key: cord-1032726-zefwsphc
authors: Wiesel, Ory; Shaw, Jason P.; Brichkov, Igor; Preis, Michal; Lagmay, Victor
title: Surgical Novelty During Pandemic: Keep It Safe and Simple
date: 2020-09-11
journal: J Am Coll Surg
DOI: 10.1016/j.jamcollsurg.2020.08.733
sha: 3f0b1e9f08840d3a101a6cd61ca60771328b773d
doc_id: 1032726
cord_uid: zefwsphc

nan

We read with great interest Foster and colleagues' 1 description of a modified method for open tracheostomy to mitigate procedural aerosolization and the risk of nosocomial infection in a patient with SARS-CoV-2. However, based on our experience with more than 70 tracheostomies performed over 5 weeks inclusive of the pandemic peak, we had little to no difficulty in executing historically standard tracheostomy techniques coupled with high-level barrier precautions recently advocated by both national and international advisory groups. 2, 3 At our institution, which is one of several New York City tertiary care academic medical centers posting a high census of mechanically ventilated COVID-19 patients (>180 during the surge), we adopted a specialized 2-team approach for timely tracheostomy, which balanced both patient and operator safety concerns with responsible use of available personal protective equipment (PPE). Briefly, bedside percutaneous tracheostomies were performed in the intensive care units, preferably in negative-pressure rooms, and using bronchoscopic guidance. Open tracheostomies were performed in dedicated negative-pressure operating rooms, without patient bed exchange, in order to minimize the shared risk of contamination, including ventilator circuit disruption. Regardless of technique, the number of at-risk participating staff was minimized, and all surgeons and anesthesiologists were outfitted with standard PPE as well as a personal air purifying respirator (PAPR) when appropriate, as per CDC guidelines. 4 In each circumstance, standard surgical site preparation was performed, routine instrumentation was used, and full paralysis was provided for every patient.

Intraoperatively, vacuum-suctioning was used sparingly. Entry into the trachea was announced by the surgeon to allow for less essential personnel to briefly exit the room at the time of near-coincidental oral extubation and tracheostomy tube placement. To date, there have been no reported COVID-19 infections in our team staff using this protocol.

Historical open and percutaneous airway techniques and existing safeguards remain practical and relevant, even under the current duress of the pandemic crisis. Minimizing procedure personnel, using paralytic agents, economizing suction evacuation, and above all, communicating with anesthesia and nursing staff appear to be the key drivers in limiting COVID-19 transmission at our center. There is no surgical protocol that completely eliminates the risk of infection from aerosolized SARS-CoV-2 during tracheostomy. Preservation of essential hospital resources, including human, is a priority for the foreseeable future. To that end, we acknowledge the important contribution of surgical improvisation by well-intentioned operators, and advocate the usual caution in adopting any novel, but unvalidated, technique.

Novel approach to reduce transmission of covid-19 during tracheostomy

Surgical considerations for tracheostomy during the COVID-19 pandemic: lessons learned from the severe acute respiratory syndrome outbreak

Guidance for surgical tracheostomy and tracheostomy tube change during the COVID-19 Pandemic

Clinical management of critically ill adults with COVID-19

Combined_Critically-Ill-Adults-COCA 4.2.2020.pdf. Accessed

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2020 by the American College of Surgeons