Elective Tracheostomy in COVID-19 positive patients
GENERAL PRECAUTIONS
- Allow adequate time for education and rehearsal with staff prior to
donning necessary PPE, as N95 masks can make communication difficult.
This will ensure all involved parties are adequately informed and
operate smoothly (7-14).
- Tracheostomy should be avoided in patients with respiratory
instability or heavy ventilator dependence (6).
- If resources allow, test all tracheostomy patients for COVID-19 within
48 hours prior to surgery (7, 8, 10, 12-14).
- COVID-19 positive patients should postpone elective cases until
testing negative, if possible (7-16).
- Airborne precautions should be followed by all team members that are
present (7-16).
LOCATION
- The operation should be performed in an ICU room or operating room,
preferably with negative pressure and a HEPA filtration system. If
performed in an ICU room, be aware the width of an ICU bed might limit
surgical access. Consider positioning the patient closer to the
surgeon prior to beginning the procedure (7, 10, 11, 13-16).
- If necessary to move the patient, care should be taken when
transporting the patient to the operating room. Designate a team
member to remain clear of contact with the patient and interact with
the environment.
PERSONNEL
- Reduce team members to only essential staff. Consider one surgeon, one
anesthesiologist, and one surgical staff member. Additional team
members may remain on standby outside of the room (7-13).
- Procedure should be performed by the most experienced staff to
maximize safety and efficiency. Trainees only to be present if no
attendings available (7-12, 16).
- Consider forming a “traveling trach team” to limit inexperienced
staff during COVID-19 positive procedures (7, 10, 13).
EQUIPMENT
- All personnel should be equipped with the proper PPE, including an N95
mask or purified air purifying respirator (PAPR) device, eye goggles,
transparent full-face shield, gown, and double gloves (7-16).
- PPE equipment should be readily available in the area where COVID-19
positive patients are managed (7-16).
- Surgical tracheotomy tray (17).
- Cuffed tracheostomy set (7-12).
- Heat and moisture exchanger (HME) device with viral filter (7-16).
- Closed suction system (7, 8, 10-16).
INTRAOPERATIVE TECHNIQUES
- Limit use of electrical cautery (17).
- Maintain adequate preoxygenation (100%) for 5 minutes (8-11, 13, 16).
- Establish complete paralysis using neuromuscular blockade to prevent
coughing and aerosol dispersion (3, 5, 6, 10, 13, 14).
- Hold ventilation prior to puncturing airway (7, 12).
- Once tracheostomy placement is confirmed, connect patient to
ventilator with HME/viral filter (8-11, 13-16).
- Suture the tube to the skin and strap separately (17).
- After removing endotracheal tube, place facemask on patient to protect
against dispersion should the patient cough (14).
- Check for proper inflation and monitor any evidence of cuff leaks (6,
7, 12, 15).
- Doffing of PPE and disposal of tools according to institutional
protocol (6-17).