key: cord-302081-l9whadpi authors: Yasin, El-Wajeh; Iain, Varley; Ajay, Raithatha; Alastair, Glossop; Austen, Smith; Ricardo, Mohammed-Ali title: Opening Pandora’s box: surgical tracheostomy in mechanically ventilated COVID-19 patients date: 2020-07-09 journal: Br J Anaesth DOI: 10.1016/j.bja.2020.06.052 sha: doc_id: 302081 cord_uid: l9whadpi nan world in last two decades. 1 Key lessons derived from the cumulative experience of Asian and European intensive care units (ICUs), which dealt with critically ill patients during the early phase of the COVID-19 pandemic and lessons from the previous SARS and MERS outbreaks allowed hospitals in the UK to prepare preventive measures and adopt specific processes for the COVID-19 crisis. 2 Proactive management strategies implemented during this crisis based on previous knowledge may have limited the number of COVID-19 related hospital admissions, reduced mortality, and limited the initial trajectory of coronavirus spread in the UK. Our hospital has seen an increase in demand for open surgical tracheostomies in COVID-19 patients admitted to the ICU. In contemporary critical care practice the most common indication for a tracheostomy is to allow gradual weaning of patients undergoing prolonged mechanical ventilation. Tracheostomized patients benefit from improved patient comfort, reducing or completely removing the need for sedation and decreasing breathing circuit dead space, all of which may aid weaning from mechanical ventilation. The current COVID-19 pandemic has presented a particular challenge to providers in this area, as large numbers of COVID-19 positive patients will require prolonged mechanical ventilation and thus potentially require a tracheostomy to facilitate withdrawal of this support. El-Wajeh, Yasin*; Varley, Iain; Raithatha, Ajay; Glossop, Alastair; Smith, Austen; Mohammed-Ali, Ricardo Performing a conventional tracheostomy in a COVID-19 patient can be compared to the Greek myth of opening Pandora's box, which unleashed untold evils. Due to the highly contagious nature of the SARS-CoV-2 virus, a tracheostomy without modification of the technique would expose the intensivist, surgeon, and supporting healthcare workers to this deadly pathogen. Thus, it is vital to implement precautionary steps during this high-risk aerosol-generating procedure. When an ope surgical tracheostomy is performed in a COVID-19 patient, the risk of viral transmission to all the involved team members can be reduced by implementing a systematic and integrated approach with the surgeon and the intensivist/anaesthesiologist working in a synchronised manner. Tay Irrespective of which of the two techniques are chosen, the operator needs to be highly experienced in order to reduce potential surgical complications, procedure time and coronavirus aerosolization. Furthermore, the type of tracheostomy is influenced by local factors such as availability of a negative pressure room within the ICU setting, and patient-related risk factors such as anatomical anomalies of the neck, obesity and serious bleeding disorders. [4] [5] [6] [7] [8] A tracheostomy should not be considered too early after patient admission. One should wait until day 14 for the prognosis to be clearer and for the viral load to decrease. 9,10 These recommendations are based on recent audit data from Intensive Care National Audit and Research 2020 and unpublished reports from Italy and China. These reports suggest that a significant proportion of COVID-19 patients are being successfully weaned and extubated between day 5 and day 10, and patients requiring longer mechanical ventilation often have poorer overall prognosis. 11 Published guidelines for open surgical tracheostomy in COVID-19 patients guidelines suggest that tracheostomies should not be routinely considered in any patient with tracheal intubation until the patient has been determined to be free from the virus and isolation precautions have ended. 12 (Table 1) . COVID-19 patients succumb to multiple pathological processes including coagulopathy, with disseminated intravascular coagulation being a primary concern. 14 COVID-19-associated coagulopathy and underlying traditional risk factors predispose these patients to an increased risk of acute pulmonary embolism. 15 Therefore, patient-specific evaluation of bleeding risk is required. In the absence of significant bleeding risk, patients should receive prophylactic low molecular weight heparin to prevent thromboembolism. 16 We administer daltaparin twice daily, omitting the morning dose if surgery is scheduled in the morning. Undertaking an open surgical tracheostomy opens up a Pandora's box of a novel viral disease, which we still do not understand fully. Pandora's curiosity got the better of her for a second time. She opened the box once more and released the only thing that was left in the box-hope. A surgical tracheostomy opens up a window of hope for the patient with benefits such as patient comfort, mobility, and speech. If carried out following the approach outlined above, it may be beneficial in this cohort of patients, while the well-being of all team members involved in the procedure is ensured. 3 Entire team in full personal protective equipment. 5 Inform intensivist/anaesthesiologist once the anterior tracheal wall has been exposed and incision for tracheal stoma is imminent. Step down from ICU with tracheostomy: To a dedicated surgical ward. or Step down from ICU post decannulation: Medical ward acceptable. 4 Surgical tracheostomies to be performed on a planned semi-elective basis. Ventilation is switched off at the end expiratory phase with intrathoracic pressure only at atmospheric. 5 A consent form to be signed by two consultants involved in care of the patient. Tracheal window created and suture stitch placed. 6 Ensure all patients are clinically stable: On FiO2 < 0.5, PEEP < 10 cm H 2 O PAP < 28 cm H 2 O, Platelets > 80,000 INR/APTT ratio < 1.5 Anticoagulation stopped preoperatively TT cuff is deflated, and retracted slowly until the end is just above the stoma. 7 Tracheostomy packs including surgical kits are prepared and stored in advance for ICU cases. Only use cuffed, nonfenestrated tracheostomy tubes to minimise aerosolization. Tracheostomy tube inserted, introducer out, inflate cuff, manually secure tube, transfer catheter mount. 8 Patient is transferred to a surgical trolley with sandbag between shoulders and head ring to attain maximum head extension. Adequate mobile lighting to be available. Wet swabs over wound as a precautionary measure if cuff leaks and recommence ventilation. 9 Use of agreed hand signals to aid communication when all staff members in personal protective equipment. Chest movements and CO 2 checks are made by the intensivist. The TT can then be disposed of safely. Clinical management and infection control of SARS: Lessons learned Outbreak of a new coronavirus: what anaesthetists should know Surgical Considerations for Tracheostomy During the COVID-19 Pandemic. lessons learned from the severe acute respiratory syndrome outbreak Tracheotomy recommendations during the COVID-19 pandemic. Airway and Swallowing Committee of the American Academy of 12 Guidance for surgical tracheostomy and tracheostomy tube change during the COVID-19 pandemic Novel Percutaneous Tracheostomy for Critically Ill Patients with COVID-19. The Annals of Thoracic Surgery Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations Tracheostomy in a patient with severe acute respiratory syndrome Care National Audit and Research (2020) ICNARC report on COVID-19 in Critical care Guidance for surgical tracheostomy and tracheostomy tube change during the COVID-19 pandemic -National Tracheostomy Safety Project COVID-19): A Meta-Analysis Pulmonary embolism in patients with COVID-19: Time to change the paradigm of computed tomography Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study The authors declare no conflicts of interest.