Inadvertent passage of a tracheostomy tube through Murphy’s eye during percutaneous tracheostomy tube insertion

Inadvertent passage of a tracheostomy tube through Murphy’s eye during percutaneous tracheostomy tube insertion

Published: 22 Dec 2017

© Anaesthesia Cases / 2017-0194 / ISSN 2396-8397

Authors

Dr Harshul Measuria [1]
Dr David Dada [2]
Dr Lucy Bates [3]
  • [1] Senior House Officer, Intensive Care, Royal Bolton Hospital, Bolton, United Kingdom
  • [2] Specialist Registrar, Intensive Care Unit, Royal Bolton Hospital, Bolton, United Kingdom
  • [3] Consultant, Intensive Care Unit, Royal Bolton Hospital, Bolton, United Kingdom

Summary

Percutaneous tracheostomies are commonly performed at the bedside in Critical Care Units. The use of bronchoscopy during the procedure is variable. We describe a case of inadvertent cannulation of Murphy’s eye with a tracheostomy which initially went unrecognised. Recommendations from the NCEPOD report “On the right Trach” related to the use of bronchoscopy during percutaneous tracheostomy insertion and awareness of the nuances of different endotracheal tubes may have prevented this complication. 

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