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|Patient preparation: |

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|Consent has been obtained. |

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|Ensure that the patient has been fasted 6 hours prior to procedure. |

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|Aspirate naso-gastric tube and place on free drainage. |

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|Review patient’s most recent laboratory data: U/Es, FBC, and Coagulation. |

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|Check that blood sample has been obtained for group & save. |

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|Check that anti-coagulation has been withheld (acceptable to administer previous day at 6pm). |

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|The patient is sedated and paralysed and hyper-oxygenated with 100% BIPAP mode. |

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|Immediate access to suction is required. Check that suction apparatus is functioning. |

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|Suction the patient’s oro-pharynx and endotracheal tube. |

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|The patient is positioned with 2-3 towels rolled under the shoulders to maximally extend the neck. |

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|Essential equipment: |

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|Sterile percutaneous tracheostomy tray |

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|Spare ET tube and gum-elastic bougie. |

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|Laryngoscope and suction. |

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|Fibre-optic scope, light source and assistant to operate. |

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|Portex connector or catheter mount. |

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|Percutaneous tracheostomy set (TRACHOE experc), marking pen and sterile lubricant jelly. |

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|500ml 0.9% sodium chloride. |

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|Sterile pack with: fenestrated drape, 2% chlorhexidine sponge and scalpel. |

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|Sterile gown, gloves, surgical cap and surgical facemask. |

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|Lignocaine with 1/200000 adrenaline: stored in refrigerator. |

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|2/0 hand-held stitch, tracheostomy fixation tape & keyhole dressing. |

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|What happens during the procedure? |

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|Two members of the medical team are required for the procedure: Consultant Intensivist and Registrar. |

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|The Consultant Intensivist (or Registrar) will stand at the head of the bed to maintain the patient’s airway during the transition from ET to tracheostomy|

|tube. |

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|Anticipate that ventilator settings may require adjustment. |

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|The bedside nurse monitors the patient’s heart rate and rhythm, blood pressure, respiration and oxygen saturations and ventilator recordings. |

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|The Consultant Intensivist (or Registrar) prepares and drapes the anterior neck. A small vertical incision is then made around the midline of the |

|patient’s neck, between the 1st and 2nd or the 2nd and 3rd tracheal rings. |

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|The Anaesthetist standing at the head of the bed suctions the patient’s oro-pharynx, loosens the tape around the existing ET small vertical incision is |

|then made around the midline of the patient’s neck, tube, deflates the ET tube cuff & withdraws the tube to a level just below the vocal cords. At this |

|point, the ventilator settings may require adjustment in order to compensate for the air leak created when the cuff is deflated. |

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|The person standing at the head of the bed operates the bronchoscope, inserting it through the ET tube so that the instruments can be visualised as they |

|are advanced through the tracheal wall. |

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|Once the tracheostomy tube is in place, the cuff is inflated and ventilation through the tube is confirmed by assessment of breath sounds. The ET tube is|

|removed, the patient is suctioned. |

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|The tracheostomy site is cleaned and sutured in place and secured with tracheostomy fixation tapes. Sutures remain in situ for 7 days. |

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|A chest x-ray is required at the end of the procedure. |

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|End-tidal CO2 monitoring is required. |

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|The fibre-optic scope requires to be cleaned as per unit policy. |

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|Emergency equipment: ensure trachi-case is assembled as per unit policy. |

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|Post procedure care: |

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|A chest x-ray is required at the end of the procedure. |

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|End-tidal CO2 monitoring is required. |

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|The fibre-optic scope requires to be cleaned as per unit policy. |

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|Emergency equipment: ensure trachi-case is assembled as per unit policy. |

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|Observe for bleeding. Slight bleeding may occur at the insertion site, but should resolve as healing occurs. Change keyhole dressing if heavily |

|saturated. Inform medical staff if bleeding is excessive or persistent. Monitor Haemoglobin/Full Blood Count and Coagulation. |

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|Observe for major bleeding: bleeding from the tube may indicate a mucosal tear or tracheal wall injury and may require endoscopic examination. |

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|Devised by: Mairi Mascarenhas Clinical Educator ICU. |

|Reviewed: November 2013. |

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PERCUTANEOUS TRACHEOSTOMY PROCEDURE

INTENSIVE CARE UNIT RAIGMORE HOSPITAL

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