SESSION TITLE: Procedures SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Bedside percutaneous tracheostomy is a common procedure performed in the ICU and has been shown to be as safe as surgical tracheostomy. Displacement of percutaneous tracheostomy, especially within the immediate postoperative period, has one of the highest mortality rates of any tracheostomy complication. We present the case of a 53-year-old male presenting to the hospital shortly after tracheostomy displacement. CASE PRESENTATION: The patient was admitted to LTACH following a prolonged ICU stay for acute hypoxemic respiratory failure with ARDS. Bedside percutaneous tracheostomy was performed during this hospitalization without any complications and the patient was discharged to LTACH. Ten days post procedure, the patient underwent a planned tracheostomy exchange at the bedside. Multiple unsuccessful attempts were made to reinsert the tracheostomy tube through the original percutaneous site. In the interim, the patient suffered cardiac arrest, was orally intubated and brought to the Emergency Department. Upon arrival the patient was noted to have chest crepitus. Chest radiograph was obtained which showed large bilateral pneumothoraces with pneumomediastinum and significant subcutaneous emphysema of the neck and chest. Bilateral small-bore chest tubes were placed to suction with no residual air leak after evacuation of pleural air. Otolaryngology was consulted, and the patient was brought to the operating room for complete tracheostomy revision. Under direct visualization, a clear false passage was found through the original percutaneous incision into the mediastinum. This was closed and a new cutaneous incision was used to revise the tracheostomy. Bilateral chest tubes were removed in the immediate postoperative period with follow up chest radiograph demonstrating no pneumothorax. The patient did not demonstrate any signs of meaningful neurologic recovery post cardiac arrest. DISCUSSION: Subcutaneous emphysema and pneumothorax are rare but well described sequelae of tracheostomy; however, these complications usually occur immediately following the procedure. In our case, these complications occurred due to tracheostomy tube displacement with creation of a false passage into the mediastinum. In prior studies, it was noted that cannula misplacement and creation of a false passage were more common with percutaneous tracheostomies than their open equivalents. CONCLUSIONS: Displacement of percutaneous tracheostomy, particularly in the early postoperative period, can have devastating consequences. We have described a case in which false passage to the mediastinum was created during a first tracheostomy exchange which ultimately lead to hypoxemia causing cardiac arrest. Understanding the causative mechanisms will help in preventing these complications. Reference #1: Cipriano, A., Mao, M., Hon, H. et. Al. An overview of complications associated with open and percutaneous tracheostomy procedures. International Journal of Critical Illness and Injury Science. 2015; 5(3): 179–188. Reference #2: Klein M, Agassi R, Shapira A, Kaplan DM, Koiffman L, Weksler N. Can intensive care physicians safely perform percutaneous dilational tracheostomy? An analysis of 207 cases. Israel Medical Association Journal. 2007;9(10):717–719. DISCLOSURES: No relevant relationships by Adrienne Markiewicz, source=Web Response No relevant relationships by Aasim Mohammed, source=Web Response No relevant relationships by Jonathon Truwit, source=Web Response