Critical Care

, 18:425 | Cite as

Checklist for percutaneous tracheostomy in critical care



International Normalise Ratio Lignocaine Atracurium Percutaneous Dilatational Tracheostomy Percutaneous Tracheostomy 



Percutaneous dilatational tracheostomy.

Simon and colleagues are to be commended for their effort in reviewing articles published since 1985 on the incidence and risk factors associated with mortality following percutaneous dilatational tracheostomy (PDT) [1].

An important milestone in an attempt to reduce surgery-related complications was the introduction of the World Health Organization Surgical Safety Checklist in 2008. A pilot study showed a reduction in both mortality and potential complications following introduction of the checklist [2]. Over 300 organisations have endorsed the campaign worldwide and 1,790 hospitals are actively using the checklist with more than 4,100 hospitals registered [3].

With such broad recognition of the importance for safety and implementation of the checklist in general surgery, it seems appropriate to follow a similar checklist for the PDT procedure in intensive care. Checklists are not alien to ICUs. Checklists have helped nursing staff to adhere to infection control guidelines and hence a reduction in bloodstream-related infections [4]. Several other checklists (mechanical ventilation, daily goals [5]) have proven useful.

The checklist before PDT (see Table 1) is intended to reduce error and harm. Although the clinician has overall responsibility for ensuring that it is safe to undergo PDT, having a checklist would also provide an opportunity for the nurses to highlight or challenge any criteria that are not followed. We believe that if the checklist is tailor-made to suit individual organisations, it does not overstrain clinicians and may actually improve safety and efficiency.
Table 1

Proposed checklist before percutaneous dilatational tracheostomy (pre and post)






Confirm patient’s consent or next of kin’s assent


Is the neck anatomy favourable (no previous surgery or radiotherapy?)


Ultrasound of the neck performed? (Midline/abnormal vessels absent?)


FiO2 requirement <70 %, PEEP <10 mm Hg


Is coagulation okay? (Platelets >80,000/μl, INR <1.5, APTT <45 seconds)


Anticoagulants and antiplatelets withheld?


Gastric feeding suspended?




Airway management and anaesthesia: Dr ……………………………………………………


Tracheostomy: Dr…………………………………………………………


Minimum monitoring (ECG/SpO2/NIBP/EtCO2)


Airway rescue equipment available?


General anaesthesia (propofol + opioid) and plysis (atracurium)


20 ml local anaesthesia – 1 % lignocaine with adrenaline


Ciaglia dilatational tracheostomy (preferably with subglottic suction). A range of tube sizes and adjustable flange tube should be available


Airway toilet/suction and bronchoscopy


Tracheostomy position is confirmed by EtCO2 and bronchoscopy


Tracheostomy is secured with sutures and tapes, and inner cannula inserted


Post procedure


Check chest X-ray satisfactory?


Document in the clinical record


Review sedation and ventilation


APTT, activated partial pressure thromboplastin time; ECG, electrocardiogram; EtCO2, level of carbon dioxide released at the end of expiration; FiO2, fraction of inspired oxygen; INR, international normalised ratio; NIBP, non-invasive blood pressure; PEEP, positive end-expiratory pressure; SpO2, blood oxygen saturation.



  1. 1.
    Simon M, Metschke M, Braune SA, Püschel K, Kluge S: Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Crit Care 2013, 17: R258. 10.1186/cc13085PubMedCentralCrossRefPubMedGoogle Scholar
  2. 2.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA, Safe Surgery Saves Lives Study Group: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009, 360: 491-499. 10.1056/NEJMsa0810119CrossRefPubMedGoogle Scholar
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  4. 4.
    Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C: An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355: 2725-2732. 10.1056/NEJMoa061115CrossRefPubMedGoogle Scholar
  5. 5.
    Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C: Improving communication in the ICU using daily goals. J Crit Care 2003, 18: 71-75. 10.1053/jcrc.2003.50008CrossRefPubMedGoogle Scholar

Copyright information

© BioMed Central Ltd. 2014

Authors and Affiliations

  1. 1.Norfolk and Norwich University Hospitals,Colney LaneNorwichUK

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