key: cord-0851895-sy8tasri authors: Hiramatsu, Mariko; Nishio, Naoki; Ozaki, Masayuki; Shindo, Yuichiro; Suzuki, Katsunao; Yamamoto, Takanori; Fujimoto, Yasushi; Sone, Michihiko title: Anesthetic and surgical management of tracheostomy in a patient with COVID-19 date: 2020-04-18 journal: Auris Nasus Larynx DOI: 10.1016/j.anl.2020.04.002 sha: dbcdc705e543fe371df7bcf18974de18e1f0ec39 doc_id: 851895 cord_uid: sy8tasri Abstract The ongoing pandemic coronavirus disease-2019 (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare. Since COVID-19 spreads through contact and droplet infection routes, careful attention to infection control and surgical management is important to prevent cross-contamination of patients and medical staff. Tracheostomy is an effective method to treat severe respiratory dysfunction with prolonged respiratory management and should be performed as a high-risk procedure. Strict precaution and sufficient use of muscle relaxants are essential during tracheostomy to minimize cross-contamination among healthcare workers in the hospital. Here, we describe the anesthetic and surgical management of tracheostomy in a patient with COVID-19. Ever since a cluster of patients with pneumonia of an un-2 known cause was linked to a seafood wholesale market in 3 Wuhan, China in December 2019, an outbreak of the novel 4 coronavirus (severe acute respiratory syndrome coronavirus 5 2; SARS-CoV-2) has led to a pandemic of coronavirus dis- 6 ease 2019 (COVID-19) [1] . After the World Health Orga-7 nization (WHO) upgraded the status of the outbreak from 8 epidemic to pandemic on March 11, 2020, the number of pa- 9 tients with COVID-19 has rapidly increased in many countries 10 worldwide. Patients with severe COVID-19 are likely to be 11 considered for tracheal intubation and mechanical ventilation 12 to support potential recovery from the illness, and in 4 -5% 13 * Corresponding author. E-mail address: hmariko@med.nagoya-u.ac.jp (M. Hiramatsu). of such patients, invasive mechanical ventilation is required 14 [2 , 3] . 15 To avoid in-hospital infection with COVID-19 among 16 healthcare workers, appropriate and strict infection prevention 17 is essential, particularly in aerosol-generating medical proce-18 dures such as tracheal intubation, bronchoscopy, cardiopul-19 monary resuscitation, and tracheostomy [4] . When perform-20 ing tracheostomy in a patient with COVID-19, meticulous 21 attention should be paid to the details of anesthetic and sur-22 gical management of the tracheostomy to minimize cross-23 contamination and occupational infection among healthcare 24 workers in the hospital. Here, we report our experience with 25 anesthetic and surgical management in a patient with COVID-26 19 who underwent tracheostomy. To prevent aerosol generation of COVID-19 if the cuff 67 would be ruptured by surgical intervention, we examined the 68 chest radiograph before performing the tracheostomy and con-69 firmed that the intubation tube would be inserted up to 27 cm 70 deep from the mouth. After intravenous injection of 70 mg 71 rocuronium for muscle relaxation, 5 mg midazolam for seda-72 tion, and 100 -200 mg fentanyl for pain control, mechanical 73 ventilation was discontinued, and chest movement was con-74 firmed to stop by the anesthesiologist. Thereafter, the intu-75 bation tube was inserted up to 27 cm deep from the mouth, 76 and mechanical ventilation was immediately reinstated. Fi-77 nally, chest movement was confirmed without listening to 78 the patient's chest using a stethoscope. During tracheostomy, 79 0.2 mg/kg of rocuronium was added every half hour to prevent 80 patient movement and coughing. Before the tracheostomy, all members inside and outside 83 the isolation room confirmed that the equipment and surgical 84 devices were ready to use. By administering local anesthe-85 sia around the neck region, surgical tracheotomy was per-86 formed by two otolaryngologists. Before opening the trachea, 87 we confirmed that muscle relaxant action and oxygenation 88 were sufficient for the subsequent surgical procedures. The 89 ventilator was turned off immediately before tracheal incision 90 to avoid aerosol generation of blood or tracheal secretions. A 91 scalpel was used to incise the trachea to reduce the risk of air-92 way fire, and the trachea was opened between the second and 93 third trachea rings. After the trachea was opened, any elec-94 trosurgical device was not used to avoid the aerosolization of 95 Table 1 Tracheostomy protocol in a suspect or probable COVID-19 patient. the tracheostomy ranged from14 days-25 days [7 , 8] . The study was performed in accordance with the Helsinki 212 Declaration of 1975 and its amendments, and the laws and 213 regulations of the Japan. Written informed consent was ob-214 tained from the patients. 215 ANL [mNS A novel 217 coronavirus from patients with pneumonia in China Clinical features of 220 patients infected with 2019 novel coronavirus in Wuhan, China Epidemiolog-223 ical and clinical characteristics of 99 cases of 2019 novel coronavirus 224 pneumonia in Wuhan, China: a descriptive study Aerosol gener-227 ating procedures and risk of transmission of acute respiratory infections 228 to healthcare workers: a systematic review Natural ventilation for infection control in health-care settings. 231 Geneva: World Health Organization Epidemic and emerging coronaviruses (severe acute respira-233 tory syndrome and Middle East respiratory syndrome) Safe tracheostomy for patients 236 with severe acute respiratory syndrome Tracheostomy in a patient with 239 severe acute respiratory syndrome Rational use of personal protective equip-241 ment for coronavirus disease (COVID-19): Interim guidance, 27 Febru-242 ary 2020 Geneva ANL [mNS Interim 245 infection prevention and control recommendations for patients 246 with confirmed coronavirus disease 2019 (COVID-19) or per-247 sons under investigation for COVID-19 in healthcare settings Outbreak of a new coronavirus: what 251 anaesthetists should know Timing of tracheotomy 254 in ICU patients: a systematic review of randomized controlled trials Tracheostomy: epidemiology, indications, 257 timing, technique, and outcomes Infection control 259 measures for operative procedures in severe acute respiratory syndrome-260 related patients SARS 262 among critical care nurses