post operative management & complications

1. PostOperative Management
Complications
Tracheostomy
Ajay Jain
Roll No.- 11 Batch:13
North DMC Medical College & HRH

2. Post Operative Management
Constant Supervision
Mobilisation of Secretions
Tracheostomy Tube Care
Patient & Caregiver Education

3. Constant Supervision
Required 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.

4. Bedside Tracheostomy Kit
Tracheostomy 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

5. 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

6. Swallowing
Swallowing 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.

7. Mobilisation of Secretions
Adequate hydration
Physical mobility
Removal of secretions

8. Adequate Hydration
Air 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.

9. 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.

10. 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.

12. 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.

13. 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.

14. 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.

15. Cleansing Stoma
Stoma 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.

16. 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.

20. Complications
Immediate
Intermediate
Late

21. 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

22. Blood aspiration
Local damage
• thyroid cartilage
• cricoid cartilage
• recurrent laryngeal nerve
• oesophagus : Tracheo-esophageal fistula
• lung apical pleura : Pneumothorax

23. 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

25. 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

27. THANK U