key: cord-0685944-6mwr23bl
authors: Valchanov, Dr Kamen; Salaunkey, Dr Kiran; Parmar, Dr Jas
title: Percutaneous Dilatational Tracheostomy in COVID-19 ECMO Patients: A Case Series
date: 2020-06-12
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2020.06.024
sha: e2a7c775ef8c74cb1570aa526f1791a1745fbce9
doc_id: 685944
cord_uid: 6mwr23bl

nan

The COVID-19 pandemic has devastated the world in 2020. Around 15% of the infected patients need intensive care(1). A small proportion of these patients could benefit from Extracorporeal Membrane Oxygenation (ECMO) (2) . Performing a tracheostomy on these patients is considered to be a high-risk aerosol generating procedure with implications for staff safety (3) . Guidelines to mitigate the risks associated with tracheostomy in COVID patients (4) have not reported actual experience but delay of the procedure (5) . The risk of bleeding is also higher in patients on ECMO who require tracheostomy (6) . Nevertheless tracheostomy can facilitate tracheal toilet, reduce sedative requirements, and decrease in duration of mechanical ventilation.

At the start of COVID Surge we established prospective tracheostomy database. We modified the procedure to reduce risk of aerosol spread to staff: 1. All procedures performed in the patient's own ICU isolation room; 2. Minimise the staff present (Table 1) . We are one of the five designated ECMO centres in the UK and received over 40 patients in the COVID-19 pandemic supported with ECMO.

The decision to perform the tracheostomy was taken by the duty day intensivist. The average time of tracheal intubation prior to tracheostomy was 11.66 days. The procedure was always successful.

Complications were minimal. No immediate complications such as pneumothorax or tracheostomy malposition was observed. No blood products transfusion was required due to tracheostomy bleeding, but 2 patients needed addition skin suture to stop skin bleed. We asked medical staff to report any sickness following the procedure. There no ill health reports or sick leave among medical staff relating to tracheostomy to date.

The tracheostomy was always by the percutaneous dilatational method by the bedside in an ICU with isolation rooms. Pre-prepared trolley with all equipment necessary for the operation was prepared in a sterile area outside ICU (Fig.1) . Family assent was obtained, WHO safe surgical checklist procedure was followed, and rescue airway equipment was placed outside the room prior to commencement. Full PPE included FFP3 facemask, visor, gown, gloves for tracheostomy team and bedside nurse.

In all patients the anaesthesia was by administration of Propofol infusion 1% at 4mg/kg/hr, which was already running usually at a lower rate. Muscle relaxation was by a single dose 50 mg atracurium or 50 mg rocuronium. Local anaesthesia with 10 ml 1% Lidocaine with 1:200000 Adrenaline was used for skin, subcutaneous tissues, and tracheal mucosa. Disposable Ambu BronchoscopeTM was used in all cases.

Ventilation was discontinued during withdrawal of the endotracheal tube, dilator exchange, and tracheostomy tube insertion. Ventilation was then resumed, and position confirmed bronchoscopically and via capnography. All tracheostomies were performed using TRACOE twist kit sizes 7-10. Skin incision with a scalpel was avoided if possible. More than half of the tracheostomies were performed by the same duo of operator-bronchoscopist.

In our previously published experience in this journal heparin infusions have to be routinely stopped 2-4 hours prior to the tracheostomy to avoid bleeding in ECMO patients. However, we found that COVID-19 patients are in hypercoagulable state (8) and anticoagulation does not need to be routinely stopped. APTT ratio of 1.5-1.8 was deemed safe for the procedure. One patient was receiving Argatroban due to Heparin induced Thrombotic Thrombocytopenia (HITT), and this was not discontinued. As our experience grew, in 15 patients anticoagulation not discontinued without bleeding complications.

Tracheostomy remains a valuable procedure for mechanically ventilated patients.

ECMO support allows discontinuing mechanical ventilation for a short period without further worsening of hypoxia, and therefore reduction of risk of aerosolization. We found that continuing anticoagulation during dilatational percutaneous tracheostomy for COVID-19 ECMO supported patients did not lead to bleeding complications.

Limiting the number of operators allows for concentration of expertise. 

Clinical Characteristics of Coronavirus Disease 2019 in China

Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations. The Lancet Respiratory Medicine

Performing tracheostomy during the Covid-19 pandemic: guidance and recommendations from the Critical Care and Acute Care Surgery Committees of the American Association for the Surgery of Trauma. Trauma Surgery & Acute Care Open

CORONA-steps for tracheotomy in COVID-19 patients: A staff-safe method for airway management

Tracheostomy in the COVID-19 era: global and multidisciplinary guidance. The Lancet Respiratory Medicine

Bleeding Complications Associated with Percutaneous Tracheostomy Insertion in Patients Supported with Venovenous Extracorporeal Membrae Oxygen Support: A 10-year Institutional Experience

Surgical Considerations for Tracheostomy during the COVID-19 Pandemic: Lessons Learned from the Severe Acute Respiratory Syndrome Outbreak

Incidence of thrombotic complications in critically ill ICU patients with COVID-19