What is the management of a cricothyrotomy (cricothyroid membrane incision) site?

From the Guidelines

Management of a cricothyroidotomy site requires careful attention to prevent infection and promote proper healing, with a focus on minimizing complications such as subcutaneous emphysema, tracheal stenosis, and voice changes. The technique for managing the site involves inserting a cannula through the cricothyroid membrane, maintaining its position, and confirming tracheal placement by air aspiration using a 20ml syringe 1. It is essential to attach a ventilation system to the cannula, commence cautious ventilation, and confirm ventilation of the lungs and exhalation through the upper airway. If ventilation fails or complications develop, immediate conversion to surgical cricothyroidotomy is necessary 1.

Key Considerations

• Clean the site daily with sterile saline solution or a mild antiseptic, gently removing any crusting or secretions.
• Apply a sterile dressing, typically a split gauze around the tube, and secure it with tape or a tracheostomy holder.
• Change the dressing at least once daily or more frequently if it becomes soiled or moist.
• Monitor the site for signs of infection, including redness, swelling, increased pain, purulent discharge, or fever.
• If infection is suspected, obtain wound cultures and consider empiric antibiotics such as amoxicillin-clavulanate or clindamycin for 7-10 days 1.

Preventing Complications

• Ensure the cricothyroidotomy tube is properly secured to prevent dislodgement and minimize movement that could irritate the site.
• Suction the tube as needed to maintain patency, using sterile technique.
• For patients with a temporary cricothyroidotomy, conversion to a formal tracheostomy should typically occur within 72 hours to reduce complications 1.
• The stoma will generally close spontaneously within 5-7 days after tube removal, though larger defects may require surgical closure.

Technique

The 4-step technique for surgical cricothyroidotomy involves identifying the cricothyroid membrane, making a stab incision, enlarging the incision with blunt dissection, and inserting the tube with caudal traction on the cricoid cartilage 1. Verification of tube position and pulmonary ventilation is crucial to ensure effective management of the cricothyroidotomy site. By following these guidelines and techniques, healthcare providers can minimize morbidity, mortality, and improve the quality of life for patients with a cricothyroidotomy.

From the Research

Management of Cricothyroidotomy Site

• The management of a cricothyroidotomy site is crucial for maintaining a secure airway and preventing complications 2.
• Studies have shown that cricothyroidotomy can be performed safely and effectively by experienced clinicians, with a high success rate and low complication rate 3.
• However, the use of new instruments and techniques, such as the indicator-guided puncture technique, may not be recommended for inexperienced operators due to a higher complication rate 4.
• Prophylactic cannula cricothyroidotomy and percutaneous oxygen insufflation can be a simple and effective tool for enhancing safety in difficult airway management 5.
• The technique of cricothyroidotomy involves making an incision through the superficial cricothyroid membrane, and careful management and expert nursing support are essential for preventing complications 6.

Complications and Outcomes

• Major complications of cricothyroidotomy can include inadvertent dislodgement of the tube, subglottic stenosis, and injury to the posterior tracheal wall, oesophageal lumen, and thyroid and/or cricoid cartilage 4, 3.
• The success rate of cricothyroidotomy can be high, with one study reporting a success rate of 94% 3.
• Neurologic outcomes after cricothyroidotomy can vary, with some patients experiencing no significant deficits, while others may have moderate or severe disability 3.

Techniques and Instruments

• The standard surgical technique for cricothyroidotomy involves making a transverse incision through the superficial cricothyroid membrane 4.
• New instruments and techniques, such as the indicator-guided puncture technique, have been developed to improve the ease and safety of cricothyroidotomy 4.
• Prophylactic cannula cricothyroidotomy and percutaneous oxygen insufflation can be performed using equipment that is safer, widely available, and already familiar to most anaesthetists 5.