Tracheal Injury Prior to Sternotomy: A Cautionary Tale

Abstract

Tracheal laceration during cardiac surgery is a rarely reported form of iatrogenic tracheal injury. During dissection prior to sternotomy, the interclavicular ligament must be divided. This structure overlies the proximal trachea, predisposing the trachea to injury at this location. Challenges related to tracheal laceration in cardiac surgery include patients with already tenuous cardiopulmonary status, surgical positioning that increases the risk of injury, obscured traditional clinical findings causing delayed recognition, increased risk of mediastinitis, and a heightened risk of airway fire. The incidence, mechanism, and ideal management of sternotomy-related tracheal injury, though a life-threatening complication, is rarely described in the literature. Consensus is lacking regarding the necessity and timing of tracheal repair versus conservative management, whether to proceed with the initially planned procedure, and the optimal timing of airway exchange in the event of endotracheal tube cuff rupture. In this article, we present the management of a full-thickness thermal tracheal injury due to electrocautery, resulting in a large air leak treated with delayed endotracheal tube exchange and tracheal repair after cardiopulmonary bypass.

Managing Critical Events During Cardiothoracic and Transplant Surgery

“…The clinical challenges forum concludes this issue of the Seminars in Cardiothoracic and Vascular Anesthesia , and our readers will have the opportunity to learn more about some of the potential complications and their respective managements that could occur in our practice such as tracheal injury prior to sternotomy, 9 massive air embolism during cardiopulmonary bypass, 10 removal of retained bronchial tissue glue after repair of a disrupted left main bronchus, 11 and a rare case of inferior vena cava stenosis after heart transplantation. 12 In summary, we present our readers with a highly pertinent set of articles with the ultimate objective on how to manage critical events that present themselves during or immediately after cardiothoracic and transplant surgery.…”