key: cord-0854712-n1w0cgnh authors: Botti, Cecilia; Lusetti, Francesca; Castellucci, Andrea; Costantini, Massimo; Ghidini, Angelo title: Safe tracheotomy for patients with COVID-19 date: 2020-05-07 journal: Am J Otolaryngol DOI: 10.1016/j.amjoto.2020.102533 sha: a4e6563c5782abde464e0273b404b8bb3a152846 doc_id: 854712 cord_uid: n1w0cgnh Abstract Patients affected by severe acute respiratory syndrome coronavirus 2 disease (COVID-19) with respiratory distress may need invasive mechanical ventilation for a long period of time. Head and neck surgeons are becoming increasingly involved in the care of COVID-19 patients because of the rapidly increasing number of tracheotomies required. This procedure, when performed without protection, may lead to the infection of the medical and nursing staff caring for the patient. The aim of this report is to share our protocol for performing a safe surgical tracheotomy in COVID-19 patients. Infection of the nursing/medical staff involved in the first 30 tracheotomies performed in patients affected by COVID-19 in the Intensive Care Unit of a tertiary referral center were evaluated. Mistakes that occurred during surgery were analyzed and discussed. None of the nursing/medical staff presented signs or symptoms of COVID-19 within 15 days after the procedure. Conclusion: The authors have prepared a protocol for performing a safe surgical tracheotomy in patients affected by COVID-19. Surgeons who might be involved in performing the tracheotomies should become familiar with these guidelines. The emergence of severe acute respiratory syndrome coronavirus 2 disease (COVID-19) is a major public health emergency [1] . COVID-19 results in a clinical picture of atypical pneumonia, with 5% of patients admitted to the intensive care unit (ICU) [2] . Many of these patients may subsequently require tracheotomy. This procedure may lead to infection of the medical/nursing staff caring for the patient. The aim of this report is to share our protocol for performing a safe surgical tracheotomy in COVID-19 patients. The possible mistakes that occurred during surgery and could lead to infection of the nursing/medical staff and are discussed here. A 56-year-old male with type II diabetes had fever and cough. His chest CT scan showed interstitial pneumonia. Molecular diagnosis based on nasal/oropharyngeal swabs confirmed SARS-CoV-2-related pneumonia. He was managed with lopinavir, ritonavir and hydroxychloroquine. Invasive ventilation with orotracheal intubation was needed. His tracheal tube frequently became blocked with secretions and a surgical tracheotomy was required five days after. J o u r n a l P r e -p r o o f 6 Performing the tracheotomy inside the ICU reduces the unnecessary disconnection of catheters and tubing during transfer to and from the operating table and reduces the need for additional nursing staff, which is awfully lacking in this emergency epidemic context. To minimize the operating time, the team consisted of at least one expert surgeon. In case 1, much time was wasted in transporting another tracheal cannula to the ICU room. At least two tracheal cannulas of different diameters must be present and immediately available inside the ICU room during the procedure. Moreover, the orotracheal tube must not be completely removed from the larynx until correct positioning of the cuffed tracheal cannula has been verified. This allows the anesthesiologist to rapidly maneuver the tube forward if needed. A nurse must be on standby in the adjacent room to allow for rapid take over in case of problems. In case 2, aerosols were generated by the incorrect generation of apnea, due to the inexperience of the young resident anesthesiologist. This fact underlines the need for the presence of an expert anesthesiologist during the procedure. Electrocautery generates aerosols with blood and should be avoided. A nurse specifically trained in infection control was required to supervise the removal of personal protective equipment. N95 masks were considered safe when performing tracheotomy in patients affected by severe acute respiratory syndrome (SARS) [3, 4] . We note that the neck of the surgeons was not completely covered during the procedure. Complete gowning to cover the whole body of medical/nursing staff should be preferred, if available. However, an incapacity to rapidly respond to the widespread epidemic can cause an unavailability of adequate protective gear in hospitals. Therefore, immediately after the procedure, the surgeons thoroughly disinfected their necks with alcoholic gel and took a shower. Careful removal of personal protective equipment with supervision Take a shower * Shoe covers, cap, N95 (or N99 if available) mask, goggles, plastic full-face shield, goggles, waterproof disposable gown (complete gowning to cover the whole body should be preferred), double gloves. The surgeons must also wear sterile gown and gloves. A Novel Coronavirus from Patients with Pneumonia in China Safe tracheostomy for patients with severe acute respiratory syndrome Tracheostomy in a patient with severe acute respiratory syndrome We want to thank all the medical and nursing staff taking care to patients affected by Journal Pre-proof J o u r n a l P r e -p r o o f