A total of 55 cases of open surgical tracheostomies were performed till September 2020 in the COVID ICU of All India Institute of Medical Sciences (AIIMS), Patna. Open surgical tracheostomy was preferred over percutaneous tracheostomy in view of -
- The chances of de-recruitment and atelectrauma-associated pulmonary edema due to transient loss of PEEP while performing tracheostomy in ARDS patients is high.4 The total duration of transient loss of PEEP during tracheotomy and tube insertion was less in open surgical tracheostomy compared to percutaneous tracheostomy (PCT).
- Open surgical tracheostomy is a cost-effective procedure as it does not involve using special equipment requirement of percutaneous tracheostomy.
- Majority of the severe COVID 19 patients on prolonged ventilation have been found to have a deranged coagulation profile to hepatic involvement. An open surgical approach provides better surgical field visualisation, hence minimizing peri-operative blood loss.
As per the WHO guidelines, a designated COVID- 19 Operating Room (OR) would require a separate ventilation circuit from the OR COMPLEX with Bio Safety Level (BSL) 3 or above norms with negative pressure suction unit, isolated green corridors for patient transit and Anaesthetic bay. However, there are practical difficulties while shifting an intubated COVID patient to OR due to increased risk of environmental contamination as well as associated increased risk of viral exposure to the shifting team. This would require more manpower in terms of personnel handling shifting, receiving and sanitization. This eventually translates into increased Personal Protective Equipment (PPE) requirement which is always a matter of concern in view of the pandemic situation. Apart from this, to provide a single OR from a pre-established Modular Operating Theatre (OT) complex with isolated room ventilation and negative pressure suction room would be cumbersome in the least. These factors directed our preference towards performing bedside tracheostomy in all these COVID patients requiring the procedure.
Performing bedside tracheostomy, however came with its own set of challenges. ICU beds were broad with restricted height adjustments. There was a lack of dedicated overhead operating light source on each bed. This overall had a detrimental effect not only in terms of patient positioning but also increased direct exposure to the aerosols generated during the procedure due to bad spinal angle of the operating surgeon leading to aggravated bending towards the patient. With full gear PPE, visualisation is already compromised due to increased fogging. This combined with an uncomfortable surgeon’s posture and inadequate lighting further compounded the problem.
All these above mentioned issues were overcome by a simple modification – Bedside tracheostomy on an OT table (Figure 1). We devised the idea of shifting a portable operating table, and portable operating light to the patient’s bedside. This had the following advantages:
a. Reduced Viral Exposure–
Shifting an operating table by the bedside rather than shifting the patient to the operating room had a major advantage of exposing minimal number of health care workers to viral laden aerosols. Shifting the patient from their ICU bed to an adjacent bed requires minimal man power and less aerosol exposure due to less physical distance covered for shifting the patient. Shifting these intubated patients to OR involves disconnecting patient off from the main ventilatory circuit and shifting them on the Bain circuit where ventilation is performed manually by the anaesthetists. This is a potentially hazardous situation where aerosols are expelled at a much greater speed and can infect people all around. Thus an operating table by the side of ICU bed was one of the most feasible thing to do at that time.
b. Better surgical environment–
Availability of a portable OT light with sterile handles which can be manoeuvred by the surgeon, provides improved focussed surgical field lighting. This is crucial in situations such as a deep seated trachea which may be due to restricted neck extension in cases of cervical injuries, obese patients, and patients with a deviated trachea. Fashioning a bedside portable OT table excludes the need of COVID-19 OR changes that would otherwise have to be implemented. The ability to adjust height and position of the OT table also improves field visualisation dramatically.
c. Better posture of operating surgeons –
Adjustable height and surgical position functions of these portable OT tables provide better spinal angle and posturing for the operating surgeon and hence adds to her/his comfort. They can avoid unnatural bending towards the patient which in turn prevents direct aerosol exposure on to their faces. The need for precise surgical steps as well as timely surgical decision is affected by surgeon’s fatigue status, which can be controlled by providing an optimal, posture to the operating surgeons. This is fulfilled better by a bedside operating room setup.
d. Better appreciation of anatomical structures–
Improved lighting of the surgical field provides better visualisation and appreciation of anatomical structures despite hampered visibility during PPE use. This can affect the final outcome in terms of surgical precision, operating time, intraoperative bleeding and perioperative complications. All this eventually contributes to decreased exposure time for the operating surgeon.
e. Better patient outcomes-
The incidence of atelectrauma and other transport associated complications are less owing to not requiring the patient to be disconnected from the ventilator for tracheotomy. This also aids in a better surgical outcome.
f. A resource efficient & cost effective alternative–
Performing a bedside tracheostomy avoids need for a major OR modification, reduces the need for manpower, and subsequent PPE resource usage. Open surgical tracheostomy is cost effective in comparison to percutaneous tracheostomy as it does not require single-use PCT instrumentation set costing about INR Rs 7000-10,000.
Along with above surgical environment modifications, certain changes needed to be incorporated in the surgical steps of open tracheostomy. Most of the steps were in accordance with international guidelines given by various international bodies of Otolaryngology, Anaesthesia and Critical care. Few steps were improvised/added to protect the surgeons from undue aerosol exposure.
Modified surgical Steps for COVID tracheostomy: