Management of surgical site infection after percutaneous tracheostomy

Author(s):
Declan Feery; Paul Lewis, DO; Yuna Kim; Deborah Kuhls MD

Background:

Tracheostomy creation is considered a clean, contaminated surgery. The incidence of
tracheostomy infection is approximately 5% and typically develops after 24 hours post-
procedure. The incidence of infection is lower with percutaneous techniques compared
to an open approach, however, the percutaneous technique leaves little room for
spontaneous drainage should a purulent infection develop.

Hypothesis:

Methods:

Results:

A 39-year-old male presented to our Level I trauma center after an unknown
mechanism with evidence of blunt head trauma. Upon arrival, he was noted to have a
subdural hematoma requiring craniotomy. He remained intubated post procedure. Due
to inability to wean from the ventilator, he required tracheostomy placement. The day
prior to placement, he was febrile to 103.3 degrees Fahrenheit. Cultures were obtained.
At the time of surgery, he had thick, malodorous tracheal secretions and was started on
antibiotic therapy for ventilator-associated pneumonia. A percutaneous tracheostomy
was performed in the usual fashion. On post-operative day 3, the patient developed
diffuse neck swelling. Computed tomography imaging revealed neck edema with no
hematoma or extravasation. The patient was taken to operating room and underwent
endotracheal intubation, removal of tracheostomy, and neck wound exploration, which
revealed a large neck abscess that was explored and drained. He was placed on broad-
spectrum antibiotics and treated with frequent dressing changes. Two days later, he
underwent repeat neck exploration, debridement, and tracheostomy revision with the
assistance of otorhinolaryngology. He completed a course of antibiotics and had
resolution of the infection with eventual discharge home with tracheostomy in place.

Conclusions:

It is crucial to monitor tracheostomy wounds in the immediate post-operative period,
particularly if there is ventilator-associated pneumonia at the time of placement, which
can result in bacterial seeding of the tracheostomy wound at the time of operation. In
rare cases of tracheal and associated soft infections, patients require prompt surgical
drainage, debridement, and antibiotic therapy.