Anesth Analg 2000;91:170-171
© 2000 International Anesthesia Research Society
CRITICAL CARE AND TRAUMA
The Use of a Tracheostomy Tube for Enteral Stomal Control
A. Nikolic, MD,
K. Lampl, MD,
C. Klasen, MD,
C. Weinstabl, MD, and
C. G. Krenn, MD
Department of Anesthesia and General Intensive Care Medicine, University of Vienna, Vienna, Austria
Address correspondence and reprint requests to Dr. Claus Georg Krenn, MD, and Ajsa Nikolic, Department of Anesthesia and General Intensive Care Medicine, University of Vienna, 18–20 Waehringer Guertel, 1090 Vienna, Austria.
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Abstract
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Implications: We found that the use of a zero-pressure tracheal foam cuff was the ideal way to drain the intestines through a colostomy, reducing skin irritations and mucosal damage.
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Introduction
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Many abdominal operations result in stomas, which require more adaptive methods of treatment for the large diversity of complications (e.g., wound maladaptation, infection, stitch decay, strictures, and peristomal skin problems) (1). Skin irritations occur with a frequency of 61% (2) and are mostly caused by digestive juices (i.e., proteolytic enzymes), fecal excrements, constant humidity, repeated application of the stomal bag, mechanical trauma, and exposure to leakage because of ill-fitting appliances. These irritations, although bland, can become severe, causing inadequate wound recovery or stoma bag adaptation. Furthermore, because of the patient’s diminished postoperative defenses, any infection can, in a worst-case scenario, lead to sepsis, thereby complicating patient outcome and prognosis and increasing treatment cost (3). Intensivists, therefore, insist on active treatment by using antibiotic creams, infusions, and operative revisions. We report on the use of a tracheostomy tube to enhance wound recovery and recreate sterile stoma conditions.
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Case Report
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A 48-yr-old man was admitted to our intensive care unit after undergoing three abdominal operations. The patient had portal vein thrombosis and hemorrhaged infarction of most of the intestine. The first two surgeries resulted in a resection of the infarction areas, stoma, an enterocutaneous fistula, and a septic condition (methicillin-resistant Staphylcoccus aureus and Pseudomonas aeroginosa). The fistula was located in the lower right abdomen, allowing intestinal contents to flow out freely. The third surgery created an atypical colostomy; the abdominal wall could not be closed and was left open as a laparostoma with the ostomy lying in the center. Because of the location of the ostomy, a stoma bag could not be fixed as usual. To ensure wound closure and sterility, the V.A.C.TM Medium Dressing (KCI Medical Ltd, Dorset, UK) system was applied. This device showed good results as long as the patient was on total parenteral nutrition. However, when the patient was began with enteral feeding via a nasogastral tube, the liquid intestinal juice could not be absorbed by the remaining jejunum and severely irritated the tissue around the device. To reduce the irritation, continue with the enteral feeding, and mobilize the patient, a urethral catheter was inserted into the stoma to drain the intestinal contents before it reached the orifice.
Two problems were encountered. First , the device could not be tightly fitted because of the nonuniform contact between the balloon and bowel wall, and second, the probability of balloon pressure causing mucosal lesions was increased; thus, we decided to apply a Fome-Cuff® (Bivona Medical Technologies, Gary, IN). This device is regularly used as a tracheal tube (4). It has a foam rubber cuff that is normally inflated at atmospheric (zero) pressure. During insertion, applying suction from a syringe deflates the cuff (Figure 1). When the tube is in place, the cuff is allowed to inflate again. The risk of pressure-induced mucosal damage is largely reduced (5). In the stoma situation, the cuff was tight, allowing the intestinal juice to be collected properly in a bag connected to the tube, enabling the peristomal tissue to recover (Figure 2). A short bowel syndrome led to death 6 mo postoperatively.
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Figure 1. Fome-Cuff® (Bivona Medical Technologies, Gary, IN) tracheal tube with zero-pressure balloon fully inflated.
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Discussion
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The atypical stoma, fistula, and sepsis complicated our patient’s situation. Because the walls of the abdomen were already so macerated that it was impossible to use a stoma bag, alternate methods of ensuring sterility with the least amount of mucosal damage caused by pressure had to be considered. The tracheostomy tube worked with zero pressure, thereby reducing mucosal pressure, allowing wound closure and making it the most adequate choice. Because age was not a factor for poor wound recovery, and poor stomal adaptation prolonged the intensive care unit stay, alternate tools used in the intensive care environment were used to facilitate rehabilitation (6–8). Other types of tracheostomy tubes and standard endotracheal tubes could probably be tried, with equal success in similar situations . One must keep in mind that, although some tools are developed for one type of application, it is interesting that they can be adapted for other uses. Such incidents should stimulate intensivists to consider other such options and to encourage the industry to develop suitable devices.
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References
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Bartha I, Hajdu J, Bokor L, et al. Quality of life of post colostomy patients. Orv-Heitl 1995;136:1995–8.
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Power KJ. Foam cuffed tracheal tubes: clinical and laboratory assessment. Br J Anaesth 1990;65:433–7.[Abstract/Free Full Text]
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Lazar P, Sarbacker JD, Kowalski M. Ostomy related skin problems. Chicago:Hollister Incorporated, 1977.
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McNamara RJ, Farber EM. Circumileostomy skin difficulties. Arch Dermatol 1964;89:675–7.
Accepted for publication March 22, 2000.
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Abstract
Introduction
