EXPERIENCE OF SURGICAL TRACHEOSTOMY IN COVID-19 HOSPITAL

Objective: To share our experience of tracheostomy in COVID-19 positive patients. Study Design: Prospective observational study. Place and Duration of Study: Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Apr to Jul 2020. Methodology: A total of 94 COVID-19 positive cases admitted to the Intensive Care Unit of this hospital, placed on ventilatory support and who ultimately underwent tracheostomy (whether percutaneous or surgical) were included in the study. Patients were included irrespective of any age group or gender. Results: Out of 94 patients placed on ventilator, tracheostomy was performed only in 17 patients. Male predominance was 13 (76%), with mean age of patients as 55.59 ± 12.93 in 12 patients, surgical tracheostomy was performed (70.58%) whereas in 5 (29.4%) cases percutaneous tracheostomy was done. On post-operative follow-up 8 out of 17 (47%) patients recovered and were successfully decannulated whereas 9 (52.9%) patients could not survive. Tracheostomy was successfully performed as early as 8th day of mechanical ventilator support. Health Care Workers (HCWs) involved were subjected to RT-PCR and remained negative for SARS- CoV-2. There was statistically significant association between the type and indication oftracheostomy, p=0.002. Conclusion: Tracheostomy, in COVID-19 positive patients, being aerosol- generating procedure remains a medical hazard for the HCWs. By following strict safety protocols according to the medical resources available and training of the HCWs, it can be performed with complete safety. It can be done as early as 8th day of ventilator support.

Unanticipated Difficult Airway Management in a Trauma Partient with Severe Ankylosing Spondylitis

Ankylosing Spondylitis is a debilitating chronic arthropathy that affects multiple joints. Anaesthesiologists face significant challenges when dealing with the airway implications of this disease, especially when it is unanticipated that a difficult airway may be encountered. This case describes a 42-year-old trauma victim who required an emergency denitive trachea at his ward. Ankylosing Spondylitis and complex airway anatomy led to his intubation failure. He was eventually given an emergency surgical tracheostomy. The successful management of a difficult airway was possible thanks to the appropriate use of modern airway adjuncts as well as workplace soft skills.

1558 Epiglottic Abscess: A Rare Complication of Adult Epiglottitis

This report summarises a case of a 23-year-old female who was found to have an epiglottic abscess, an unusual complication of epiglottitis not commonly reported in the literature. Despite the reduced incidence of childhood epiglottitis following widespread Haemophilus Influenzae vaccination, the adult incidence is nonetheless increasing, which would lead to expected higher numbers of resultant complications. Abscess formation should form part of the differential diagnosis when epiglottitis fails to adequately respond to medical management. In these cases, cross-sectional imaging is often required in order to guide surgical management. This involves endoscopic transoral incision and drainage under general anaesthesia, which here brought rapid resolution. Perioperative support of the anaesthetic team is vital: if endotracheal intubation is not possible, a surgical tracheostomy may be required. We reaffirm that endoscopic examination by experienced personnel is appropriate in the initial and ongoing investigation of supraglottic laryngeal infections in order to make a diagnosis and evaluate an airway in stable patients. Such patients must be managed on a ward with airway trained nursing staff and an escalation plan in case of airway compromise. In patients that present in airway obstruction, airway stabilization, with early input from ENT surgeons and anaesthetists, is the priority.

Multidisciplinary Simulation Training for Surgical Tracheostomy in Patients Mechanically Ventilated Secondary to Severe Acute Respiratory Syndrome Coronavirus 2

Objective: A proportion of patients with coronavirus disease (COVID) and severe respiratory manifestations of disease will require admission to intensive care for intubation and ventilation. When anticipating prolonged ventilation, the patient may proceed to surgical tracheostomy to afford safe respiratory wean. As surgical tracheostomy is an aerosol-generating procedure, it poses a high risk of viral transmission and ultimately may prompt anxiety and caution in participating staff members. We aimed to mitigate these risks by providing staff with appropriate training and experience, to improve their confidence as well as practical ability. Methods: We developed a multidisciplinary simulation training experience and checklist in order to optimize team performance during the high-stakes procedure. We evaluated staff confidence before and after the training with questionnaires. Results: Post-simulation, surgeons were more confident with donning the high level personal protective equipment, and nurses were more confident in performing their role. Conclusions: Simulation allows the multidisciplinary team an opportunity to practice high-risk procedures and prompts the team to assess staff knowledge base, troubleshoot queries, and teach roles and responsibilities in a safe environment. In the context of COVID-19, simulation encourages staff sense of preparedness and protection for true participation during a high-risk procedure.

UNANTICIPATED DIFFICULT AIRWAY MANAGEMENT IN A TRAUMA PATIENT WITH SEVERE ANKYLOSING SPONDYLITIS

Ankylosing spondylitis is a chronic debilitating arthropathy affecting multiple joints in the body. Airway implications related to the disease pose a signicant challenge to the anaesthesiologists especially when an unanticipated difcult airway is encountered. A case of 42 year old trauma victim who needed an emergency denitive airway at ward set up, is reported here. Failed intubation due to complex airway anatomy associated with ankylosing spondylitis ensued him being ended up with an emergency surgical tracheostomy. Appropriate use of newer airway adjuncts and workplace soft skills contributed to successful management of an unanticipated difcult airway.

Safety of surgical tracheostomy under continued antithrombotic therapy

Objective: Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains a challenge. We investigated the risk factors for complications after ST by focusing on CAT use during ST. Method: Patients’ medical records from 2009 to 2020 were reviewed in this retrospective study. We selected patients who underwent ST at the Department of Otolaryngology of the University of Tokyo Hospital. Patient demographics, complications, and blood test values were recorded and statistically analyzed to identify the risk factors for postoperative complications. Results: We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly higher values of activated partial thromboplastin time (p = 0.002) and prothrombin time-international normalized ratio (p = 0.006) than those of antithrombotic naïve patients, no statistically significant intergroup differences were observed in the risks of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p = 0.01) and ST for airway emergency (p = 0.02) significantly increased the risk of early postoperative complications. Conclusion: The results of the present study suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergency. Key points: 1. We aimed to investigate the risk factors for complications after ST by focusing on CAT use during ST. 2. Patients undergoing CAT had significantly higher values of APTT and PT-INR than those of antithrombotic naïve patients. 3. ST under CAT can be safely performed without any increased risk of postoperative complications. 4. ST under local anesthesia and airway emergency was a risk factor for complications after ST. 5. Among the complications, subcutaneous emphysema was significantly more frequent in ST under local anesthesia and under airway emergency.

O47 Safe delivery of surgical tracheostomies in COVID-19 patients during the pandemic

Introduction During the corona virus disease (COVID-19) pandemic, frontline units worldwide faced the challenging task of providing high-risk services (like surgical tracheostomy) while safe-guarding the very people performing the high risk procedures. The aim of our study was to assess the incidence of COVID-19 infection among staff involved in surgical tracheostomy on COVID-19 patients Method A surgical tracheostomy protocol and operation theatre modifications were put in place at our centre, dictated by local resources, staff availability and previous tracheostomy experience. Between 26/03/2020 and 27/05/2020, staff participating in 71 tracheostomy procedures were sent a questionnaire. The presence of COVID-19 symptoms (new onset continuous cough, fever, loss of taste and/or loss of smell) in tracheostomy staff and patient related data were analysed. Result Among the responders (72/122), compliance with personal prophylaxis equipment use was 100%. Eleven (15%,11/72) reported key COVID-19 symptoms and self-isolated. 10 had a COVID-19 swab test and three tested positive. One staff attended (1/72) hospital for symptomatic treatment, none required hospitalisation. 43/72 staff (60%) underwent a COVID-19 antibody test, 18.6% (8/43) were positive. Among the tracheostomised patients, the mean age was 58 years(29–78) and 65.5% were males. The median time from intubation to ST was 15 days (range 5–33, IQR = 9). There were no tracheostomy related deaths and overall mortality was 11%(6/55). Conclusion Safe delivery of tracheostomy during a pandemic like COVID-19 is possible with strict adherence to personnel protective equipment, surgical protocols and regulation of traffic flow in theatres to mitigate the potential transmission of COVID-19 among surgical staff. Take-home Message Compliance with PPE, adherence to tracheostomy protocol and local modifications can mitigate potential COVID-19 transmission among health care personnel.

Tracheostomy Timing and Outcome in Severe COVID-19: The WeanTrach Multicenter Study

Background: Tracheostomy can be performed safely in patients with coronavirus disease 2019 (COVID-19). However, little is known about the optimal timing, effects on outcome, and complications. Methods: A multicenter, retrospective, observational study. This study included 153 tracheostomized COVID-19 patients from 11 intensive care units (ICUs). The primary endpoint was the median time to tracheostomy in critically ill COVID-19 patients. Secondary endpoints were survival rate, length of ICU stay, and post-tracheostomy complications, stratified by tracheostomy timing (early versus late) and technique (surgical versus percutaneous). Results: The median time to tracheostomy was 15 (1–64) days. There was no significant difference in survival between critically ill COVID-19 patients who received tracheostomy before versus after day 15, nor between surgical and percutaneous techniques. ICU length of stay was shorter with early compared to late tracheostomy (p < 0.001) and percutaneous compared to surgical tracheostomy (p = 0.050). The rate of lower respiratory tract infections was higher with surgical versus percutaneous technique (p = 0.007). Conclusions: Among critically ill patients with COVID-19, neither early nor percutaneous tracheostomy improved outcomes, but did shorten ICU stay. Infectious complications were less frequent with percutaneous than surgical tracheostomy.