Transcript
- Alright, thanks for joining us everybody.
Welcome to the Sono site, Behan behind the scan webinar.
Revolutionizing critical care intervention POCUS
for percutaneous tracheostomy
and gastrostomy at the bedside.
At the bedside with our guest speakers, Dr.
Sam Cohen and Dr.
Angelina Lopez from Cedar-Sinai Medical Center.
My name is Chris Pennell and I'll be
hosting today's webinar.
Before we begin, let me just go over some important
information about this webinar.
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provided for general education purs purposes
and as a supplement to professional experience,
education and training.
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Alright, to get started,
let me introduce our guest speakers.
Dr. Cohen is a pulmonary
and critical care faculty, physician
and assistant professor
of medicine at Cedar-Sinai Medical Center.
He was an early adopter
of percutaneous ultrasound guided gastrostomy or a pug
and help to form a dedicated tracheostomy
and pug service at his hospital.
And Dr. Lopez is an as assistant professor
of medicine in pulmonary
and critical care at Cedar-Sinai Medical Center.
She has exclusive, sorry.
She has extensive experience in bedside ultrasound
for diagnosis and management at advanced bro bronchoscopy
and pug procedures
and was among the early adopters of pug at her institution.
And with that, I'll get our presentation started.
Thanks for joining us everybody.
- Hi, my name's Sam Cohen and my colleague Dr.
Angelina Lopez. And I will be presenting
to you today on point of care ultrasound
for both percutaneous tracheostomy as well
as percutaneous gastrostomy at the bedside.
And she and I both have background in bedside ultrasound
guided procedures and,
and we're hoping
to today both go over these procedures individually as well
as in a combined format
and with the plan to highlight how ultrasound can be helpful
for improving your preparation
and success with these procedures.
So we'll first start
by talking about percutaneous dilation tracheostomy,
or we may reference it as PDT throughout this presentation.
And whenever you're doing any procedure, it's important
to know what are the indications when it may make sense
to do that procedure and what are the
contraindications to doing it.
So with a tracheostomy in general, the most common scenario
that you'll be thinking about doing a tracheostomy is
for patients who have prolonged ventilator dependence
for various reasons.
Other scenarios
where this may come up is if a patient has upper airway
obstruction or you know, a growing tumor with, you know,
impending upper airway obstruction where you're trying
to get out in front of it and provide a safe airway.
Secretion management is another reason this may come up,
especially in the scenario where you have patients
with recurrent aspiration events, recurrent need
for ventilators and that sort of thing.
Tracheostomy may be something that allows
for more aggressive ventilator weaning as well
as secretion management.
And then, and then neuromuscular disease is another one
where, you know, for, for with, you know, various types
of neuromuscular disease,
patients may develop respiratory muscle weakness and,
and require ventilator dependence.
And tracheostomy is something that may be considered to make
that process more comfortable.
So once you've decided that a tracheostomy may make sense,
what are some reasons that you may decide,
well actually I don't think we can do this.
So, so the anatomy's important.
So if the patient doesn't have identifiable anatomical
landmarks, meaning if you can't feel
where the tracheal rings are, the trico cartilage
or, you know, sternal notch is an important landmark.
So, so if you aren't able to palpate or
or identify certain landmarks, you may have
to second guess whether
or not it makes sense, inability to extend the neck.
So this is actually an important one
that at least in our practice is probably one
of the more common reasons why we would potentially not do a
tracheostomy when it's requested.
And that's because if the patient has, you know,
a chronically flexed neck
or a contracted neck, you, you may not be able
to position them in a way where you can feel the anatomy
and safely, you know,
place the tracheostomy tube in the appropriate position.
C spine instability is another one where you may not be able
to extend the patient's neck the way you would
for a bedside procedure if they have, you know,
an unstable C-spine uncorrectable coagulopathy, like
for a lot of procedures would potentially be a reason
that, that you don't proceed.
And you would have to identify, well is this something that,
you know, if you treat, which whatever underlying condition,
does it become an option later if there's active infection
of the skin or soft tissue over the place
where you're planning to insert the tracheostomy tube,
that would be a reason not to proceed.
And we'll talk about this a little bit later,
but if there's a significant amount
of pretracheal vasculature
or if you identify a high writing a nominate artery, it,
it may impact your procedural planning and whether
or not you proceed and ultrasound is, is an excellent way
to help predict this ahead time.
And then another thing is, if,
if the patient is still requiring quite a bit
of support from the ventilator, it may not be the,
the right time or a safe time
to proceed with the tracheostomy.
So if, if they're requiring, you know,
a hundred percent FI O2
or a very high peep, usually we like to see that, that
you're able to wean them down a little bit further so
that you know there's some sort
of ventilatory reserve while you're doing the procedure.
And then in the setting of an emergency,
an emergent scenario, you're, you know, more likely going
to, to go to cricothyroid autotomy as as your,
you know, emergency airway maneuver.
That being said, once you have enough experience
with tracheostomy, that does help
with identifying the anatomy
and if you've done a lot of tracheostomies it, it,
it should in theory help with your ability to do
crico an emergent cricothyroid otomy.
So with patient selection, you know, the question becomes,
well, does it make sense to do this at the bedside as a PDT
or should it be a surgical approach?
What's the timing? What are some other anatomic
considerations to help sort this out?
So in terms of the timing, the the reason
for ventilator dependence may impact your timing.
So, you know, we primarily are working in a medical ICU
where a a lot
of the patients have a primary respiratory issue
as their reason for ventilator dependence and intubations.
So, you know, in that scenario it it,
we may wait a little bit longer
to see if they can just be liberated from the ventilator
without requiring a procedure compared to, you know,
in a neuro ICU, if the patient had a catastrophic neurologic
event and you know that they're going
to be ventilator dependent for many weeks or months
or longer, then it may make sense to do it earlier.
You, you may hear people say, you, you want to try
to make this decision, you know, appro
as you're a approaching the two week mark or
before then the longer you wait there is risk
of tracheal malacia or even trache necrosis
or other pressure injury related problems.
But, but we try to factor in what the,
the underlying condition is
and what the likelihood
of successful extubation at any point is
before deciding on the exact timing of the,
the tracheostomy in terms of the approach.
So, so the percutaneous dilation approach requires less
dissection than the surgical approach and,
and less, you know, disruption of fascial planes
and as a result seems to, to trend towards lower likelihood
of having wound infection at the, the site of the procedure
as well as less bleeding.
And then another advantage for,
for PDT is you can do it at the bedside without transporting
to the operating room.
You don't need additional, you know,
doctors like anesthesiologists.
So it can just be done by the,
the ICU doctor who's doing the procedure.
Some scenarios where you would think about,
well maybe we should do a surgical approach in
instead of at the bedside.
So, so that would include, you know, in terms
of the patient's anatomy.
So if it's a very obese patient,
you may not be able to feel where you're going.
It may make more sense to do this in a controlled
setting in the operating room.
That being said, as you do more
and more of these procedures,
you may develop a different comfort zone and, and,
and be able to still safely do it on larger patients.
Some of it also depends on, you know,
not just the BMI alone,
but what is the actual distribution
of the, the adipose tissue.
And if it's not so much in the anterior part of the neck,
you may still be able to, to do this on a large patient.
So there's not, you know, a steadfast rule for this,
but it is something that you want to factor in.
And if it's not safe to do at the bedside,
then it would make sense to discuss with the, the,
your surgical colleagues degree of neck extension.
As we, as we mentioned earlier, you know,
if you can't extend the neck and, and, and,
and get a good entry point, it,
it may not be appropriate to do at the bedside.
Whereas in the operating room there,
there's other techniques they can use to,
to pull the trachea higher and get better access points.
And then, you know, the patient's thyroid,
if they have goiter or large thyroid in the way that that's,
you know, obvious that it may make more sense
to do this in the operating room as well.
And then of course if your ultrasound exam identifies
abnormal vasculature, that makes it dangerous
to be going without direct visualization of it,
that also may be safer in the operating room.
This is an example of, of what a
bedside PVT kit looks like
and you know, this comes with most
of the tools that you need.
You have a 15 blade for making your incision.
It comes, you have a either a straight needle
for cannulating the trachea
or you can use a catheter over the needle approach as well.
There's a guide wire that you'll use
and then punch dilator
and then the, the what we call the rhino dilator that
sequentially dilates to the size that you need for the stoma
as well as loading obterator
for the tracheostomy tube insertion.
And some of these kits actually even come with lidocaine
with epinephrine, which is nice.
As far as the tracheostomy tubes, I think it's important
to be familiar with the nomenclature.
So the, the, at, at least at our institution,
the the tubes that are compatible with this kit are sized
where there's basically the first number
is what we're referring to.
If we say size eight or size six for example, then the CN
after it means it's a cupped trach.
So when you're placing a new tracheostomy tube on a
ventilator dependent patient,
you're typically going to be starting
with a cuffed tube since you're still ventilating.
Then the next number, the eight five here is referring
to the diameter of the or
or the inner diameter of the tube without the inner cannula.
And this is an important reference point
because when you're deciding which loading obterator
to use it, it should match with the inner diameter of the,
the, the trach tube that you're using.
So for example, here you see 9.0 millimeters,
that would match with a size nine tracheostomy tube
where the inner diameter is nine zero
for for the size.
And this, this picture here is just an example of
what our tracheostomy we, we have a, a dedicated cart
of procedural cart for our tracheostomies.
So we have a drawer filled with the different sizes that we,
we may or may not use related to
our tracheostomy insertions.
Okay, so what are the steps of the procedure?
So we, this is basically a two person procedure
where one person is doing the tracheostomy insertion itself
and then you have a colleague who's doing the bronchoscopy
or upper airway portion, you know,
we'll typically position the patient
with their neck extended, we'll put either a towel roll
or pillow underneath and
and really get them with their, their head extended back.
And, and the goal should be
to place the tracheostomy tube either between the second
and third tracheal rings or the first
and second tracheal rings.
There are reasons for this of course,
and if, if you place it too low, there's a higher chance of
developing a tracheal nominate fistula, which is one
of the more catastrophic downstream complications
that you can have with this procedure.
And if you place it too high, then there's higher risk
of subglottic stenosis.
Sometimes your choice is limited by the patient's anatomy,
especially in terms of the, the higher up insertions.
So you know,
when this comes up we are factoring in things like,
while is this a patient that's likely
to ever wean off the ventilator
and be decannulated in the future?
And if the answer to that is no
and they're likely to be vent dependent forever,
then we're maybe less worried about downstream subglottic
stenosis and, and maybe will accept a a, an insertion
between CRI and one.
But if it's a patient where the expectation is, oh,
this is more of a bridge to weaning
and you think that you are likely to
potentially decannulate in the future,
then certainly you want to be
placing it in the most ideal position you can
to minimize these, these downstream risks.
And then, you know, like any sterile procedure you
will prepare your field with, you know, wide field,
sterile drapes, all that stuff.
This starts out as a sterile procedure,
but of course once you enter the airway it turns into
more of a clean procedure.
But we still try to do this as, you know, cleanly
and sterly as possible.
And then while you're doing this, it's important
to have the, the FIO two set to a hundred
during the procedure.
As I mentioned, you don't want the patient to be needing
that leading into it,
but in, in order to give them as much reserve
as possible while we're doing it, we always increase
to a hundred percent and we we'll use a volume control mode
even if the patient was already on a pressure control
ventilator mode because once you start in starting the
bronchoscope during a pressure control mode, the, you know,
minute ventilation delivered is less reliable.
So we'll typically use volume control for this.
So then when you're actually doing the procedure,
as we mentioned, this is a a a two person process and,
and the a bronchoscopist
and the procedural is doing the tracheostomy insertion
or kind of doing these steps in parallel.
It's sort of almost like you're doing a dance with your,
your partner while you're, you're doing this
because you need to sort of feed off each other
to figure out, okay, this person's doing this part so far
so I need to be adjusting this or that.
So the bronchoscopist typically will, you know,
put the bronchoscope in the endotracheal tube different than
when you're doing a bronchoscopy, you're actually planning
to keep the tip of the scope so
that you're visualizing the tip of the endotracheal tube
and then you'll withdraw the, the scope and the ET tube
and tandem together all the way until you,
you can visualize the cricoid cartilage.
So you'll be watching the, the tracheal rings anteriorly
and once you see them kind of smooth out
and you see the smooth area where the,
there's no longer rings
and it's just cricoid cartilage, you'll stop.
If you pull too far you could
accidentally extubate the patient.
So this is actually a very important part of the,
the procedure that requires a lot of attention.
And then the point of the bronchoscopist at the,
at the point is to actually visualize the insertion steps
that, that the, the person doing the tracheostomy is doing
so that you can see that you're putting the
tube in the correct position.
So while the bronchoscopist is adjusting the endotracheal
tube, the the person who's actually doing the trach
insertion will give some lidocaine with epinephrine.
This is more for hemostasis effects than it is for analgesia
because you're going to be doing this on,
on a deeply sedated patient, usually also with paralytics.
So there's no movement during the procedure.
You'll make a skin incision at this point we typically do a
horizontal incision, but vertical
or horizontal are both, you know, acceptable and,
and different people have preferences at different places.
Although sometimes something that will change
that is if we've done an ultrasound exam
and we see various vessels in the way with one approach
or the other, we may alter our approach.
Then you'll gain access to the tracheal lumen by cannulating
with either a straight needle
or the catheter over the needle approach followed
by guidewire insertion.
And, and this is an example of of
what your guidewire may look like once you've inserted it,
visualize with the, the bronchoscope
within the tracheal lumen.
And then next you'll do a, a dilation step
with the 14 french punch dilator followed by
using the, the larger rhino dilator,
which is a hydrophillic activated device.
So we'll usually squirt a little bit of saline on it so
that it goes in more smoothly.
Then you'll remove that
and leave the the white stiffening stylet
that you see right here.
And then you'll insert the, the tracheostomy tube
that already has its size appropriate loading ator
over the G wire and stiffening stylet.
The stiffening stylet, it's hard to see on this
but there's a little bump on it that you want
to line it up nicely with so that it inserts smoothly
and then you'll insert your tracheostomy tube
and then remove everything except for the trach tube itself.
So you'll remove the ator, the stylet
and the G wire at this point
and then your bronchoscopist will place the scope down the
tracheostomy tube and visualize appropriate position
above the Corina that's shown here.
And then we've also started looking from above as well.
So before the ET tube is removed,
we'll just put the scope back down the ET tube
and take a look above the tracheostomy tube to to show
that there's good balloon apposition against the the trachea
and hopefully not too much bleeding.
And then you'll have to remember
to insert the inner cannula, connect to the ventilator
and inflate the balloon
and make sure you have adequate tidal ball volumes
and then secure the tube with sutures
and then that's basically the procedure.
So now I'll hand over to Dr. Lopez who's going to go over
the ultrasound exam that you can use with
percutaneous tracheostomy insertion.
- That was excellent. Thank you Dr. Cohen.
So I think when we talk about using ultrasound
for percutaneous tracheostomy, it's not I, I think one
of the more mainstream thoughts of how to use ultrasound,
but it is a very powerful tool
and just like any other percutaneous procedure that we do,
ultrasound can really provide a lot of guidance,
alter your approach like Dr. Cohen was talking about earlier
and also help you troubleshoot the procedure
before a problem comes up.
And so we've included several videos here that we'll go
through now and this is the first one is a longitudinal
evaluation of the trachea
and we are going down quite far on this ultrasound
evaluation and you'll notice
that we have the depth set relatively shallow
and that's to highlight the CRICO cartilage
and then the subsequent tracheal rings.
And so what you see at the very first part of the image
that looks like a more rounded koic structure
that is the CRICO cartilage there
and then you see tracheal ring one and two
and like I said, we've gone down pretty far
to like four and five.
Part of the reason that evaluation is done as deep
as you can is so that while you're looking at this trying
to identify the landmarks of
where the crico cartilage are is
and the first tracheal ring, you'll also looking at trying
to find vessels in this view
that if you see vessels when you're looking longitudinally,
those are going to be directly overlaying the midline part
of the trachea and so are going to be in your field if they're
around tracheal rings one
and two, it is really nice to do this ultrasound evaluation,
both of these ultrasound evaluations
with the patient in the procedural position
with their neck extended
because then you can place an external mark on the neck
that guides you as to where you're going
to make your initial incision
and do your blunt dissection down.
So this is now a short axis view of
what we were looking at from a long axis perspective
and we are now going from a more superior to inferior view.
First identifying the CRICO cartilage
and then progressing downwards to tracheal rings one, two
and then subsequently to three.
And the nice thing with both
of these ultrasound evaluations is
that it does afford you the opportunity not only
to place external landmarks
for once you start doing the tracheostomy procedure
to guide you in conjunction with your palpation of exterior
and anatomical landmarks, but you also can,
and there is precedence for this,
do a live needle ultrasound guided cannulation
into the tracheal lumen.
There are some institutions that have started doing this
particularly when maybe the external anatomical landmarks
are a little bit more difficult
and even when there's some issues with for patients
who have been intubated for very long periods of time,
the internal tracheal anatomy can also become quite
difficult to determine
where is the first tracheal ring in crike
and the smooth subglottic space.
The ultrasound gives you another tool to help guide you
to make sure you're putting the per the tube in the
appropriate location.
We like to use color doppler also one
of the biggest surprises
that you can have when you're doing any sort
of percutaneous procedure
or any procedure at all is unexpected bleeding and,
and using the color doppler on the ultrasound helps you
identify if you need
to be concerned about something overlaying the field.
But it also helps you identify vessels
that you know are going to be in the area
to help improve the safety profile of the procedure.
So here this is just an ultrasound evaluation,
putting the color doppler over trach rings one
and two to see if there is any evidence
of any vasculature in that area that we need
to be concerned about.
The other pretty cool part of this and
and there actually is some evidence
to use ultrasound guidance to confirm tracheal cannulation
with endotracheal intubation.
That's not what this is for but you can see on this
ultrasound image the endotracheal tube in place
in the tracheal lumen.
Again, if the internal anatomy
or the external are abnormal,
the ultrasound gives you an extra piece
to let you know you've moved to the ET tube back far enough
because you can visualize the ET tube in the trachea here
and it helps you identify other structures that are going
to potentially be problematic for you
but also ensure that again you are targeting the right area
for your cannulation.
This particular patient had some more difficult anatomy,
the trachea, the crike cartilage
and the first tracheal ring were a little bit deeper.
We actually weren't able to ultrasound
or really palpate down very far
with keeping in within the confines of
where you want to be when you're making your incision
lengthwise above the sternal notch.
And the patient also had significantly calcified
OID cartilage that you can see in this ultrasound evaluation
and tracheal rings.
The other surprise here was the location of of
how far down the thyroid tissue went
but we were able to anticipate
and see all of that
by doing the ultrasound evaluation upfront
and this helped us mark an externally
where we were going to make our incision
and then do our blood dissection
and we were able to successfully complete this
percutaneous tracheostomy without issue.
Identification of vasculature is a big deal
and there's certain vasculature that you know you're looking
for and one of those things is the a nominate artery.
This ultrasound evaluation, this is not overlying the field
of where we were going to be working.
This was an intentional identification
of the patient's nominate artery.
Looking down a little bit
underneath the clavicle into the thoracic cavity
with the field with the beam of the ultrasound.
And so you can see clearly there there's something moving if
you throw color doppler over that,
that looks pretty suspicious for an artery
and given the size of it you kind of start
to anticipate what you're working with.
But you can also put the tissue doppler over it,
which can give you an indication of if it's VA venous
or arterial.
This is scanning again looking for pretracheal vessels
and identifying things
that we know should be in the the neighborhood
and making sure they're well outside of the field of
where we're going to be working.
This in contrast to the previous image was a venous
vessel instead of an arterial.
And then you know, we can continue forward
and look at how you can utilize doppler for this.
And this is a very clear arterial doppler tissue
doppler wave form.
You get these really high velocity spikes here
and that's how you know you're dealing
with something arterial as opposed to something venous
where you have these much lower velocity spikes
and almost more of a constant
or consistent flow pattern on it.
The power here is
that if you identify something in the field
that you're going to be working in, you have the ability
to use this to determine if this, is this an arterial vessel
or is this a venous vessel,
which is going to change a couple things.
It may change your approach.
If this is kind of off to the side of midline,
you may decide I'm going to do a vertical incision instead
of a horizontal incision here.
It may make you think that if there's too much vasculature
or a lot of highly vascular vascular thyroid tissue,
you may ask your surgical colleagues to weigh in
or to take the patient to the OR
to do this under more controlled settings
or as your comfort level
and you know some of the skills that you acquire progresses.
You may then change your approach
to say I'm going to do a pretty shallow incision
and a very gentle dissection in anticipation
of tying these vessels off
before I progress forward with the rest
of the tracheostomy procedure.
So troubleshooting the tracheostomy procedure, you know,
you can have a couple different things
that occur pretty commonly.
Visualization difficulties either from the bronchoscopy end
because the anatomy is abnormal
or the ET tube has been in place for a long time
or trying to get the see the needle
or even externally finding the appropriate
anatomic landmarks.
I think that's where ultrasound can be really beneficial
because if you've used the ultrasound with the patient
with their neck in the extended position
and you've made a mark of where the cricoid cartilage is,
it serves as an indicator
for the person doing the trach procedure
and the bronchoscopist needle insertion similarly really
just need to make sure
that the et t tube is pulled back far enough
to visualize the cricoid cartilage far
and away not being able
to visualize the needle insertion if it's really getting
into the trachea lumen happens
because the bronchoscopist may have inadvertently let the ET
tube slide back in
or didn't come out up far enough to begin with
with needle insertion also, you know, you want to make sure
that the angle that you're trying
to cannulate the trachea is appropriate.
The trachea dives deeper
as it progresses into the thoracic cavity,
which makes it more at an angle than a a flat surface
and you just want to make sure that you're coming into like
orthogonal or 90 degrees to that anterior tracheal surface
to keep your needle from skidding off of the trachea.
When it comes to bleeding, there's many different ways
to address that.
You can utilize vicral sutures
or disposable sutures is what we prefer to use
to tie off vessels,
especially if you saw them on your ultrasound evaluation.
You can use handheld cautery which really should only be
used for superficial skin
or superficial subcutaneous issue
since the patient is on a hundred percent FI O2
and lidocaine with epinephrine,
you can always use a little bit more lido with epi to kind
of help clamp those vessels down and deal with the bleeding.
Sometimes you'll get the trach tube in
and everything looks like it's going really well,
the procedure's going great
and then you notice that you're either having a leak
or high pressures
or not delivering volume on the ventilator
when you change the patient's position
or immediately once the tube is in place.
And that's typically the trache tube is seated in a,
in a poor position,
sometimes the balloon will not be well opposing the tracheal
walls and sometimes the distal end
of the tracheostomy tube can be abutting against the
posterior tracheal wall.
The fix for both of those issues is
to utilize a different size tracheostomy tube
when you're doing that
because the so stoma is so fresh, you want to make sure
that you're using the wire
and the stiffening stylet in the kit to advance
through the existing tracheostomy tube.
Take the old tube out,
use the appropriately sized loading operator
for your new tracheostomy tube
and make sure that it's sitting nice on that little ledge
or nub on the white stiffening stylet
and advance it back in place.
There's many different types of tracheostomy tubes
that that are out there.
The xts are usually a longer length
and so they can help kind of avoid
or fix some of this issue.
And then you can also sometimes just use a larger diameter
endotracheal tube post procedure.
You can have, you know, a couple different things
that that occur.
Air leak can happen because either the balloon has ruptured
or, and that's typically an immediate problem
in the delayed sense.
Sometimes patients will develop a little bit
of tracheal malacia and so the balloon is not
opposing the tracheal wall.
Well if,
if you have a ruptured balloon in the immediate post phase,
you just need to place a new, a new tube
but you need to utilize that wire exchange if the
stoma is fresh.
With trachea malacia, you sometimes just need to upsize
or change the positioning of
where the balloon is sitting in the trachea bleeding.
Again, immediate is typically related to kind
of normal post-procedure stuff.
If it's a little bit more of a delayed bleed, that's
where you get concerned for a trachea nominate fistula,
which we're going to talk about in a couple slides
and then a dislodged in a trach tube.
If the stomas not mature, that again takes you back
to needing to use the wire exchange
or at least have the full tracheostomy kit,
procedural kit available to you.
If it's a mature stoma, you just use the loading ator
with the new trach and
and should be able to place it back in relatively easily.
Post procedure care got to prevent pressure injuries.
So there needs to be some barrier between the flange
of the trach and the patient's skin.
We typically use sutures when we place our trachs.
Not all institutions do,
but if you use sutures you can remove them
after seven to 10 days.
You want to make sure that the trach tie is
appropriately tight.
If it's too loose, the trach can kind of start
to work its way out and we've seen patients have dislodged
fresh trachs because of that with bleeding, if it happens in
that early phase, you know, look to your common causes
of bleeding, so anticoagulation, antiplatelet medication,
resumed or drop in platelets, things like that and,
and correct those and you can utilize things like sutures
again or lidocaine with epinephrine again
or even surgicel to kind of help
with those minor bleeding issues.
If it's delayed bleeding
and it's a significant amount of blood,
this is when you need to think about a trachea nominate
fistula utilizing the uly maneuver where you're either kind
of trying to pull the trach forward and
and put pressure against the the clavicle or breastbone
or physically placing your finger in the stoma
and using that forward motion
to put pressure on the a nominate artery
and an immediate call to surgery.
That's something that needs to be dealt with
and exploded, explored in the or.
And then you are going
to utilize intermittent CHA trach changes for hygiene
after the fistula has appropriately formed
and the stoma is mature
and we usually recommend the first trach change happen
no sooner than 14 days.
So moving forward to percutaneous ultrasound, gastrostomy
or pug tube placement, this is a novel procedure
for placement of a G-tube
and the method is actually quite nice
because it has a lot of beneficial points to it.
So since it's a little less mainstream,
I'll talk a little bit first about what it is.
It utilizes a specialized oral gastric tube
that has a balloon that can be inflated with fluid
and a magnetic core.
Utilizing an external magnet you can form a connection
between the internal balloon OG magnet
and the external magnet.
And by filling the balloon with fluid, you now have a target
that you can find on ultrasound, cannulating that
with a needle and threading a guide wire through
that can capture inside that balloon.
Then removing the oral gastric tube now gives you a track
from the mouth to the external stomach
and that allows you to place a typical push
tube gastrostomy tube.
So anytime something new comes along,
the first question should be, is it safe?
And there actually was a study done in 2021 by cook etal
that looked at pug versus radiology, placed G-tubes
and found that both procedure techniques had a pretty high
success rate near 96% with similar complication rates.
And then looking further at the safety profile
by evaluating STA safety study data from
various different G two placement approaches
and physician specialties also indicates a similar safety
profile between a pug
and a peg, a surgical G-tube
and a radiology placed G-tube.
And this is what the specialized oral
gastric balloon looks like.
And so you can see there's a port where you have a stylet,
a stiffening stylet that can go into facilitate placement.
There's another port that you can use to
inflate the balloon with fluid
and once thatt is removed that port can then be used to
insufflate the stomach with air.
So indications same as a peg, any, any patient
that can get a peg, can get a pug.
Contraindications are also very similar.
You know, anything that you would say,
I'm not going to do a a PEG tube in this patient like severe
ascites or uncorrectable coagulopathy
or active infections like peritonitis are going to
keep you from doing a pug.
Also here, also the inability
to safely insert the oral gastric tube
and importantly a pacemaker
or other implantable magnetic devices are contraindications
because of the interference that the magnet can cause.
When you talk about patient selections at this time the pug
is only approved for adult patients greater than the age
of 18 and patients who are going to need enter access
for at least four weeks and that's really for NEG tube.
And and the reason that's there is
because it can be removed
just like any other oral
or just like any other gastric tube
can any other feeding tube.
But these need to be in place for six to eight weeks prior
to removal to allow for that track to mature so
that once you take the the gastrostomy tube out,
gastric contents don't spill into the peritoneal space.
This can cause peritonitis infection
and so you don't want that.
And and for any fe gastric tube
that you're placing in a patient, they it you need
to plan on it being in place for for six to eight weeks.
And so if this is somebody who you think is just going to need
temporary axis, use a nasogastric or oral gastric tube.
We already talked about, you know, avoiding this in patients
with other devices
that the magnet could cause interference with.
And that's pacers spinal stimulators are the two main
that you get concerned about
for anatomic considerations, you know,
ideally you would like a,
a depth from the anterior wall of the stomach
to the external skin of less than 4.5 centimeters,
having said as your comfort level progresses,
if you can see the balloon
and you can see the entire track on ultrasound
and you can see your needle tip the entire time
as you're cannulating depths beyond
that are, are achievable.
You need to be aware of patients with hepatomegaly
or liver displacement
because it's going to move the antrum
of the stomach from the anticipated location.
Thankfully Dr. Cohen will talk
to you about ultrasound examination for these things
and that can help you determine where you need
to be targeting cannula, your cannulation site externally
and the ultrasound will help you identify these
things before you do it.
Your entry site should be at least one finger breadth
below the costal margin.
Having the patient in the reverse t trendelenberg position
and insufflating the stomach appropriately can help with
that 'cause it's going to push all those contents down.
And then you can also look for
and should be aware of a vascular evaluation if there are a
significant amount of accessory vasculature
or abnormal vasculature in the stomach, the
abdominal wall that may not be somebody that you, you want
to, to do a pug on.
And then you need to be aware of notable vessels to look out
for like the gastro epichloric vessels
on the greater curvature of the stomach
and the superior epigastric arteries in the abdominal wall.
So what kind of equipment do you need?
This is a lot of where the benefit
of this procedure comes in.
You don't need any specialized GI towers
or carts or endoscopes.
You need the Puma G kit, any push technique, G-tube,
the external magnet, an ultrasound preferably
with a curva linear probe,
but a phased array probe would work.
Also sterile drapes and towels, gowns and gloves
and potentially a gause meter.
The setup, you're going to have two people, at least one person
who can operate the balloon
by inflating it and deflating it.
The procedure list will be on the patient's left side
ultrasound positioned across from you on the patient's right
patient in reverse trendelenberg
and be generous with the body draping.
You need space to rest the magnet on the bed,
not on your procedural table or you'll never get it off.
It's magnetic. And then having a generic procedure kit
with basic instruments and gauze and needles
and towels may be helpful.
This is a nice example of how to set up the field.
You can see on the table you have the, the wire there
that has that nice coil tip.
That's to help it catch inside that specialized balloon
OG all the drapes
and how the room is set up
with the ultrasound on the patient's right hand side,
the proceduralist would be on the patient's left hand side.
Ultrasound across the body magnet on the bed,
just a nice field setup example there.
So for procedural sets steps,
you want to set the room up like we talked about,
make sure you've made your external marks.
And then while the procedural list is opening up the
equipment, whoever the assistant is
that's going to operate the balloon should
be priming the balloon.
So you're going to both work in tandem so that you can
move efficiently.
And the assistant can also insert the oral gastric tube.
While they do that though, they should make note
of if they see any movement on the exterior abdominal wall.
So that's referred to as the baby kick.
And that's that oral gastric tube pressing against the
anterior wall of the stomach.
That's a great clue as to where you should be cannulating.
The fluid that you fill the balloon OG
with is going to be a mix between sterile water
and a blue food dye.
And you just want to make sure that it's not too dark.
Should be a light to medium blue
and that's so that it can be easily identified
as something other than any bodily fluid.
So you have to prime the balloon, got to get all
of the air out of that system so
that it doesn't affect the ultrasound.
And to do that, you fill a syringe with 35 milliliters of
that blue fluid, you're going to inject all
of it into the balloon og.
And then holding the syringe upright, you're going
to remove all of it along with the air that's been in
that system until you feel kind of like a vacuum effect.
And then the balloon is primed and ready to go.
You are going to clean and drape using your external marks
as a guide and again,
prepping a nice large sterile field in case you need
to search for the balloon OG with the external magnet.
And once you've got everything set up, you're going
to have a second person hand the procedure list, the magnet,
the ultrasound probe,
and usually we have them also help open the specialized wire
that comes for the procedure.
So now to start the procedure, you need to make sure
that the balloon is deflated and
after priming the balloon,
it should be in the deflated position
that's going to help the mag external magnet coapt
to the internal magnet in the balloon og.
And you just want to place the external magnet first.
Starting over the sites
that you identified on your pre-procedure ultrasound,
or if you saw a baby kick,
you should feel a slight coaptation
between the external magnet
and the internal magnet in the balloon og.
Meaning when you try to pull the magnet off the body,
it feels like it kind of gets stuck.
And then you want to direct the ultrasound
beam under the magnet.
The balloon is attached to the underside of the magnet.
So if you put the ultrasound looking straight down,
it's not going to find it.
You got to look underneath the magnet
with your ultrasound beam, ask the balloon person
to inflate the balloon
and you should see it appear in your
ultrasound field of view.
You can then completely deflate it
to evaluate the tissue track between that area
and make sure there's nothing in
between the exterior and the balloon.
And then agitate the fluid again to confirm that
that isn't in fact the balloon you're seeing
Under live ultrasound guidance, keeping track
of your needle tip the entire time
of the ultrasound cannulate the balloon
and aspirate that blue fluid advance the guide wire through
that needle until there's a white depth
indicator on the line.
Once that is no longer visible outside
of the feeder apparatus, you'll know
that the wire has been advanced deep enough or far enough,
and you'll also feel a drop in resistance when you're
threading that guide wire.
Once the guidewire's in place, it's very important to follow
a specific order of steps.
First, remove the needle, then deflate the balloon,
and finally remove the magnet.
This will catch the wire inside of the balloon og.
From this point forward, the procedure should be done
by only one operator
and that's so that they can have a good feel on if there's
any tension on the wire or not.
And you're simply going to overfeed the wire
through the track that you've made into the stomach
and slowly withdraw the balloon OG from the patient's mouth.
And so we do a feed, feed, pull feed, feed pull method
once the balloon OG is completely out of the patient's mouth.
The guide wire should now create a track from the mouth
to the external abdomen.
You're going to cut the guide wire on the designated area
so it doesn't fray,
and then advance the gastrostomy tube over the wire, pull it
through the abdomen and secure the tube at the appropriate
depth marking, which you should note on the
ultrasound when you're doing your exam.
And now I'd like to hand it over to Dr. Cohen to talk
to you about the ultrasound evaluation.
- All right, great, thank you.
So, you know, as, as we'll show you in a moment,
you use the ultrasound live during the procedure
for your needle cannulation.
But you can do certain pre-procedure ultrasound
techniques to, to, you know, look for vessel walls and or,
or to look for vasculature within the abdominal wall as well
as for other anatomic landmarks.
So this, we recommend to do it
before you've insufflated the stomach with air
because the air will, you know, disrupt your,
your ultrasound view.
And, but
by taking the curve linear ultrasound probe and,
and using it in the the sagittal plane,
you can actually identify the, the antrum of the stomach,
which will help you figure out approximately
where you expect the, the, the tip of the
or gastric balloon to go when you're actually doing the,
so it should decrease your, your time during the procedure
of searching, you know, for it.
And it also, you know, will help you identify the edge
of the liver and,
and other anatomic landmarks that you're trying
to avoid during the procedure.
So the way you do that, as, as I mentioned,
you'll start in the midline, take a curve linear ultrasound
and, and use it pointed towards the head looking
at the sagittal plane.
And a, a good landmark to look for is the liver
and then to the patient's left of the liver,
you should be able to find the, the antrum and,
and approximately
where you expect the insertion point to be.
And then you'll cross references to make sure that,
that it's low enough outside of the thoracic cavity
and not, not near ribs or anything like that.
For this part of the ultrasound exam, we start
with more depth usually in the 10 to 15 centimeter range so
that you can see all, all the structures around it.
But during the procedure usually will decrease the depth
because our, as Dr. Lopez mentioned, the
insertion point, usually the anterior wall of
where you're inserting should be, you know,
usually not a lot more than four or five centimeters.
So you should be able to find it within a, a shallower
range on the ultrasound exam.
So now moving on to using ultrasound when you're
actually doing the procedure.
So one of the first things you want
to do is identify the balloon in an appropriate position
and you should be looking to make sure that there's no
structures that you don't want
to have in your needle track in the way.
So here you can see an image
of basically everything from skin to the balloon.
And there you can see the balloon is now being inflated
and this is a very nice view
of there was nothing there previously.
And then all of a sudden the balloon comes into appearance
as you instill the, the saline into the balloon
and you can see the nice bubbles agitated as it's happening.
So that,
and the nice thing is it's timed with, you know,
you're giving the instructions
to the person who's holding the syringe with the saline
and you can see temporarily that this correlates to,
as they're instilling the saline,
the balloon comes into view.
So now that you've identified the balloon is in a place
that's where you expect it to be, you're ready
to start the actual cannulation step of the procedure.
And you can do this in whatever orientation
you're comfortable with.
You can use a short axis approach,
a longitudinal in plain approach,
or you, you may change depending on different situations
with patient and anatomy and that sort of thing.
So on the left side of the screen you see
the short axis approach, kind of similar to
how we would place a central line
where the needle is now visualized perfectly in the center
of the balloon where, you know,
there was basically a safe cannulation of skin to balloon,
nothing in the way with the needle not going any
further than the balloon.
And on the right side of the screen is a in plain approach
where you can actually see the entire length
of the needle on its pathway into the balloon as it enters.
So, you know, we, we've gotten comfortable
with both approaches and,
and we'll modify based on patient's anatomy and,
and various other factors.
So like any procedure, everything can go perfectly
with no issues or there are things
that can come up along the way where it's important
to be aware of the possibilities
and know how to, to troubleshoot.
So for us at least, one of the more common things
that we found is, is just difficulty advancing the,
the actual or gastric balloon.
And this can happen at any point in the pathway,
but where we find it's most often an issue is
as you're approaching the
gastroesophageal junction, sometimes there,
there's some resistance where it may not advance as easily
as you'd like even though you know
that you're deep into the esophagus.
So there are some troubleshooting
techniques you can use for this.
Sometimes we'll pull, withdraw the stylet
by a few centimeters
and then use the external magnet
to see if we can feel good coaptation.
And then if we do together we'll sort of use the,
the external magnet to guide the balloon to
where we would like it to go.
Sometimes even though you feel like you're in the right
spot, it's just very difficult to, to visualize the balloon.
So again, you want to be feeling to, to feel
that tactile feedback of coaptation
with the external magnet.
And if you really are having a lot of difficulty,
you can use a gause meter which basically identifies,
you know, the, the intensity of the magnetic field
and we'll usually start with where we expect the the balloon
to be and then work our way up to find if there's,
if basically the magnet is just higher up
than you'd expect it to be.
And sometimes we'll see this in cases if the patient has
some degree of hiatal hernia
or something like that where the part
of the stomach is not all the way outside
of the thoracic cavity.
So while you're doing this exam, it is important
to make sure that the, the external magnet you're using
for the procedure is not near your gause meter because
otherwise it may throw you off
and you'll get a very high reading
and it's actually not from the internal balloon.
Other things you can do if you can't visualize the balloon
aside from, you know, the troubleshooting tips
for proper location is you can insufflate more air.
One of the nice things with this oral gastric tube is
that there's a port where you can insufflate additional air
during the procedure
and then sometimes you just have to really, you know,
move the, the magnet around, change your angle,
change your approach, and, and,
and just be very comfortable
with the different ultrasound maneuvering techniques to,
to find what you're looking for.
And if you don't have a clear view of the balloon,
do not cannulate right that this is one
of the probably more important things we,
that will end up saying about this procedure today is,
you know, if, if you can't find the balloon,
even if you've gone through all these steps, as long
as you haven't inserted the needle yet,
very unlikely to cause harm.
So what you don't want to do is think
that you're looking at the balloon, it turns out it's not
that and cannulate something that you're trying to avoid.
So the whole key is that you have a good ultrasound view,
you're confident that what you're looking at is
definitely the balloon.
And, and then under ultrasound guidance cannulated,
if you don't have that good ultrasound view,
then you shouldn't advance the, the needle.
So with pug, so, so some things
to think about after the procedure.
So, and, and this is true for peg as well,
but pneumoperitoneum can happen
since you're insufflating the stomach with quite a bit
of air to do the procedure.
And in this case we don't have the advantage
of using CO2 which reabsorbs faster.
So the, you know, the room air that we're using may sit
around longer and it can escape due
to the increased pressure gradient due to the procedure.
So it's important to be aware of this
and to correlate clinically
because if you identify some error on, just
as an incidental finding afterwards on a chest x-ray
for example, it may not be clinically significant,
but if it, if the patient is clinically deteriorating
and there's concern for perforation, then
that would be a different story where you need
to involve the surgeons right away.
So the context is important for this
and what we've started doing just routinely afterwards is
connecting the newly placed G-tube to
either low intermittent suction
or just leave it open to, to vent, to gravity just
to help deep compress some
of the air that's been insufflated.
Like any procedure bleeding is possible in this case.
You know, most commonly it would just be some bleeding at
the insertion site.
Tube dislodgement can also happen.
So especially on some of the, the patients
that you end up putting the, these devices in,
if they're delirious or agitated
or you know, moving their extremities,
they can accidentally dislodge it.
So if that happens
before the tract is ma matured, like Dr. Lopez mentioned,
the stomach contents can,
can spill out into the peritoneal space
and cause peritonitis, which would be, you know,
obviously an unwanted situation.
So it's important to make sure that if there's, you know,
risk of the patient dislodging, that you have their,
their arms properly positioned so
that it's not easy access as well.
And it's also important to secure the, the bolster properly
to make sure that it's not too tight
but also not too loose so that the,
the, the tube is positioned properly.
If it's too tight, you can have a pressure ulcer effect and,
and cause pressure injury and ulceration.
If it's too loose, you may not form the,
the fistulas track properly and,
and can have other downstream issues as well.
So if this were to happen way downstream
after, you know, six weeks plus,
then in theory the the track should be matured
and it's less of a big deal.
But especially in the, the first few weeks
after the procedure, you really want to make sure
that it's secured properly.
And now we'll move on to the combined procedure as we like
to call it t pug.
And you know, intuitively it it, it makes sense
that these would be combined, right?
Many patients who need a tracheostomy tube are also going to
to be considered for G-tube placement.
And if you can do them in one procedural sedation setting
by the same physician without needing
to use anesthesiology there,
there are potential benefits to that.
So then of course you need to, to prove
that even if intuitively it makes sense.
So there have been some studies looking at
outcomes in ICU patients receiving either con concomitant
or sequential versions of these procedures.
In terms of the feasibility, the, the safety profile is,
is similar to the individual procedures
and there does seem to be the ability
to reduce ICU length of stay
by doing these combined
because it eliminates, you know, coordination
of two different procedures, transport to operating rooms,
that sort of thing, as well as recovery time in
between procedures or even just coordinating
with different services.
And the result of that is actually potential
for lower per patient hospital cost By combining these two
procedures over the past several years,
there have been other studies looking at this
with various forms of looking at either length of stay cost
or combination of both.
And pretty consistently there there's been ability
to decrease hospital length of stay on the order of days
and cost per patient in the tens of thousands per patient.
And then Dr. Lopez will talk about a few more
of the combined benefits of
doing these procedures together. Thank
- You.
Yeah, so I think the take home across the literature and,
and rather than just go through each one of those studies
like Dr. Cohen mentioned, consistent reduction in length
of stay or length of stay impact.
Some centers are going to see this more than others depending
on how fast or how robust your ancillary services like GI
and IRR, but it really has an impact on those.
And along with that comes a cost impact, not just
because of the length of stay, but
because when you start talking about a patient needing to go
to the operating room or to the IR suite
or with gi, there's a lot of downstream costs
that comes into that, there's those specific specialty staff
and then the time slot that it takes up for something
that can't be done at the bedside
for the G-tube placement occupying that spot.
And importantly across the literature,
there's been no significant difference in mortality.
And I think that's probably one
of the biggest take homes across the literature
because if we're going to start talking about doing a different
approach for a procedure
and it's got all these benefits to the patient,
there can't be something that offsets those benefits.
When you look at the economic benefits, we,
I think have really hammered home the,
the decreased ICU length of stay is, is really robust.
There's also improved patient throughput.
So for an ICU patient, it's, it's also what comes
after the ICU.
And so for some of these patients,
you're going to be talking about going to a facility,
especially your trach and peg PA or your trach
and G-tube patients.
And the facility isn't going to start looking at placement
until the procedures are done.
This is a more efficient method
of getting the procedures done.
And so you're going to have a decreased length of time
to getting them to the, the facility.
And then there's the ancillary service burden
that's decreased.
And I think that that comes not just by
not needing to utilize those folks for that procedure,
but freeing those sub those other up for procedures
that only they can do.
So when you look at the combined profe procedural benefits,
there's no mortality difference seen in combining these
versus doing them separately.
This is a single sedation event.
You don't, what comes along with that is decreased risk
that comes along with any sedation event being whittled down
to just once and not interrupting nutrition as frequently.
There's no transport needed off unit,
which is really beneficial.
Most ICU physicians don't like for their patients
to leave the unit or be transported.
And there's reasons for that.
There's risk associated every time a patient goes off a unit
for anything, this is ultrasound evaluation
of the entire tissue track,
which theoretically actually gives you an added piece
of information that you can't see with a PEG tube
or an IR placed gastrostomy tube surgery still, you know,
they're doing an actual dissection so they,
they are visualizing the entire track.
Also, it eliminates the need to coordinate
between specialties, which opens up the possibility
of doing this, like outside
of quote unquote traditional hours
or on the weekends intensivist
monitoring during the procedure.
There's no kind of way around it.
Sometimes procedures are going to get delayed
because a patient may be a little bit tachycardic
or maybe they're still on a little pressors
or you know, something like that that the anesthesiologist
or the GI doctor or IR may not feel comfortable with.
But as an intensivist we do,
because that's what we deal with all the time
and we've been treating that patient during the duration
of their stay so we know, you know, what for them,
quote unquote is normal or abnormal.
And then there's not any evidence to, to suggest this yet.
But I do think it begs the question
that if we're decreasing length of stay for these patients,
are we also can competently reducing hospital acquired
infection and hospital acquired complications for them.
And so I think that's where the real power
of combining these procedures together comes in
and the power of having the ultrasound
to evaluate the entire field that you're working with
and do live guide, needle guided cannulation
or evaluation of the entire tissue track
for both of these procedures.
And we would like to thank you so much.
It's been really great being able to, to give this webinar
to you all and I'd also like to thank Dr. Cohen
for his fantastic contribution to this.
- Yep. Thank you very much
and feel free to reach out if you have any questions
and we we're happy
to answer any questions right now if you have any.
- All right, well thank you so much guys. That was amazing.
Doctors Cohen and Lopez are here for questions.
So looks like we had one during the presentation here,
but if anybody else has any questions, feel free
to put them in the q and a box at the bottom
or the side of your screen, or if you're on the YouTube
or LinkedIn streams, feel free
to put those in the chat box also and we'll get to those.
So during the tracheostomy troubleshooting section,
somebody asked is the trachea vertical
or horizontal incision?
So maybe you guys could kind
of talk about why you would use one or
or the other over the other.
- Sure. So E either is acceptable, some of it is just,
you know, personal preference.
We typically like to do horizontal incisions,
but you know,
we'll make adjustments depending on if we see evidence
of superficial vessels
or anything on the ultrasound exam that makes us think,
you know, changing the direction may be of benefit.
So, so it has more to do with
that than I think one is better than the other.
- Yeah, definitely there's, you know,
certain patient populations also,
especially post neurosurgical patients
who have had anterior cervical neck approach
that require tracheostomy post
procedure for whatever reason.
And in those patients I do tend to favor a vertical incision
because the previous neurosurgical insertion site kind
of rides close to the field, but either is acceptable.
I think for us, like Dr. Cohen said, we tend
to gravitate more towards doing a horizontal incision,
but we'll adjust that decision based on the patient
that we're doing the procedure on.
- Excellent. And we also have another question.
Are these procedures performed by MDs DOS only or can NPS
and PAs perform these as well?
- So at our institution, this is a physician level procedure
and I think a lot of that is
because of the additional skillset that's kind of required
to be proficient at these, you know, for
percutaneous tracheostomy, our, we have a specific
percutaneous tracheostomy team so that it, you know,
every physician on there can do all parts of the procedure,
including the bronchoscopy
and airway, which includes being able
to do a pretty significant rescue airway.
But for the tracheostomy portion also, the,
the part you have to be able to do also is things up to
and including a blind trach or an emergency cricothyrotomy.
And so for us it's, it's a physician only procedures
and same thing with the gastrostomy tube.
- Yeah. And then, you know, in addition to that, you have
to remember that besides the procedure itself,
you're also managing the patient while you're doing it
because while it's an advantage
that we're doing it without an anesthesiologist, part
of the way that we're able to replace that is you're,
it's a critical care physician who's doing the procedure.
So you're monitoring the patient, managing the sedation
and paralysis and all of that in addition to all of the,
you know, procedural things that you're keeping track of.
- Right. - And you both helped kind of
form de dedicated tracheostomy
and pug service at your hospital.
Could you guys kind of talk about what went into that
and how you kind of got that started?
- Sure. So we've been doing tracheostomies,
the PDT approach for a long time, you know, at,
at our hospital long before either
of us probably even started our training there.
But the, so, so there had already been a variety
of doctors doing that,
but during COVID it sort of mandated
that we formalize a team a little bit more so
that there was a structured approach
to doing a much larger volume
of tracheostomies than had historically been the norm.
And then, you know, around
that time the pug was becoming, you know, more common in,
in the critical care community.
So some, somebody had reached out to us, reached out
to the hospital to see who was doing a lot of tracheostomies
and, and they ended up contacting us.
And when we vetted the procedure, it seemed like something
to, to incorporate into our skillset,
but with any new procedure there were a lot of, you know,
logistical considerations to take into account.
So since this was a novel thing, we had to actually go
through a whole process of, you know,
doing a cost value analysis with, with the materials
and management team
and also having an actual privilege
added to our privilege form.
It required support from GI and or gastroenterology
and trauma surgery as well.
So it, it, it, there were a lot of steps to doing it,
but overall it's actually been a pretty positive experience
to, to add this new procedure where it was actually nice
to see the support that we had from other,
you know, departments.
And we've even had situations where like radiology or GI
or surgery have even reached out to say, Hey,
would your approach make sense here?
We be, we're concerned about doing it our
way for these reasons.
So, so it's actually been a very interesting thing
to add on a few years ago.
- Well, does it look like we have any more questions?
So I would really love to thank Doctors Cohen
and Lopez for taking the time
to put together in really in-depth presentation
and for hanging around to answer questions for us.
I really appreciate you sharing your expertise with us.
A quick reminder to everybody,
you can watch the previous webinars and this one later
and sign up for upcoming webinars on sonos
site.com/behind the scan webinar.
And this webinar
and other recorded webinars are available on YouTube
and the Sonos Site Institute as well.
So once again, thank you so much for joining us today,
Dr. Cohen and Lopez, and we'll see you at the next one.
- All right. Thank you very much.
- Thank you.
Join our comprehensive webinar designed for healthcare professionals seeking to master percutaneous tracheostomy and ultrasound-guided gastrostomy (TPUG) tube placement. This session covers appropriate patient selection, in-depth knowledge of anatomical landmarks, and ultrasound applications essential for both procedures. Learn step-by-step procedural setups, necessary equipment, and explore the advantages of performing these interventions concurrently. Additionally, develop skills in basic troubleshooting to enhance confidence and efficiency in the clinical setting.
What You'll Learn
- Indications, contraindications, and appropriate patient selection for percutaneous tracheostomy and percutaneous ultrasound guided gastrostomy (TPUG) tube placement
- Anatomical considerations and use of ultrasound for both procedures
- Procedural preparation and necessary equipment for TPUG
- Potential benefits of performing percutaneous tracheostomy and ultrasound guided gastrostomy tube place concurrently or as a single procedural event
- Basic troubleshooting for percutaneous tracheostomy and PUG
Assistant Professor of Medicine Division of Pulmonary and Critical Care Cedars-Sinai Medical Center
Dr. Angelena Lopez is an Assistant Professor of Medicine in Pulmonary and Critical Care at Cedars-Sinai Medical Center, also serving as Associate Director of the Medical Intensive Care Unit and is a member of the Advanced Bronchoscopy service. Dr. Lopez has extensive expertise in percutaneous and ultrasound-guided procedures, bedside ultrasound for diagnosis and management, advanced bronchoscopy, and Percutaneous Ultrasound-Guided Gastrostomy (PUG), and was among the early adopters of PUG at her institution. In addition to her clinical and leadership roles, she is deeply committed to medical education and procedural training.
Director, Pulmonary Physiology and Blood Gas Laboratories Division of Pulmonary and Critical Care Medicine Cedars-Sinai Medical Center
Dr. Samuel Cohen is a Pulmonary & Critical Care Faculty Physician and Assistant Professor of Medicine at Cedars-Sinai Medical Center. In addition to caring for patients in the Intensive Care Unit, Pulmonary Consult Service, and Advanced Bronchoscopy Service, he serves as the Director of both the Pulmonary Physiology and Pulmonary Blood Gas Laboratories. He has a specific interest in innovations in ultrasound-guided procedures and was an early adopter of percutaneous ultrasound-guided gastrostomy (PUG). He was among the first on the West Coast to use this technique and helped to form a dedicated tracheostomy + PUG service at his hospital.
This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.