Emergent tracheostomy during the pandemic of COVID-19: Slovenian National Recommendations

Abstract

Purpose Emergent tracheostomy under local anaesthesia is a reliable method of airway management when orotracheal intubation is not possible. COVID-19 is spread through aerosol making the emergent tracheostomy a high-risk procedure for surgeons. The surgical establishment of the air conduit in emergency scenarios must be adjusted for safety reasons. Methods To establish the Slovenian National Guidelines for airway management in cannot intubate-cannot ventilate situations in COVID-19 positive patients. Results Good communication and coordination between surgeon and anaesthesiologist is absolutely necessary. Deep general anaesthesia, full muscle relaxation and adequate preoxygenation without intubation are initial steps. The surgical cricothyrotomy is performed quickly, the thin orotracheal tube is inserted, the cuff is inflated and ventilation begins. Following patient stabilisation, the conversion to the tracheostomy is undertaken with the following features: skin infiltration with vasoconstrictor, a vertical incision, avoidance of electrical devices in favour of classical manners of haemostasis, the advancement of the tube towards the carina, performing the tracheal window in complete apnoea following adequate oxygenation, the insertion of non-fenestrated canulla attached to a heat and moisture exchanger, the fixation of canulla with stitches and tapes, and the cricothyrotomy entrance closure. Appropriate safety equipment is equally important. Conclusion The goal of the guidelines is to make the procedure safer for medical teams, without harming the patients. Further improvements of the guidelines will surely appear as COVID-19 is a new entity and there is not yet much experience in handling it.

Features of mastering practical skills by students during the COVID-19 pandemic using simulation training methods

“…That is why it was implemented in the curriculum of all senior students and interns of all specialties in Odessa National Medical University [10,11,12].…”

Emergency surgical tracheotomy in the era of COVID-19 pandemic

“…The wound is then closed around the cannula with interrupted silk stitches. retraction of the borders of the wound and visualization of the surgical field, with the only disadvantage of worst cosmetic results once the tracheostomy has been removed [33].…”

“…Indications to elective tracheotomy in COVID-19 patients. • Improve management of patients in non-intensive departments manipulation of the airway should be minimized as much as possible, some authors suggest proceeding to formal tracheotomy straight afterward a rescue airway has been obtained by surgical CT [33,43]. This recommendation is supported by the evidence that, once the critical situation has been relieved by emergency CT, conversion to tracheotomy can be carried out without any pressing need, taking care of both patient and clinician safety, and thus avoiding the additional risks associated with a later staged second procedure [33].…”

“…• Improve management of patients in non-intensive departments manipulation of the airway should be minimized as much as possible, some authors suggest proceeding to formal tracheotomy straight afterward a rescue airway has been obtained by surgical CT [33,43]. This recommendation is supported by the evidence that, once the critical situation has been relieved by emergency CT, conversion to tracheotomy can be carried out without any pressing need, taking care of both patient and clinician safety, and thus avoiding the additional risks associated with a later staged second procedure [33]. Nevertheless, in a recent editorial, Mesolella endorsed an even more dynamic approach, suggesting upfront OST whenever ESA is needed in case of ETI failure in patients with documented or unknown SARS-CoV-2 positivity to avoid the unnecessary exposure of the involved personnel to the risk of infection carried by multiple procedures [54].…”

“…Despite the magnitude of the problem of the lost airway in COVID-19 patients, international recommendations addressing OST procedure in detail are still lacking. Since the beginning of the SARS-CoV-2 outbreak, Slovenian national guidelines are to date the only ones available with specific indications for the safe management of CICO scenario with OST in patients with documented or suspected infection by novel coronavirus [33]. Nevertheless, the expertise gained during the SARS emergency in 2002 constitutes precious evidence to build up a baseline, with particular regard to healthcare workers' protection [45].…”