We report three deaths following percutaneous dilatational tracheostomy in a series of 1187 procedures undertaken in a single intensive care unit over a 13-year period. All deaths were due to severe haemorrhage. The first patient died during the procedure from uncontrollable haemorrhage from the innominate vein. Delayed haemorrhage in the other two patients was caused by the tracheostomy tube eroding into the aorta in one patient and into the innominate vein in the other. In both these patients, the tracheal stoma was found at postmortem to be sited unexpectedly low. Fatal haemorrhage is a rare complication of percutaneous tracheostomy (0.25% in this series), but is probably under-reported. While bronchoscopy is now used routinely during percutaneous tracheostomy insertion in most units, we speculate that ultrasound examination of the neck is more likely to identify major vascular structures at risk. However, whilst intuitive, there is little evidence that either bronchoscopy or ultrasound scanning reduces the incidence of complications. Magnetic resonance images of normal subjects are presented to demonstrate the anatomical relations of the trachea to major vascular structures and their variability.
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