Post on 12-Apr-2017
PostOperative ManagementComplications
Tracheostomy
Ajay JainRoll No.- 11 Batch:13
North DMC Medical College & HRH
Post Operative Management
Constant Supervision
Mobilisation of Secretions
Tracheostomy Tube Care
Patient & Caregiver Education
Constant SupervisionRequired after shifting to Post-operative Ward.
Specialist nurse should be in attendance.
Tracheostomy kit should be present at the patient’s bedside.
Essential to look for proper placing and patency.
Bell or writing material are provided to communicate.
Bedside Tracheostomy KitTracheostomy tube of the same size and type currently in place
Tracheostomy tube 1 size smaller than the one currently in place
Obturator
Suction catheters (usually 12F or 14F)
Functional suctioning system
Manual resuscitation bag and oxygen
Endotracheal tube of appropriate size
Tracheostomy cleaning kit
Disposable inner cannulas (not required for single-cannula tubes)
10-mL syringe (not required for cuff less tubes)
Tracheostomy holder or ties
Drain sponges
Hydrogen peroxide
Physiological saline
Intubation equipment
Oxygen source
SwallowingSwallowing problems due to: • Tube limit the normal movement of larynx during
swallowing.• Overinflation of cuff can cause pressure sensation in
upper esophagus.Flexible nasoendoscope passed through the tube to visualize the distal end following tracheostomy.
Mobilisation of Secretions
Adequate hydration
Physical mobility
Removal of secretions
Adequate HydrationAir enters trachea directly -> is irritant to trachea -> increase in production & viscosity of secretions.Adequate hydration thus necessary to keep secretions thin & mobile, and prevent crusting.For hospitalised patients, humidity provided by heat & moisture exchanger, a T-piece, tracheostomy mask ,or a ultrasonic nebuliser.At home by keeping a boiling kettle in the room.To loose crusts, drops of NS or RL instilled into trachea 2-3 hrly or use of mucolytic agents to liquify tenacious secretions.
Physical Mobility
Deconditioning in ICU can be prevented with regular physical mobility.A program of progressive mobility, combined with range-of-motion exercises of upper extremeties help in mobilizing secretions.Having the patient sit helps maintain a position of function; the diaphragm is used more effectively, allowing a more effective cough.
Removal of Secretions
Achieved by suctioning and allowing the patient to cough.Suction depends on amount of secretion.When cough strength is less than 15 mL/kg, or the cough reflex is diminished, more frequent suctioning may be required.Suction catheters with Y connector to break suction force.Apply suction to catheter while withdrawing to prevent tracheal mucosa injuries.
Tracheostomy Tube CareChange tracheostomy tube on or after 3rd postoperative day to
allow stoma tract to form. Premature change results in recoiling of dilated stoma tract tissues. Tube secured with sutures until the first tube change, thereafter done with tapes in neck neutral position.Indications for changing tracheostomy tube:
• need for a different size tube• tube malfunction• need for a different type of tube• routine changes for ongoing airway management &
prevention of infection. Replace ties to avoid inadvertent dislodgement of the tracheostomy tube.When the new ties are secure, 2 fingers should fit between the tie and the neck.
Confuse with cuffs?Provide a closed system to prevent aspiration; allow effective ventilation and/or airway protection.
Under inflation promotes leakage of secretions around cuff causing ventilator-associated pneumonia.Overinflation causes tracheomalacia, tracheoinnominate artery fistula, tracheal ulcerations, fibrosis, tracheal stenosis, and tracheoesophageal fistula.Cuff should be deflated every 2hrs for 5min ideally.Use of tubes with two cuffs; alternate inflations on one side of trachea.
Inner cannulaPrevent tube obstruction by allowing regular cleaning or replacement.Clean with a solution of full or half-strength hydrogen H2O2 & NS.Clean atleast 3 times a day, depending on the volume and thickness of patient’s secretions.
Cleansing StomaStoma should be cleaned everyday carefully without dislodging tube.Cotton-tipped swabs or gauze pads with NS applied in semicircular motion, inward to outward.Dried secretions loosened with diluted H2O2 & rinsed with NS.
Patient and Caregiver Education
Utmost important in preventing complications.
Taught to perform basic care of tracheostomy.
Assessment & evaluation of their competency in caring; and home care instruction manual of tube be given before the patient is discharged.
Possible home emergencies should be discussed.
Complications
Immediate
Intermediate
Late
Immediate(at the time of operation)
Anaesthetic complications
Haemorrhage
• most common complication; fatal;
• indicates that the site should be explored, & a vessel may require ligation
Aponea
• due to CO2 washout; administer 5% CO2 in oxygen.
Air embolism
• large neck veins get inadvertently opened; air can be sucked in right atrium
Blood aspiration
Local damage
• thyroid cartilage
• cricoid cartilage
• recurrent laryngeal nerve
• oesophagus : Tracheo-esophageal fistula
• lung apical pleura : Pneumothorax
Intermediate(during first few hours or days)
Bleeding, reactionary or secondary
Displacement of tube
Tube obstruction
Surgical emphysema
Local infections: perichondritis; tracheitis; tracheobronchitis
Atelectasis; Lung abscess
Granulations
Late(with prolonged use for weeks & months)
Laryngeal stenosis : due to perichondritis of cricoid cartilage
Tracheal stenosis : due to tracheal ulceration & infection
Tracheo-esophageal fistula : due to cuffed tube erosion of trachea
Decannulation
Keloid; Disfigured scar
Tube corrosion
Aspiration of tube fragments
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