web 4C=FPO
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
print & web 4C=FPO
PANCHAL AND ZIDE
FIGURE 3. The strap muscles are opened vertically. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
on the bottom fourth of the cricoid cartilage (on top of, but not through, the cartilage). Insert a tracheotomy hook within the nick to grasp the underside of the cricoid and pull the cricoid cartilage superiorly (Fig 5). , Dissect with a mosquito hemostat from the nick inferiorly under the thyroid isthmus and on top of the trachea (Fig 6) and have an assistant move the Bovie device on the mosquito hemostat through the thyroid gland using a blend of cutting and cautery (ensure absolute hemostasis; Fig 7). , Retract the thyroid segments laterally with the Army-Navy retractors. Incise sharply above the second tracheal ring with a number 15 blade from the sides to the middle and complete the inverted ‘‘U’’-shaped flap with scissors. Suture through the U-shaped flap for subsequent attachment to the chest wall (Fig 8). , Insert a pretested tracheotomy device and connect it to the anesthesia circuit (confirm carbon dioxide return).
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336
PARKLAND 12-MINUTE CHECKLIST TRACHEOTOMY
FIGURE 5. Using a Bovie device, a nick incision is made on the bottom fourth of the cricoid cartilage and a tracheotomy hook is inserted by pulling the cricoid superiorly. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
, Suture the plastic wings of the tracheotomy device with 2-0 sutures (Fig 9), secure the U-shaped flap suture to the chest, and place a tracheotomy tie around the neck.
Results Six consecutive patients undergoing tracheotomy (mean, 48 yr; range, 24 to 55 yr; 4 men and 2 women) were included in the study. The average time recorded from the incision to correct insertion of the tracheotomy tube and confirmation of carbon dioxide return by the anesthesiologist was 10.66 minutes (range, 8 to 12 minutes).
Discussion The checklist tracheotomy ensures a safe and reliable outcome. The checklist methodology was introduced to increase the culture of safety in the operating room. This checklist has an additional value as an
print & web 4C=FPO
print & web 4C=FPO
337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392
4
FIGURE 6. The area under the thyroid isthmus is dissected bluntly. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
algorithm or educational tool for surgical residents. It is important for the resident surgeon to understand the underlying reason for each step on the checklist. The appropriate placement of a shoulder roll shifts the airway in a more ventral position. Neck extension facilitates palpation and visualization of anatomic reference points. Cervical injuries that preclude neck extension complicate the ease of tracheotomy. Despite this difficulty, patients with cervical injury underwent tracheotomies with this technique using a vertical neck incision, requiring an additional 5 minutes in surgical time. The 4- to 5-cm horizontal neck incision is midway between the cricoid cartilage and the sternal notch. If the surgeon elects a vertical neck incision, then the incision is drawn between these 2 anatomic references. Grasping the adipose tissue in the midline with an Allis clamp and removing a plug of fat to the level of the strap muscles minimizes the amount of tissue between the skin and the tracheal wall, easing the identification of the midline raphe of the strap
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448
5
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449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
print & web 4C=FPO
PANCHAL AND ZIDE
FIGURE 7. The trachea is exposed after division of the thyroid using a blend of cutting and cautery. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
Q4
muscles and subsequent retraction. Wide exposure under the strap muscles ensures easy visualization and palpation of critical anatomic landmarks. The authors commonly use Metzenbaum scissors to divide the strap muscles; however, electrocautery is an alternative option. The nick incision on the bottom fourth of the cricoid cartilage allows for clean dissection between the thyroid gland and the trachea. A literature review showed that this specific access incision through the pretracheal fascia has not been suggested. The nick incision on the bottom fourth of the cricoid cartilage allows for clean dissection between the thyroid cartilage and the trachea. Blunt dissection under the thyroid isthmus and on top of the trachea ensures that when the thyroid is divided using cutting and cautery blend, there is no accidental entry into the trachea. This additional safeguard permits the surgeon
FIGURE 8. A U-shaped flap is created in the trachea. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
to achieve adequate hemostasis through the vascular thyroid gland. The tracheal airway should be incised from the sides to the middle to hinder accidental risk of cutting adjacent vessels to the trachea. By pulling on the U-shaped flap, the surgeon can easily insert the tracheotomy tube without a dilator. Four permanent sutures through the tracheotomy base and the skin of the neck firmly secure the tracheotomy, preventing accidental decannulation.7 This checklist facilitates the execution of a timeefficient tracheotomy. Each step must be followed in succession. This technique can be applied to almost all tracheotomies. Even for complex cases, surgical time can be shortened. Residents have noted that this checklist method fosters a relatively bloodless, fearless, safe, and reliable 12-minute tracheotomy.
FLA 5.4.0 DTD YJOMS57017_proof 1 December 2015 6:45 pm CE AH
505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560
PARKLAND 12-MINUTE CHECKLIST TRACHEOTOMY
Future studies will evaluate the authors’ primary objective of formulating the checklist, namely decreasing a surgeon’s anxiety, blood loss, and complications. Q5 Acknowledgments The authors thank Dr Atul Gawande for his editorial assistance in the submission of this article.
References
print & web 4C=FPO
561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 584 585 586 587
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FIGURE 9. The tracheotomy tube is inserted and secured by sutures on the skin. Panchal and Zide. Parkland 12-Minute Checklist Tracheotomy. J Oral Maxillofac Surg 2015.
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