P003: ANESTHETIC MANAGEMENT OF A TRACHEOINNOMINATE ARTERY FISTULA IN A PATIENT WITH PRIOR LARYNGOTRACHEAL SEPARATION
Emily Chung, DO; Kayla Yoshida, DO; David McDougal, DO; Nicholas Nedeff, MD; Tyler Chonis, MD
HCA Florida Kendall Hospital
Introduction/Background: An 18-year-old male with a medical history of cerebral palsy, seizures, and developmental delay presented to the emergency department for coughing bright red blood from the tracheostomy.
On arrival, the anesthesia and surgery departments were called emergently for assessment and management of a complicated airway with high suspicion of a tracheoinnominate artery fistula. Of note, the patient has a past surgical history of left pneumonectomy and laryngotracheal separation.
Methods: Due to the significant bleeding at the tracheostomy and the patient’s hemodynamic instability, cardiothoracic surgery (CTS) and ENT were also consulted. After a discussion between the multidisciplinary team and the family, it was best to go to the operating room to evaluate. The plan agreed upon by the different specialties was to attempt moderate sedation to perform a tracheostomy exploration, bronchoscopy, and possible sternotomy.
Before the patient’s arrival to the OR, a rapid infuser, a flexible bronchoscopy cart, and an extracorporeal membrane oxygenation machine were placed in the room. Massive transfusion protocol was also activated. The patient was sedated with ketamine and midazolam with boluses of dexmedetomidine. CTS placed the bronchoscopy into the tracheostomy to find the source of bleeding. After many attempts, the surgeon was unable to view the respiratory tract due to bleeding and patient movement. The tracheostomy was then replaced with a cuffed fenestrated tracheostomy tube to secure the airway to convert to general anesthesia. After confirmation of the secured airway, the cuff was inflated and the bleeding was stopped. The patient was stabilized and the decision was made to take the patient for CT scans to find the location of bleeding for better surgical planning.
Results: The CT angiogram of the neck and chest showed no contrast extravasation at the tracheostomy site. The patient was then transferred to the ICU for closer monitoring. The patient was monitored in the ICU for one week with the tracheostomy cuff inflated. After one week, CTS deflated the cuff to check for bleeding. Once deflated, bright red blood was noted coming from the tracheostomy. The cuff was reinflated and transferred to an outside facility that performed the original tracheostomy and laryngotracheal separation.
Discussion/Conclusion: This case highlights the challenges faced in the management of a TIAF and the preparation necessary in case of rapid decompensation. TIAF is a rare, life-threatening complication of tracheostomies, with an incidence of 0.1-1%. Approximately 50% of patients have relatively minor bleeding that stops spontaneously before the diagnosis. However, for those who present with massive hemorrhage, the first step is to attempt to control the bleeding by hyperinflation of the tracheostomy cuff or digital compression. Once in the OR, rigid and flexible bronchoscopy is recommended to directly visualize the fistula. While the surgeons locate the fistula, the priorities of the anesthesiologist are to control the airway, maintain spontaneous ventilation, control bleeding, and initiate MTP. The most definitive treatment is surgical correction. Even with immediate attention, survival rates are 25-50%, with long-term survival less than 25% after 1 year postoperatively.