Percutaneous dilational tracheostomy (PDT) is a commonly used technique in intensive care units (ICUs) for persistent respiratory failure. Early complications of placement includeairway loss, bleeding, and tracheal ring fracture. Tracheostomy tube fracture is a rarely reported complication that can lead to loss of airway and require emergent intervention. We present two case reports of tracheostomy flange fracture and dislocation after PDT. Shortly after insertion, the tracheostomy flange was incidentally noted to have irreparably fractured and separated from the outer cannula. Both patients were orotracheally intubated and converted to open revisional surgical tracheostomy. Outer cannula separation from the flange is a rare but important complication of PDT due to the risk of occult airway loss. The tracheostomy tube supplied in the PDT set is manufactured in three parts and the plastic outer cannula is snapped to the silicone flange during manufacturing. The flange is not meant to be separated during insertion or use. PDT insertion requires significant force to be exerted, as the catheter has to travel through the subcutaneous tissue of the neck before entering the trachea. These cases suggest that the junction of the flange and the outer cannula may be a weak point and that fracture and dislocation at that site may occur due to excessive or misdirected force. Dislocation may cause loss of airway and a need for orotracheal intubation as performed in our cases. Understanding this complication and carefully examining the flange after placement is essential for early recognition to avoid loss of airway.

Flange Fracture and Dislocation: An Unusual Complication of Percutaneous Tracheostomy

BACKGROUND
While direct oral anticoagulant (DOAC) use is increasing in the Emergency General Surgery (EGS) patient population, our understanding of their bleeding risk in the acute setting remains limited. Therefore, the objective of this study was to determine the prevalence of perioperative bleeding complications in patients using DOACs vs. warfarin and AP therapy requiring urgent/emergent EGS procedures (EGSPs).


METHODS
This was a prospective observational trial, conducted between 2019-2022, across 21 centers. Inclusion criteria were age ≥ 18 years, DOAC, warfarin/AP use within 24 hours of requiring an urgent/emergent EGSP. Demographics, preoperative, intraoperative, and postoperative data were collected. ANOVA, Chi-Square, and multivariable regression models were used to conduct the analysis.


RESULTS
Of the 413 patients enrolled in the study, 261(63%) reported warfarin/AP use and 152 (37%) reported DOAC use. Appendicitis and cholecystitis were the most frequent indication for operative intervention in the warfarin/AP group (43.4% vs. 25%, p = 0.001). Small bowel obstruction/abdominal wall hernias were the main indication for operative intervention in the DOAC group (44.7% vs 23.8%, p = 0.001). Intraoperative, postoperative, and perioperative bleeding complications and in-hospital mortality were similar between the two groups. After adjusting for confounders, a history of chemotherapy (OR 4.3, p = 0.015) and indication for operative intervention including occlusive mesenteric ischemia (OR 4.27, p = 0.016), non-occlusive mesenteric ischemia (OR 3.13, p = 0.001), and diverticulitis (OR 3.72, p = 0.019) were associated with increased perioperative bleeding complications. The need for an intraoperative transfusion (OR 4.87, p < 0.001), and intraoperative vasopressors (OR 4.35, p = 0.003) were associated with increased in-hospital mortality.


CONCLUSION
Perioperative bleeding complications and mortality are impacted by the indication for EGSPs and patient's severity of illness rather than a history of DOAC or warfarin/AP use. Therefore, perioperative management should be guided by patient physiology and indication for surgery rather than the concern for recent antiplatelet or anticoagulant use.


LEVEL OF EVIDENCE
III (prognostic/epidemiologic).

Anticoagulation in Emergency General Surgery: Who Bleeds More? The EAST Multicenter Trials ACES study.

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Flange Fracture and Dislocation: An Unusual Complication of Percutaneous Tracheostomy

Anticoagulation in Emergency General Surgery: Who Bleeds More? The EAST Multicenter Trials ACES study.