What the Anesthesiologist Should Know before the Operative Procedure
Tracheostomy is performed to provide an airway alternative to orotracheal or nasotracheal intubation. Frequently it is an elective procedure for patients requiring prolonged intubation who have a stable airway in place. Tracheostomy may also be performed as the primary airway access in patients with a difficult or threatened upper airway or those who are about to have surgery on their larynx or upper trachea.
1.What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
The risk of delay in tracheostomy varies greatly by indication, spanning an urgency of minutes to days. Clearly, if the airway cannot be obtained and spontaneous ventilation is precluded, anoxic brain damage will quickly ensue.
Emergent:Tracheostomy, along with variants percutaneous tracheostomy and cricothyroidotomy, fall under “Emergent Invasive Airway Access” as a rescue option in the ASA’s Difficult Airway Algorithm.
Urgent: For a threatened airway, the urgency depends on the underlying condition. Swelling from angioedema or expanding airway hematoma has greater urgency than progression of a laryngeal tumor or neuromuscular disease.
Elective:In a patient with a stable airway, the risk of delay is small. Studies in trauma patients with anticipated prolong respiratory support found small benefits to early (less than 7 days) versus late conversion of orotracheal intubation to tracheostomy. Benefits include earlier ICU discharge, easier oral care, and patient comfort. In patients with anticipated difficult airway, elective tracheostomy (or tracheostomy as a backup plan) has the urgency of the underlying procedure. In that case, full evaluation and backup equipment and personnel should at hand.
2. Preoperative evaluation
The most critical factors to evaluate are airway anatomy and the stability of the patient to withstand the transition period between current airway management and ventilation via the tracheostomy.
In the emergent situation, the only factors for evaluation are the best technique for restoring oxygenation. These include:
Open tracheostomy or cricothyroidotomy
Orotracheal intubation or Laryngeal Mask Airway
Restoring spontaneous ventilation, possibly with BiPAP, Heliox, and patient positioning
Non-emergent tracheostomy should be re-evaluated if there is pathology at the site of the incision.
Elective tracheostomy for ICU patients should be delayed depending on:
acute decompensation of hemodynamic status
very high ventilatory requirements
3. What are the implications of co-existing disease on perioperative care?
Upper airway assessment should proceed in a standard fashion (e.g. using the guidelines from the ASA algorithm).
Subglotic airway anatomy can be assessed by imaging studies and prior airway exams.
b. Cardiovascular system
Tracheostomy is considered a low risk procedure with respect to cardiovascular risk assessment. Performing the procedure in patients with coronary stents and on antiplatelet agents should be discussed with the surgeon and physician supervising the patient’s cardiac management. It may be possible to perform a tracheostomy without reversing anticoagulation.
Acute/unstable conditions: In non-emergent situations, acute changes in hemodynamic status should be addressed.
Patients with coronary stents and antiplatelet agents should be discussed with the surgeon and physician supervising the patient’s cardiac management. It may be possible to perform a tracheostomy without reversing anticoagulation.
Baseline coronary artery disease or cardiac dysfunction – Goals of management: Manipulation of the trachea it very stimulating. Transient increases in systemic blood pressure, heart rate, carbon dioxide, and pulmonary artery resistance may occur.
In general COPD is not a contraindication to tracheostomy. There is the risk of iatrogenic hyperventilation and air trapping with resulting hemodynamic compromise.
ii. Reactive airway disease (Asthma)
Manipulation of the airway is a potent stimulus to bronchospasm in general. However, converting from an endotracheal tube to tracheostomy probably will not significantly exacerbate bronchospasm.
No specific considerations.
Tracheostomy is frequently performed on patients with severe neurological issues to aid long term management and protect the airway. In the acute phase, there is a transient increase in ICP with airway manipulation. Techniques to monitor and mitigate this increase (brief hyperventilation) may be indicated.
Tracheostomy may also be indicated for patients with progressive neuromuscular disease (including ALS and Myasthenia Gravis) to allow ventilatory support. Considerations of a tracheostomy tube, ventilator, and long term management should be addressed.
No specific considerations.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
Access the trachea is best accomplished with neck extension in the midline. Conditions that limit access to the neck or movement of the neck, and a tumor, vessel, or infection over the site of the trachea will complicate the planning and execution of tracheostomy.
4. What are the patient's medications and how should they be managed in the perioperative period?
Typically, most medications are continued unchanged. Anticoagulants should be discussed with the surgeon. Usually a mild coagulopathy can be easily managed. Tube feedings should be discontinued for a period prior to the procedure to reduce the risk of passive reflux and aspiration.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
Patients current being ventilated have a higher FiO2. It is safest to increase the FiO2 transiently during the transition between an endotracheal tube and tracheostomy.
i. What should be recommended with regard to continuation of medications taken chronically?
Anti-platelet: Discuss with surgeon. Typically continue.
j. How To modify care for patients with known allergies –
Most patients undergoing tracheostomy are already being treated with antibiotics and supportive medicines, which should be continued. Otherwise avoid known allergic triggers.
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Confirm that the tracheostomy tube and the dressings and strap are latex-free. Avoid latex-containing products in the surgical field. Take precautions when drawing up IV drugs with latex vial stoppers.
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
m. Does the patient have a history of allergy to anesthesia?
5. What laboratory tests should be obtained and has everything been reviewed?
There are no specific laboratory tests required for tracheostomy. Typically coagulation, hemodynamic stability, and the ability to survive a brief interruption in ventilation are the main concerns. If the anatomy cannot be easily palpated, or if there is question about the condition of the distal trachea, imaging, including CT of the neck and fiberoptic exam of the trachea, is indicated.
Common laboratory normal values will be the same for all procedures, with a difference by age and gender.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
a. Regional anesthesia
Regional anesthesia is an appropriate technique for both open and percutaneous tracheostomy. Local infiltration of the neck and transtracheal instillation of local anesthetic will be adequate.
Difficulties with regional anesthesia include patient cooperation and their ability to tolerate neck extension, a supine position, and rather vigorous tracheal manipulation.
Regional anesthesia as the sole modality is most common in patients with impending airway loss (tumor, infection), or where the ability to orally intubate the patient is compromised.
b. General Anesthesia
For patients already intubated, general anesthesia is the easier technique. Typically patients are already heavily sedated and receiving ventilatory support, so the transition to a complete general anesthetic is minor.
Benefits- Cooperation and positioning is easier. The patient can tolerate a longer period of apnea if there is difficulty advancing the tracheostomy tube.
Drawbacks- If spontaneous ventilation needs to be suppressed and the patient paralyzed, it is less safe if the tracheostomy is unsuccessful. Deeper general anesthesia commonly has a hemodynamic cost. In ICU patients, this may require an increase in vasopressor support.
Other issues- If the patient has marginal respiratory function, or the procedure is performed in the ICU, there may not be an anesthesia machine available. Using IV anesthetics and having a method of CO2 measurement for confirmation of ventilation should work.
Airway concerns- This is paramount.
When the airway is first entered, the endotracheal tube cuff should be deflated to lessen the risk of puncture. Typically the cuff will be reinflated and a period of ventilation performed after this point to allow for a greater margin of safety for the actual tracheostomy insertion.
The endotracheal tube will need to be pulled back proximally to allow for tracheostomy insertion. Avoiding complete extubation allows for easy reintubation if the tracheostomy insertion is difficult.
Secretions, bleeding, and prior injury or anatomical problems can make ventilation more difficult and make it harder to determine proper positioning of the tracheostomy tube.
c. Monitored Anesthesia Care
See the regional anesthesia section above.
6. What is the author's preferred method of anesthesia technique and why?
What prophylactic antibiotics should be administered? Skin flora.
What do I need to know about the surgical technique to optimize my anesthetic care?
There are two main approaches to tracheostomy: open and percutaneous. Percutaneous is typically done with fiberoptic confirmation of guidewire placement, and the anesthesiologist may be the one wielding the bronchoscope. Open technique requires some caution with electrocautery in the presence of high oxygen concentrations. In both cases, the position of the tracheostomy should be confirmed by CO2 and compliance before the endotracheal tube is removed.
What can I do intraoperatively to assist the surgeon and optimize patient care? Suctioning the oropharynx before deflating the endotracheal tube cuff. Hyperventilating and using increased FiO2 just prior to the transition.
What are the most common intraoperative complications and how can they be avoided/treated? Prioritize them by urgency.
Loss of airway. The new endotracheal tube can be introduced into tissue planes and not the trachea. Rapid recognition, communication, and conversion back to endotracheal ventilation is the treatment. The hole in the trachea will need to be covered by the surgeon’s finger, and subcutaneous air is not unexpected.
Bleeding superficially at the site of insertion is treatable by standard surgical techniques. The tracheostomy tube flange may make access more difficult, and coordination between the surgeon and anesthesiologist is important.
Injury to the posterior tracheal wall. At worst, a tracheo-esophageal fistula is possible. Position the tracheostomy cuff distal to the injury, and plan definitive repair when the situation is stable.
b. If the patient is intubated, are there any special criteria for extubation?
Tracheostomy can be reversed when full recovery of ventilation and airway patency has occurred.
c. Postoperative management
What analgesic modalities can I implement?
The tracheostomy incision typically causes only minimal pain. Non-steroidal analgesics, mild narcotics, or local infiltration are all appropriate solutions. Any airway device is initially very stimulating. If the patient was previously intubated with an endotracheal tube, there should be no additional discomfort. Even discomfort from a new tracheostomy will rapidly attenuate unless there is a lot of movement or traction on the device.
What level bed acuity is appropriate?
There are 3 components to assessing a post-tracheostomy patient’s disposition. In general, one of the goals of tracheostomy is to facilitate transfer of the patient from the ICU setting.
Ventilatory support: The need for mechanical ventilation and supplemental oxygen, PEEP, and airway toilet will be unchanged. The pace of ventilation weaning may be temporarily set back by the anesthetic and procedure. This is typically in an ICU, specialized hospital floor, or a specialized nursing facility.
Risk of extubation: Until the tracheostomy track is well established (typically one week of more), there is considerable danger if the tracheostomy is dislodged. Staff in the postoperative setting must have personal experience in handling a tracheostomy and be able to acutely diagnose and manage tracheostomy dislodgment. Typically a hospital ward or nursing facility is trained to manage tracheostomy patients.
Acute airway problem: Bleeding at the site of the tracheostomy, problems with fit of the tracheotomy (pressing into membranous wall, carina, or cuff problems), or secretions and blood clots obstructing ventilation can all occur in the immediate post-operative setting. Observation in the recovery room or ICU for a variable period (an hour or more) is warranted.
What are common postoperative complications, and ways to prevent and treat them?
Bleeding at the site of tracheostomy. Managed with clotting factors, re-exploration and cautery, or additional hemostatic sutures. Late erosion into the innominate artery is a life-threatening injury.
Erosion into the innominate artery. Should be part of the surgical consideration of placement. Acute and potentially lethal complication. Requires distal intubation and immediate surgical exploration.
Injury to the trachea occurs from pressure and ischemia to the trachea mucosa and cartilage. This is more common in cuffed tracheostomy tubes, and higher cuff pressures, especially when the patient has long periods of marginal perfusion due to underlying conditions. Stenosis at the site of the stoma or cuff in not uncommon. The preceding period of endotracheal intubation also contributes to the tracheal injury.
What's the Evidence?
“Timing of tracheostomy. Durgin CG Tracheostomy: why, when, and how?”. Respir Care. vol. 55. 2010 Aug. pp. 1056-68. (A comprehensive review of tracheostomies in the ICU population, including methodology and results of investigations as to optimal timing.)
Pappas, Sotirios, Maragoudakis, Pavlos, Vlastarakos, Petros, Assimakopoulos, Dimitrios, Mandrali, Thomi, Kandiloros, Dimitrios, Thomas, P., Nikolopoulos. “Surgical versus percutaneous tracheostomy: an evidence-based approach”. Eur Arch Otophinolaryngol. vol. 68. 2011 Mar. pp. 323-30. (A medline search of publications on surgical versus percutaneous tracheostomies documented a paucity of studies with type I evidence, suggesting that the choices are not based on particularly convincing evidence.)
O’Connor, HH, White, AC. “Tracheostomy decannulation”. Respir Care. vol. 55. 2010 Aug. pp. 1076-81. (Discusses decannulation of tracheostomies.)
Talving, P, DuBose, J, Inaba, K, Demetriades, D. “Conversion of emergent cricothyrotomy to tracheotomy in trauma patients”. Arch Surg. vol. 145. 2010 Jan. pp. 87-91. (There is no data supporting conversion to tracheostomy; the manuscript discusses this issue.)
Engels, PT, Bagshaw, SM, Meier, M, Brindley, PG. “Tracheostomy: from insertion to decannulation”. Can J Surg. vol. 52. 2009 Oct. pp. 427-33. (Review of steps placing percutaneous tracheostomy and management.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1.What is the urgency of the surgery? What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management