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| CASE SERIES |
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| Year : 2022 | Volume
: 1
| Issue : 1 | Page : 22-24 |
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Anesthetic considerations in COVID-19 patients undergoing tracheostomy: A case series
Riniki Sarma1, Kiran Mahendru1, Anuja Pandit2
1 Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R.A Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
2 Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R.A Institute-Rotary Cancer Hospital; National Cancer Institute, Jhajjar, All India Institute of Medical Sciences, New Delhi, India
| Date of Submission | 18-Oct-2021 |
| Date of Acceptance | 09-Jan-2022 |
| Date of Web Publication | 20-Apr-2022 |
Correspondence Address:
Dr. Kiran Mahendru
Department of Oncoanaesthesia and Palliative Medicine, Dr. BRA IRCH, All India Institute of Medical Sciences, New Delhi
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jica.jica_4_21
Being an aerosol-generating procedure (AGP), tracheostomy for patients infected with severe acute respiratory syndrome-coronavirus-2 poses a great risk of infection for health-care workers. We present a series of four COVID-19-infected cases who underwent surgical tracheostomy and discuss the anesthetic concerns regarding the same. Keywords: COVID-19, severe acute respiratory syndrome-coronavirus-2, tracheostomy
How to cite this article:
Sarma R, Mahendru K, Pandit A. Anesthetic considerations in COVID-19 patients undergoing tracheostomy: A case series. J Ind Coll Anesth 2022;1:22-4 |
How to cite this URL:
Sarma R, Mahendru K, Pandit A. Anesthetic considerations in COVID-19 patients undergoing tracheostomy: A case series. J Ind Coll Anesth [serial online] 2022 [cited 2023 Sep 25];1:22-4. Available from: https://www.jicajournal.in//text.asp?2022/1/1/22/345599 |
| Introduction | |  |
Tracheostomy can facilitate ventilator weaning, free up equipment, personnel, and beds given the finite nature of advanced respiratory support resources, especially in a developing country like India. Nevertheless, the decision of tracheostomy should be patient centric and is of critical importance during the disease management course of a COVID-19-infected patient. Being a highly aerosol-generating procedure (AGP), it is important to take adequate precautions with proper planning to conduct anesthesia for these patients.
| Case Report | | |
All patients underwent open surgical tracheostomy in a positive pressure operation theater (OT) [Table 1]. Informed consent was taken over a video call which was recorded from a relative involved with decision-making process. Nasogastric feed and low-molecular-weight heparin (LMWH) were withheld (all patients received prophylactic LMWH) 12 h before the procedure. All the patients had a normal platelet count and coagulation profile. Before the day of surgery, the anesthesia team, surgical team along with nursing staff and OT assistant underwent a debriefing for smooth conduction of the procedure. The same anesthesia team was involved in all the four cases. On the day of surgery, the OT was prepared with all the necessary drugs, instruments, and machines by one member of anesthesia team, surgery, and nursing team without wearing any personal protective equipment (PPE) before shifting the patient. Once OT was prepared, all the personnel involved with the procedure wore a level three PPE. Meanwhile, the patient was shifted on a trolley with a portable ventilator from the intensive care unit (ICU) by a member of the anesthesia team. After receiving the patient inside OT, he was connected to the anesthesia machine with a viral filter and ventilated through the same. The Standard American Society of Anesthesiologists monitors were attached, and neck extension position for tracheostomy was done using a Shoulder roll. Adequate muscle paralysis was given. Local infiltration was done with 2% lignocaine with adrenaline to reduce oozing. A vertical incision was given, layer-wise dissection was done. The trachea was confirmed after aspiration of air in a saline-filled syringe. At this point, the endotracheal tube was pushed further inside well below the tracheostomy site, and 100% oxygen was supplemented. Just before tracheal window was made, ventilation was totally stopped and was resumed only after tracheostomy tube was placed in situ. The tracheal placement was confirmed with capnography and chest rise. The endotracheal tube was removed under the drapes inside a plastic sheet and discarded in a closed container. No diathermy was used. The tracheostomy tube was then sutured and secured with neckties. The patients were then shifted back to ICU by the anesthesia team. The average time taken for the whole procedure right from shifting the patient from ICU to shifting back took 45 min. None of our health workers involved with the procedure reported any infection later.
| Discussion | | |
Tracheostomy is a highly AGP.[1] Due to the paucity of data, only a handful of expert opinions and consensus guidelines have been generated on this topic.[2] Although tracheostomy was done between day 12 and 18 in our setup, it was mostly guided by the patient's clinical condition and their need rather than focusing on “timing” of the infective period. In terms of viral load, it has been seen that there is no such data that suggest any specific period of delay before taking the decision of tracheostomy.[3] The choice of type of tracheostomy whether it is open surgical or percutaneous should be based on expertise and equipment available. Percutaneous tracheostomy can be done bedside, requires greater expertise, and may be difficult in patients with abnormal airway or obese patients. The use of ultrasound to identify airway structures may improve percutaneous tracheostomy technique by decreasing the need of bronchoscopic guidance. In our cases, open surgical technique was chosen. Studies have found that anticoagulant therapies may be continued till the procedure, but considerable variations do exist.[4] At our institution, we stopped LMWH 12 h before the procedure and started 4 h after tracheostomy.
Before surgery, consent should be obtained from patients' nearest relatives through telephonic and video calling and the same should be documented. A good planning and communication should be there between anesthesia, surgery, and nursing staff so that this procedure can be done quickly with minimal aerosol generation. A runner should be available outside the OT to provide for any emergency backup. The anesthesia machine should be checked before taking the patient inside OT, all equipment of emergency airway cart should be kept ready, the instrument trolley for surgeons should have tracheostomy tube of various sizes, and a catheter mount along with a viral filter should be kept ready to connect the tracheostomy tube with the anesthesia machine as soon as the tracheostomy tube is in situ.
It is important that proper donning and doffing should be done to minimize the risk of infection, and a level three PPE should be worn.[5] All team members must have undergone institutional training on infection control before performing such procedures. Ideally, all AGPs should be done in a negative pressure room to minimize the escape of virus particles. However, if negative pressure rooms are not available, it is recommended to use a normal pressure room with High efficiency particulate air (HEPA) filters in the presence of a strict door policy.[3] Performing this procedure in the ICU itself may minimize the aerosol generation, decrease the number of exposed personnel and save time. However, this is not feasible due to suboptimal patient positioning, limited movement, and limited vision already compromised by PPE and fogging over goggles.[4]
Carefully shifting the patient from ICU to OT is an important part of anesthesiologists' role as these patients have high ventilator requirements and may not maintain saturation in a portable ventilator. They need to be monitored constantly. In the OT, one must ensure that the patient receives adequate muscle relaxation and no patient movement or coughing should occur during the procedure. The assessment of possible drug interactions should be made since all such patients have received treatment with one or the other institutional recommended drugs for treatment in a COVID-positive patient.[6] It is the anesthetist who pushes the endotracheal cuff toward the carina to prevent its rupture during tracheal dissection. Apnea phase after opening of the tracheal stoma until the connection of the tracheostomy tube to the ventilator also requires a close monitoring.[7] This process reduces the dispersion of aerosols into the environment.
No diathermy should be used. Electrosurgical procedure should not be done once the tracheal stoma is made. Suction should be as minimal as possible and should be done using an in-line suction system. Postprocedure complete documentation is vital. Chest X-ray to confirm tube position should be done. A tracheostomy tube should not be changed for up to 4 weeks of placement.[8]
| Conclusion | | |
Appropriate precaution against AGP, good muscle relaxation, proper planning, and communication among team members is the key to the management of tracheostomy procedure of a severe acute respiratory syndrome-coronavirus-2 infected patient.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS One 2012;7:e35797.  |
| 2. | Cook TM, El-Boghdadly K, McGuire B, McNarry AF, Patel A, Higgs A. Consensus guidelines for managing the airway in patients with COVID -19: Guidelines from the difficult airway society, the association of anaesthetists the intensive care society, the faculty of intensive care medicine and the royal college of anaesthetists. Anesthesia 2020;75:785-99. |
| 3. | Lamb CR, Desai NR, Angel L, Chaddha U, Sachdeva A, Sethi S, et al. Use of tracheostomy during the COVID-19 pandemic: American College of Chest Physicians/American Association for Bronchology and Interventional Pulmonology/association of interventional pulmonology program directors expert panel report. Chest 2020;158:1499-514. |
| 4. | Gosling AF, Bose S, Gomez E, Parikh M, Cook C, Sarge T, et al. Perioperative considerations for tracheostomies in the era of COVID-19. Anesth Analg 2020;131:378-86. |
| 5. | Angel L, Kon ZN, Chang SH, Rafeq S, Palasamudram Shekar S, Mitzman B, et al. Novel percutaneous tracheostomy for critically ill patients with COVID-19. Ann Thorac Surg 2020;110:1006-11. |
| 6. | Velly L, Gayat E, Quintard H, Weiss E, De Jong A, Cuvillon P, et al. Guidelines: anaesthesia in the context of COVID-19 pandemic. Anaesth Crit Care Pain Med 2020;39:395-415. |
| 7. | Bassi M, Ruberto F, Poggi C, Diso D, Anile M, De Giacomo T, et al. Is surgical tracheostomy better than percutaneous tracheostomy in COVID-19 – Positive patients? Anesth Analg 2020;131:1000-5. |
| 8. | McGrath BA, Brenner MJ, Warrillow SJ, Pandian V, Arora A, Cameron TS, et al. Tracheostomy in the COVID-19 era: Global and multidisciplinary guidance. Lancet Respir Med 2020;8:717-25. |
[Table 1]
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