Brigham and Women's Hospitals

Surgery

Updated: April 30, 2020

This section is in development

Preoperative Precautions Decision Pathway

Tracheostomy

For patients with resolved COVID

  1. Please page the COVID Trach Team in the Partners Paging Directory
  2. Criteria for candidacy:
  1. ICU patients with evidence of resolution of COVID infection (must be cleared by Infection Control) and prolonged mechanical ventilation requiring a tracheostomy tube.
  2. Patients must meet these four physiologic criteria:
  1. Able to lay supine for 30 minutes
  2. Hemodynamically stable
  3. FIO2 < 60%
  4. PEEP ≤ 10
  1. Procedure:
  1. Standard percutaneous tracheostomy tube or open tracheostomy tube placement (per the discretion of the consulting surgeon) should be performed using airborne strict isolation and PPE precautions as per BWH guidelines.

For patients with active COVID

  1. Page the COVID Trach Team via the Partners Paging Directory
  2. Criteria for candidacy:
  1. In special situations patients who have not yet cleared their infection can be considered for tracheostomy.
  1. Tracheostomy carries significant risk of viral transmission to healthcare workers. Patients with COVID 19 who require prolonged mechanical ventilation have a high mortality rate. The selection of these patients and the appropriate timing of the procedure require careful multidisciplinary discussion. We no longer require 21 days of intubation prior to tracheostomy.
  2. Indication for tracheostomy in COVID+ patients mirror standard critical care consideration (anticipated prolonged mechanical ventilation, need for improved pulmonary toilet, demonstrated / anticipated extubation failure, etc). These guidelines are subject to change as knowledge on the disease grows
  3. Patients must meet these four physiologic criteria:
  1. Able to lay supine for 30 minutes
  2. Hemodynamically stable
  3. FIO2 < 60%
  4. PEEP ≤ 10
  1. Procedural considerations:
  1. Patients are eligible for either a percutaneous tracheostomy tube or an open tracheostomy tube placement per the surgeon’s preference.
  1. All procedures should be done in a negative pressure room and full PPE with the minimum number of people in the room: Surgeon, Assistant (2 attending surgeons are preferred), Anesthesiologist with the remaining members of the team (RT and nursing standing outside of the room).
  1. Concurrent PEG placement should be discussed for each patient. Performing both procedures at once minimizes the total number of aerosol generating events and thus net exposure to personnel.
  2. Tracheostomy tube selection will be cuffed Portex, either 8-0 or 7-0, to facilitate downsizing (as these tubes have smaller outer diameters compared with other brands) when patients are no longer ventilator dependent
  1. Open surgical tracheostomy (Chao et al, Annals of Surgery, 2020 Chao TN, Braslow BM, Martin ND, Chalian AA, Atkins JH, Haas AR, et al. Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway Safety Committee of the University of Pennsylvania Health System. Annals of Surgery. April 2020 [e-publish before print])
  1. The patient should be paralyzed to minimize cough reflex and spontaneous breathing during airway entry.
  2. Ventilation should be held prior to incision of the trachea.
  3. If ventilation needs to be resumed after the trachea is incised, the cuff should be inflated.
  4. Ventilation should be held during any movement of the ETT and during insertion of the tracheostomy tube.
  5. The tracheostomy cuff is inflated and connected in line to the ventilator prior to resuming ventilation.
  6. Tracheostomy tube placement should be confirmed with end tidal CO2 and bilateral breath sounds and then secured in the usual fashion
  1. Percutaneous tracheostomy (Chao et al, Annals of Surgery, 2020 Chao TN, Braslow BM, Martin ND, Chalian AA, Atkins JH, Haas AR, et al. Guidelines from the COVID-19 Tracheotomy Task Force, a Working Group of the Airway Safety Committee of the University of Pennsylvania Health System. Annals of Surgery. April 2020 [e-publish before print])
  1. The patient needs to have appropriate anatomy for percutaneous procedure:
  1. No c-collar
  2. Normal sternal-cricoid distance
  3. Able to extend neck
  4. No prior neck surgery or neck radiation or other anatomic variations such as a neck cancer.
  1. The patient should be paralyzed to minimize cough reflex and spontaneous breathing during airway entry.
  2. A Blue Rhino tracheostomy kit should be used. If a flexible bronchoscope is used, it should be used only while the ventilator is paused. A modified approach is preferred with the incision and dissection to directly visualize the tracheal ring that will be accessed.
  1. If a bronchoscope is used, consider using a sterile probe cover over the bronchoscope to minimize aerosolization of secretions.
  2. Ventilation should be held during any use of the bronchoscope and placement of the bronchoscope adapter (which should not be cut).
  3. The mouth can be packed with a moist gauze to reduce aerosols.
  1. Ventilation should be held during retraction of the ETT with minimal cuff deflation until the site of needle insertion into the trachea is visualized. Ventilation can be resumed once the cuff is re-inflated.
  2. Ventilation should once again be held during tracheal dilation until the tracheostomy tube is connected in line with the ventilator.
  3. A surgical sponge should be used to cover the guidewire and dilators during insertion and removal to minimize the spray of aerosols.
  4. Tracheostomy tube placement is confirmed with end tidal CO2 and bilateral breath sounds and then appropriately secured.
  1. Postoperative care
  1. PPE should be worn
  2. A viral filter should be used with the ventilator circuit.
  3. Only closed in-line suctioning should be used.
  4. Bronchoscopy is performed only as necessary.
  5. Tracheostomy tube change should be avoided until cleared by infection control from COVID infection.

COVID or PUI ICU patients requiring an emergent surgical airway

  1. Due to significant risk of infection to the healthcare team during a surgical airway this procedure will be offered to patients who are COVID + or PUI but with the minimal amount of people present in the room as possible and only after all other intubation measures have been exhausted.
  2. All members in the room during an emergency airway should be in full PPE
  3. If possible, it is preferable to stabilize the patient with an LMA and take the patient to the operating room for a controlled tracheostomy as above

Perioperative Extubation

  1. Don clean gloves on top of baseline PPE
  2. Confirm patient will tolerate extubation:
  1. <0.4 FiO2
  2. chemical paralysis reversed
  3. maintaining adequate minute ventilation and tidal volumes with minimal support (i.e. PSV 5/5)
  4. hemodynamically stable
  5. severe metabolic derangements absent
  6. airway reflexes intact
  1. “Clean anesthesia provider” places patient on 1.0 FiO2, “Extubator” loosen tape securing ETT, suction mouth, remove OG tube, eye protection and temperature probe
  2. “Extubator” places a nasal cannula in the patient’s nares with oxygen flow “OFF
  3. Consider placing a plastic drape on top of patient to prevent exposure to any coughing that may occur(i.e. Clear plastic head piece from Bair hugger)
  4. “Clean anesthesia provider” turns all gas flows to “OFF” and “extubator” extubates the patient. Some minimal O2 flow will remain as a safety feature in most machines when flows are turned “OFF”
  5. Circulating RN will remove plastic drape and ETT as one item and discard while “extubator” will immediately place anesthesia facemask over patient with good seal and connect circuit, “clean anesthesia provider” will increase gas flows to confirm that the patient is ventilating appropriately
  6. Once the patient is confirmed to be supporting their own oxygenation/ventilation - the “clean anesthesia provider” will turn “OFF” gas flows. Some minimal O2 flow will remain as a safety feature in most machines when flows are turned “OFF”
  7. “Extubator” will remove the anesthesia face mask and immediately place surgical face mask down from forehead to cover the patient’s mouth/nares
  8. “Clean anesthesia provider” will turn on supplemental nasal cannula O2 to appropriate L/min flow
  9. All providers will sanitize/change gloves while maintaining base layer PPE. Do not allow anyone into the room for at least 18 minutes after extubation to facilitate 99% of aerosolized virus removal by negative pressure room (assumes ACH of 15/hr)