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Background: The aim of the study was to evaluate the safety of fiberoptic bronchoscope guided percutaneous dilatational tracheostomy performed in the intensive care unit.Methods: This was a prospective clinical study done on 30 critically ill patients in Intensive care unit. A puncture was made with 16G cannula at the second or third tracheal interspace which was confirmed by the fiberoptic bronchoscope. This was followed by insertion of guide wire through the cannula followed by insertion of the guiding catheter over the guide wire. The tract was enlarged with white single stage dilator to allow placement of a standard tracheostomy tube. The procedure was continuously monitored with the fiberoptic bronchoscope. Complications were noted during procedure and till patient’s stay in Intensive care unit.Results: The study included 18 (60%) male and 12 (40%) female patients. The mean age was 64.5±8 years. Percutaneous dilatational tracheostomy was done early (<10 days) in 10 (33.3%) patients and late (>10 days) in 20 (66.7%) patients. Fentanyl was used for the procedure in all the patients and among them 8 (26.6%) patients required injection rocuronium. Average procedure duration, from incision to suture for 30 patients was 12.6± 2 minutes. Indication for tracheostomy was weaning failure in 22 (73.3%) patients and airway maintenance in 8 (26.6%) patients. The mean duration patient remained on mechanical ventilation was 12.6 days and mean length of stay in critical care unit before shifting to ward was 7.6 days after tracheostomy. Acute postprocedure complications were transient bleed in four patients (13.3%), two (6.7%) had stomal bleeding, one (3%) had tracheal mucosa laceration and another (3%) had subcutaneous emphysema. No cases of stomal infection, pneumothorax, tracheal laceration, paratracheal insertion, pneumothorax and pneumomediastinum. There was no procedure-related mortality. Conclusion: Fiberoptic bronchoscope guided percutaneous dilatational tracheostomy is safe and the method of choice for elective tracheostomy in the majority of intensive care patientsJournal of Society of Anesthesiologists of Nepal 2015; 2(2): 52-55

Use of harmonic scalpel has increased in the recent past for different surgical procedures. We report a case of damage to an endotracheal tube inflation line in a 47 year old female patient who underwent elective tonsillectomy due to harmonic scalpel. Pre-anaesthetic evaluation of the patient revealed no abnormalities. The patient’s trachea was intubated via nasal route with a cuffed north facing Ring, Adair and Elwyn tube of 7.0 mm internal diameter. The cuff was inflated after confirmation of tracheal placement of tube and pharyngeal packing was done. After 30 minutes of surgery, the bellows of the ventilator were collapsing. Suspecting a leak an attempt was made to inflate the cuff, which revealed high resistance in inflation tube. Surgeon was immediately asked to stop the surgery. Check laryngoscopy revealed damage to cuff inflation tube which was sealed by harmonic scalpel in semi-inflated condition. Anticipating that the tracheal extubation in that inflated position would result in vocal cord trauma, a 23 gauge spinal needle attached to 5ml syringe was introduced under direct laryngoscopic guidance. The cuff was punctured and air aspirated so as to deflate the cuff. The tube was taken out and was replaced. The surgery continued for next one hour, was uneventful and trachea extubated at completion.