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		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4141</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4141"/>
		<updated>2022-03-19T19:06:27Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheostomy tube (TT)&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy under general vs awake, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using dexmedetomidine, then converting to general when the tube is secured&lt;br /&gt;
| considerations_postoperative = Complications with the highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as in critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as reduce the need for sedation and improve overall patient comfort and airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a percutaneous tracheostomy, various procedure methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.&amp;lt;ref&amp;gt;{{Cite journal|last=Nates|first=Joseph L.|last2=Cooper|first2=D. James|last3=Myles|first3=Paul S.|last4=Scheinkestel|first4=Carlos D.|last5=Tuxen|first5=David V.|date=2000-11|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:|url=http://journals.lww.com/00003246-200011000-00034|journal=Critical Care Medicine|language=en|volume=28|issue=11|pages=3734–3739|doi=10.1097/00003246-200011000-00034|issn=0090-3493}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* Neck ultrasound to identify anatomy&lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Most institutions have a &amp;quot;trach set&amp;quot; for the surgical team&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventil&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;ation is impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
* May consider TIVA if patient at decreased risk for hemodynamic instability&lt;br /&gt;
|-&lt;br /&gt;
|As part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex; avoid bolusing as it may cause airway obstruction&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon&lt;br /&gt;
** Important to tape ETT securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil; remifentanil may not be necessary however consider small boluses of fentanyl&lt;br /&gt;
&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Usually no antibiotics indicated&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large TT (&amp;gt;7.5), obese patients (often sized with inappropriately large TT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4061</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4061"/>
		<updated>2022-02-26T16:19:52Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheostomy tube (TT)&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy under general vs awake, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using dexmedetomidine, then converting to general when the tube is secured&lt;br /&gt;
| considerations_postoperative = Complications with the highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis&lt;br /&gt;
}}&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
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Indications for tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as in critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as reduce the need for sedation and improve overall patient comfort and airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
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A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
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In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
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In a percutaneous tracheostomy, various procedure methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.&amp;lt;ref&amp;gt;{{Cite journal|last=Nates|first=Joseph L.|last2=Cooper|first2=D. James|last3=Myles|first3=Paul S.|last4=Scheinkestel|first4=Carlos D.|last5=Tuxen|first5=David V.|date=2000-11|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:|url=http://journals.lww.com/00003246-200011000-00034|journal=Critical Care Medicine|language=en|volume=28|issue=11|pages=3734–3739|doi=10.1097/00003246-200011000-00034|issn=0090-3493}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|}&lt;br /&gt;
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=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
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* Head and Neck CT/MRI &lt;br /&gt;
* Neck ultrasound to identify anatomy&lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Most institutions have a &amp;quot;trach set&amp;quot; for the surgical team&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventil&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;ation is impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
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* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
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=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
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* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
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== Intraoperative management ==&lt;br /&gt;
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=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
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* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
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=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
* May consider TIVA if patient at decreased risk for hemodynamic instability&lt;br /&gt;
|-&lt;br /&gt;
|As part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex; avoid bolusing as it may cause airway obstruction&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
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=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
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* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon&lt;br /&gt;
** Important to tape ETT securely&lt;br /&gt;
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* Table may be turned 180 degrees in awake cases&lt;br /&gt;
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=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
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* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Usually no antibiotics indicated&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
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=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
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=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
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* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large TT (&amp;gt;7.5), obese patients (often sized with inappropriately large TT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4059</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4059"/>
		<updated>2022-02-24T20:17:43Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheostomy tube (TT)&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using precedex, then converting to general when the tube is secured.&lt;br /&gt;
| considerations_postoperative = Complications with highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a percutaneous tracheostomy, various procedure methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.&amp;lt;ref&amp;gt;{{Cite journal|last=Nates|first=Joseph L.|last2=Cooper|first2=D. James|last3=Myles|first3=Paul S.|last4=Scheinkestel|first4=Carlos D.|last5=Tuxen|first5=David V.|date=2000-11|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:|url=http://journals.lww.com/00003246-200011000-00034|journal=Critical Care Medicine|language=en|volume=28|issue=11|pages=3734–3739|doi=10.1097/00003246-200011000-00034|issn=0090-3493}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* Neck ultrasound to identify anatomy&lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
* May consider TIVA if patient at decreased risk for hemodynamic instability&lt;br /&gt;
|-&lt;br /&gt;
|As part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex; avoid bolusing as it may cause airway obstruction&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large TT (&amp;gt;7.5), obese patients (often sized with inappropriately large TT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4058</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4058"/>
		<updated>2022-02-24T19:05:14Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using precedex, then converting to general when the tube is secured.&lt;br /&gt;
| considerations_postoperative = Complications with highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
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&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a percutaneous tracheostomy, various procedure methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.&amp;lt;ref&amp;gt;{{Cite journal|last=Nates|first=Joseph L.|last2=Cooper|first2=D. James|last3=Myles|first3=Paul S.|last4=Scheinkestel|first4=Carlos D.|last5=Tuxen|first5=David V.|date=2000-11|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:|url=http://journals.lww.com/00003246-200011000-00034|journal=Critical Care Medicine|language=en|volume=28|issue=11|pages=3734–3739|doi=10.1097/00003246-200011000-00034|issn=0090-3493}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* Neck ultrasound to identify anatomy&lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
* May consider TIVA if patient at decreased risk for hemodynamic instability&lt;br /&gt;
|-&lt;br /&gt;
|As part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex; avoid bolusing as it may cause airway obstruction&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large TT (&amp;gt;7.5), obese patients (often sized with inappropriately large TT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4057</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4057"/>
		<updated>2022-02-24T17:55:38Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = If general anesthesia, communication with surgeon is key for slowly removing ETT. Do not remove past the vocal cords until surgeon indicates. If an awake tracheostomy, consider sedation using precedex, then converting to general when the tube is secured.&lt;br /&gt;
| considerations_postoperative = Complications with highest morbidity/mortality to be aware of include creation of a false passage, occlusion of tracheostomy tube, tube displacement, tracheoinnominate artery fistula, airway stenosis&lt;br /&gt;
}}&lt;br /&gt;
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&lt;br /&gt;
&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can also be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, several techniques can be used to create a tracheostomy: a vertical slit, a horizontal slit, formation of a tracheal flap consisting of the 2nd or 3rd tracheal rings which is secured to the skin inferiorly, or formation of a window for a more permanent stoma. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a percutaneous tracheostomy, many methods may be utilized. Most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased complications such as bleeding.&amp;lt;ref&amp;gt;{{Cite journal|last=Nates|first=Joseph L.|last2=Cooper|first2=D. James|last3=Myles|first3=Paul S.|last4=Scheinkestel|first4=Carlos D.|last5=Tuxen|first5=David V.|date=2000-11|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:|url=http://journals.lww.com/00003246-200011000-00034|journal=Critical Care Medicine|language=en|volume=28|issue=11|pages=3734–3739|doi=10.1097/00003246-200011000-00034|issn=0090-3493}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|As part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex; avoid bolusing as it may cause airway obstruction&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large TT (&amp;gt;7.5), obese patients (often sized with inappropriately large TT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4056</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4056"/>
		<updated>2022-02-24T17:07:13Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Although there are many methods to perform a percutaneous tracheotomy, most commonly an initial tracheal aperture is made with a needle followed by progressive blunt dilations. A more recent technique allows for dilation in one step. Another method is based on enlarging a small tracheal aperture with blunt forceps, however this method is associated with increased bleeding.&amp;lt;ref&amp;gt;{{Cite journal|last=Nates|first=Joseph L.|last2=Cooper|first2=D. James|last3=Myles|first3=Paul S.|last4=Scheinkestel|first4=Carlos D.|last5=Tuxen|first5=David V.|date=2000-11|title=Percutaneous tracheostomy in critically ill patients: A prospective, randomized comparison of two techniques:|url=http://journals.lww.com/00003246-200011000-00034|journal=Critical Care Medicine|language=en|volume=28|issue=11|pages=3734–3739|doi=10.1097/00003246-200011000-00034|issn=0090-3493}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large TT (&amp;gt;7.5), obese patients (often sized with inappropriately large TT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4055</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4055"/>
		<updated>2022-02-24T16:55:30Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Consider precedex bolus or infusion at end of procedure for its sedative, anxiolysis, and analgesic-sparing properties&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
* Inpatient unit&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4054</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4054"/>
		<updated>2022-02-24T16:45:07Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV, arterial/central access depending on patient condition&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly be interchanged with tracheostomy, which by definition is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt; Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&amp;lt;ref name=&amp;quot;:3&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref name=&amp;quot;:3&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheotomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms of upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with carefully titrated inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Consider sedation using precedex&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
* Table may be turned 180 degrees in awake cases&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil&lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, can advance ETT closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely to avoid airway loss&lt;br /&gt;
* Once TT secured, connect to circuit and gently suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
* Once TT secured, convert to GA while surgeons finish the procedure&lt;br /&gt;
* Can use propofol/remifentanil&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Transport to ICU on similar ventilator settings and level of sedation&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), low dose bolus opioids/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4053</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4053"/>
		<updated>2022-02-24T16:28:15Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly referred to as tracheostomy, which is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* For patients not already intubated, prepare equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;&lt;br /&gt;
* Surgeon should be immediately available to perform cricothyrotomy/tracheostomy if ventilation proves impossible&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedicatio&amp;lt;span class=&amp;quot;reference&amp;quot; id=&amp;quot;cite_ref-:2_2-0&amp;quot;&amp;gt;&amp;lt;/span&amp;gt;n&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake &lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
* Consider calming music such as classical&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; important to tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4052</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4052"/>
		<updated>2022-02-24T16:20:36Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
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&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea. It can be commonly referred to as tracheostomy, which is a procedure that exteriorizes the trachea to the neck skin to produce a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a surgical tracheotomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid cartilage. The strap muscles are retracted laterally, and the anterior tracheal wall is identified. The thyroid isthmus may need to be retracted or divided if necessary. In adults, a tracheal flap consisting of the 2nd or 3rd tracheal ring is made and secured to the skin inferiorly. The ETT is withdrawn in conjunction with placement of the tracheostomy tube (TT), and the TT is subsequently sutured to the skin.&amp;lt;ref&amp;gt;{{Cite journal|last=De Leyn|first=Paul|last2=Bedert|first2=Lieven|last3=Delcroix|first3=Marion|last4=Depuydt|first4=Pieter|last5=Lauwers|first5=Geert|last6=Sokolov|first6=Youri|last7=Van Meerhaeghe|first7=Alain|last8=Van Schil|first8=Paul|date=2007-09|title=Tracheotomy: clinical review and guidelines|url=https://doi-org.stanford.idm.oclc.org/10.1016/j.ejcts.2007.05.018|journal=European Journal of Cardio-Thoracic Surgery|volume=32|issue=3|pages=412–421|doi=10.1016/j.ejcts.2007.05.018|issn=1010-7940}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite book|last=Jaffe|first=Richard A.|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Wolters Kluwer|year=2020|isbn=9781496371256|location=Philadelphia|pages=209-214}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal fistula&lt;br /&gt;
** Tracheoinnominate artery fistula&lt;br /&gt;
*** Potential for catastrophic bleeding&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4011</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4011"/>
		<updated>2022-02-23T04:30:13Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = Cause of respiratory failure and ability to perform tracheostomy awake vs under general, avoidance of premedication if concern for airway obstruction&lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4010</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4010"/>
		<updated>2022-02-23T04:22:33Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Local infiltration of neck and transtracheal instillation of local anesthetic&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
* Regular cleaning of tube with careful suctioning, stomal care, and monitoring of cuff pressure if inflated&lt;br /&gt;
* Humidification of inspired air&lt;br /&gt;
* Opioids (and opioid sedation) can minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients, already intubated&lt;br /&gt;
|&lt;br /&gt;
* Continue on similar ventilatory support settings in the ICU&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining non-opioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4009</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4009"/>
		<updated>2022-02-23T01:50:58Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
A '''tracheotomy''' refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake, often with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Understand restrictive versus obstructive deficit and cause. Manipulation of airway is a stimulus for bronchospasm, particularly in reactive airway disease&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Regular cleaning of tube, stomal care, and monitoring of cuff pressure&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4008</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4008"/>
		<updated>2022-02-23T01:45:08Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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A '''tracheotomy''' refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is also reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|Thorough evaluation of airway anatomy. Understand relative contraindications to bedside tracheostomy including short/large neck, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery.&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Assess neurological deficits, neurological or neuromuscular disease as cause of respiratory failure&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for GERD/possible recurrent aspiration&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill or symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Regular cleaning of tube, stomal care, and monitoring of cuff pressure&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4007</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4007"/>
		<updated>2022-02-22T23:48:15Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
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&lt;br /&gt;
Regarding terminology, a tracheotomy refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is reasonable to consider tracheotomy to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. &lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin.&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess risk of aspiration/GERD&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic disease&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Regular cleaning of tube, stomal care, and monitoring of cuff pressure&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large tracheal tube (&amp;gt;7.5), obese patients (often sized with inappropriately large tracheal tube)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
*** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|Advantages over tracheostomies in the OR&lt;br /&gt;
&lt;br /&gt;
* Less time/personnel required&lt;br /&gt;
* Half of cost&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
Absolute contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* pediatric age group&lt;br /&gt;
&lt;br /&gt;
Relative contraindications&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* short/large neck or obesity with unidentifiable anatomy&lt;br /&gt;
* enlarged thyroid&lt;br /&gt;
* inability to extend the neck&lt;br /&gt;
* suspected/confirmed C-spine fracture&lt;br /&gt;
* prior neck surgery&lt;br /&gt;
* some believe anticoagulation&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4006</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4006"/>
		<updated>2022-02-22T23:18:50Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is reasonable to consider tracheotomy after 10 days to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. Absolute contraindications to performing bedside tracheostomy include pediatric age group, while relative contraindications to performing a bedside tracheostomy include short/large neck or obesity with unidentifiable anatomy, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery, and some believe anticoagulation.&amp;lt;ref&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
Regarding terminology, a tracheotomy refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;  &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic illness&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Regular cleaning of tube, stomal care, and monitoring of cuff pressure&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large ETT (&amp;gt;7.5), obese patients (often sized with inappropriately large ETT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
**** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4005</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4005"/>
		<updated>2022-02-22T23:16:14Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, Invasive depending on patient condition&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is reasonable to consider tracheotomy after 10 days to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. Absolute contraindications to performing bedside tracheostomy include pediatric age group, while relative contraindications to performing a bedside tracheostomy include short/large neck or obesity with unidentifiable anatomy, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery, and some believe anticoagulation.&amp;lt;ref&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
Regarding terminology, a tracheotomy refers to any procedure that involves opening the trachea, and a tracheostomy refers to a procedure that exteriorizes the trachea to the neck skin producing a more permanent opening.&amp;lt;ref&amp;gt;{{Cite journal|last=Cheung|first=N. H.|last2=Napolitano|first2=L. M.|date=2014-06-01|title=Tracheostomy: Epidemiology, Indications, Timing, Technique, and Outcomes|url=http://dx.doi.org/10.4187/respcare.02971|journal=Respiratory Care|volume=59|issue=6|pages=895–919|doi=10.4187/respcare.02971|issn=0020-1324}}&amp;lt;/ref&amp;gt;  &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic illness&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal &lt;br /&gt;
*** Most commonly from cut edge of the thyroid&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Subcutaneous emphysema&lt;br /&gt;
** Pulmonary edema from breathing against obstruction prior to procedure&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Granulation tissue, cellulitis / tracheitis&lt;br /&gt;
** Infection such as pneumonia&lt;br /&gt;
** Vocal cord dysfunction&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large ETT (&amp;gt;7.5), obese patients (often sized with inappropriately large ETT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
**** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
** Tracheocutaneous, tracheoesophageal, tracheoinnominate artery fistula&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4004</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4004"/>
		<updated>2022-02-22T18:27:39Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, it is reasonable to consider tracheotomy after 10 days to protect the larynx from injury and decrease the risk of sinusitis and ventilator-associated pneumonia (VAP),&amp;lt;ref&amp;gt;{{Cite journal|last=Ranes|first=Justin L.|last2=Gordon|first2=Steven M.|last3=Chen|first3=Pam|last4=Fatica|first4=Cynthia|last5=Hammel|first5=Jeffrey|last6=Gonzales|first6=Jeffrey P.|last7=Arroliga|first7=Alejandro C.|date=2006-10-01|title=Predictors of Long-Term Mortality in Patients with Ventilator-Associated Pneumonia|url=https://www.amjmed.com/article/S0002-9343(06)00610-3/abstract|journal=The American Journal of Medicine|language=English|volume=119|issue=10|pages=897.e13–897.e19|doi=10.1016/j.amjmed.2005.12.034|issn=0002-9343}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=HOLZAPFEL|first=L.|last2=CHEVRET|first2=S.|last3=MADINIER|first3=G.|last4=OHEN|first4=F.|last5=DEMINGEON|first5=G.|last6=COUPRY|first6=A.|last7=CHAUDET|first7=M.|date=1994-06|title=Influence of Long-Term Oro- or Nasotracheal Intubation on Nosocomial Maxillary Sinusitis and Pneumonia|url=http://dx.doi.org/10.1097/00132586-199406000-00057|journal=Survey of Anesthesiology|volume=38|issue=03|pages=177???178|doi=10.1097/00132586-199406000-00057|issn=0039-6206}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Cavaliere|first=S.|last2=Bezzi|first2=M.|last3=Toninelli|first3=C.|last4=Foccoli|first4=P.|date=2016-02-03|title=Management of post-intubation tracheal stenoses using the endoscopic approach|url=http://www.monaldi-archives.org/index.php/macd/article/view/492|journal=Monaldi Archives for Chest Disease|volume=67|issue=2|doi=10.4081/monaldi.2007.492|issn=2465-1028}}&amp;lt;/ref&amp;gt; as well as to improve patient comfort, reducing need for sedation, lowering airway resistance, and improving overall airway care&amp;lt;ref&amp;gt;{{Cite journal|last=Heffner|first=John E.|last2=Hess|first2=Dean|date=2001-03|title=Tracheostomy Management in the Chronically Ventilated Patient|url=http://dx.doi.org/10.1016/s0272-5231(05)70025-3|journal=Clinics in Chest Medicine|volume=22|issue=1|pages=55–69|doi=10.1016/s0272-5231(05)70025-3|issn=0272-5231}}&amp;lt;/ref&amp;gt;&amp;lt;ref&amp;gt;{{Cite journal|last=Diehl|first=J|last2=El Atrous|first2=S|last3=Touchard|first3=D|last4=Lemaire|first4=F|last5=Brochard|first5=L.|date=1999|title=Changes in the Work of Breathing Induced by Tracheotomy in Ventilator-dependent Patients.|url=http://dx.doi.org/10.1097/01823246-199910020-00013|journal=Cardiopulmonary Physical Therapy Journal|volume=10|issue=2|pages=60|doi=10.1097/01823246-199910020-00013|issn=1541-7891}}&amp;lt;/ref&amp;gt;. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
A tracheostomy may be performed open during a general anesthetic or awake with local anesthesia. It can be performed at the bedside with several percutaneous techniques. Absolute contraindications to performing bedside tracheostomy include pediatric age group, while relative contraindications to performing a bedside tracheostomy include short/large neck or obesity with unidentifiable anatomy, enlarged thyroid, inability to extend the neck, suspected/confirmed C-spine fracture, prior neck surgery, and some believe anticoagulation.&amp;lt;ref&amp;gt;{{Cite journal|last=Nun|first=Alon Ben|last2=Altman|first2=Eduard|last3=Best|first3=Lael Anson|date=2005-10-01|title=Extended Indications for Percutaneous Tracheostomy|url=https://www.annalsthoracicsurgery.org/article/S0003-4975(05)00184-0/abstract|journal=The Annals of Thoracic Surgery|language=English|volume=80|issue=4|pages=1276–1279|doi=10.1016/j.athoracsur.2005.02.007|issn=0003-4975}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic illness&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Cellulitis / tracheitis&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large ETT (&amp;gt;7.5), obese patients (often sized with inappropriately large ETT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
***** Tracheal airway diameters` do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
** Tracheocutaneous or tracheoesophageal fistula&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4003</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=4003"/>
		<updated>2022-02-22T17:36:18Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, awake/local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
Indications for a '''tracheotomy''' are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Airway&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Pulmonary&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic illness&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative&lt;br /&gt;
** Bleeding although EBL generally minimal&lt;br /&gt;
** Pneumothorax &lt;br /&gt;
*** Seen if low neck dissection of false passage formation&lt;br /&gt;
** Pneumomediastinum&lt;br /&gt;
** Creation of false passage during procedure&lt;br /&gt;
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
*** Signs include absent end tidal, increased PIP&lt;br /&gt;
*** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Cite journal|last=Halum|first=Stacey L.|last2=Ting|first2=Jonathan Y.|last3=Plowman|first3=Emily K.|last4=Belafsky|first4=Peter C.|last5=Harbarger|first5=Claude F.|last6=Postma|first6=Gregory N.|last7=Pitman|first7=Michael J.|last8=LaMonica|first8=Donna|last9=Moscatello|first9=Augustine|last10=Khosla|first10=Sid|last11=Cauley|first11=Christy E.|date=2011-12-19|title=A multi-institutional analysis of tracheotomy complications|url=https://onlinelibrary-wiley-com.stanford.idm.oclc.org/doi/full/10.1002/lary.22364?casa_token=EgJBA3f52xUAAAAA:cS-N8QCDJrYB6ciKyr5EAXti28Yhrlhf2LePJY_YdKrZMJSR0yr_uuHtOK9rlMTm6I2UGd6cfRsZ|journal=The Laryngoscope|volume=122|issue=1|pages=38–45|doi=10.1002/lary.22364|issn=0023-852X}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
* Early postoperative complications (within 1 week):&lt;br /&gt;
** Cellulitis / tracheitis&lt;br /&gt;
** Occlusion of tracheostomy tube&lt;br /&gt;
*** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
** Tracheostomy tube displacement&lt;br /&gt;
*** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
* Late complications (seen beyond 1 week):&lt;br /&gt;
** Note early postoperative complications may also occur after 1 week&lt;br /&gt;
** Airway stenosis&lt;br /&gt;
*** Posterior glottic, subglottic, tracheal&lt;br /&gt;
*** Risk factors: inappropriately large ETT (&amp;gt;7.5), obese patients (often sized with inappropriately large ETT)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
**** Tracheal airway diameters do not correlate with body weight&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
** Tracheocutaneous fistula&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
!Bedside - Percutaneous&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|2.2x more likely to have early postoperative complications vs open&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;br /&gt;
[[Category:Otolaryngology]]&lt;br /&gt;
[[Category:Neck surgery]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3851</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3851"/>
		<updated>2022-02-20T00:15:20Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|Assess for renal disease if chronic illness&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Bleeding although EBL generally minimal&lt;br /&gt;
* Cellulitis / tracheitis&lt;br /&gt;
* Tracheal stenosis&lt;br /&gt;
* Pneumothorax &lt;br /&gt;
** Seen if low neck dissection of false passage formation&lt;br /&gt;
* Pneumomediastinum&lt;br /&gt;
* Creation of false passage during procedure&lt;br /&gt;
** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
** Signs include absent end tidal, increased PIP&lt;br /&gt;
** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
&lt;br /&gt;
* Occlusion of tracheostomy tube&lt;br /&gt;
** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
&lt;br /&gt;
* Tracheostomy tube displacement&lt;br /&gt;
** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3850</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3850"/>
		<updated>2022-02-20T00:09:16Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* PONV prophylaxis with dexamethasone, ondansetron&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Critically ill patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning, humidified oxygen&lt;br /&gt;
* Opioid sedation will minimize reaction to suctioning in early postoperative period&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|Awake or as part of scheduled procedure&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Bleeding although EBL generally minimal&lt;br /&gt;
* Cellulitis / tracheitis&lt;br /&gt;
* Tracheal stenosis&lt;br /&gt;
* Pneumothorax &lt;br /&gt;
** Seen if low neck dissection of false passage formation&lt;br /&gt;
* Pneumomediastinum&lt;br /&gt;
* Creation of false passage during procedure&lt;br /&gt;
** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
** Signs include absent end tidal, increased PIP&lt;br /&gt;
** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
&lt;br /&gt;
* Occlusion of tracheostomy tube&lt;br /&gt;
** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
&lt;br /&gt;
* Tracheostomy tube displacement&lt;br /&gt;
** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!General&lt;br /&gt;
!Awake&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3849</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3849"/>
		<updated>2022-02-19T23:44:56Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, local&lt;br /&gt;
| airway = ETT, tracheotomy&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|Consider adrenal suppression, hyperglycemia if ICU patient&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Note nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors&lt;br /&gt;
** Invasive monitors depending on condition&lt;br /&gt;
* Avoid ECG pads in the prepped area&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|Intubated&lt;br /&gt;
|&lt;br /&gt;
* Convert ICU sedation to GA with propofol/remifentanil or inhalational agent&lt;br /&gt;
|-&lt;br /&gt;
|Not intubated with plan for GETA&lt;br /&gt;
|&lt;br /&gt;
* Standard IV induction&lt;br /&gt;
* Consider awake FOI if airway problems anticipated&lt;br /&gt;
|-&lt;br /&gt;
|Awake Tracheostomy&lt;br /&gt;
|&lt;br /&gt;
* Precedex&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended with shoulder roll&lt;br /&gt;
** Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* Normovolemia, normothermia&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|ICU patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Cellulitis / tracheitis&lt;br /&gt;
* Tracheal stenosis&lt;br /&gt;
* Pneumothorax &lt;br /&gt;
** Seen if low neck dissection of false passage formation&lt;br /&gt;
* Pneumomediastinum&lt;br /&gt;
* Creation of false passage during procedure&lt;br /&gt;
** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
** Signs include absent end tidal, increased PIP&lt;br /&gt;
** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
&lt;br /&gt;
* Occlusion of tracheostomy tube&lt;br /&gt;
** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
&lt;br /&gt;
* Tracheostomy tube displacement&lt;br /&gt;
** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3848</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3848"/>
		<updated>2022-02-19T22:29:43Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, local&lt;br /&gt;
| airway = &lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
&lt;br /&gt;
Indications for a tracheotomy are numerous but include securing the airway in anticipation of or actual airway obstruction, for example edema, Ludwig angina, or retropharyngeal abscess. Tracheostomy can be part of a scheduled procedure, such as a laryngectomy. If prolonged intubation is anticipated, such as critically ill patients in an ICU setting, tracheotomy is indicated to protect the larynx from injury. In addition, tracheotomy should be performed when convenient following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. Rarer indications for tracheotomy include bilateral vocal cord paralysis or a history of recurrent allergy associated with laryngospasm.&lt;br /&gt;
&lt;br /&gt;
In a tracheostomy, a short transverse incision or midline vertical incision is made 1-2 cm inferior to the cricoid. The tracheostomy tube is sutured to the skin. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|If malignancy or chronic disease, coagulopathies or anemia may be present&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
* CXR, ABG as indicated from H&amp;amp;P&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication if elective&lt;br /&gt;
** Avoid if critically ill of symptoms upper airway obstruction&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, head extended&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|General&lt;br /&gt;
|&lt;br /&gt;
&lt;br /&gt;
* Consider TIVA with propofol/remifentanil &lt;br /&gt;
* Muscle relaxation required, may use rocuronium&lt;br /&gt;
* To avoid ETT cuff puncture, may advance closer to carina before trachea opened&lt;br /&gt;
* Slowly remove ETT under visualization of surgeon however do not remove completely&lt;br /&gt;
* Once tracheostomy tube secured, connect to circuit/suction&lt;br /&gt;
* Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits&lt;br /&gt;
|-&lt;br /&gt;
|Awake&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!&lt;br /&gt;
|-&lt;br /&gt;
|ICU patients&lt;br /&gt;
|&lt;br /&gt;
* Continue on ventilatory support in the ICU&lt;br /&gt;
* Careful suctioning&lt;br /&gt;
* Do not remove for 5-7 days until track formed&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Cellulitis / tracheitis&lt;br /&gt;
* Tracheal stenosis&lt;br /&gt;
* Pneumothorax &lt;br /&gt;
** Seen if low neck dissection of false passage formation&lt;br /&gt;
* Pneumomediastinum&lt;br /&gt;
* Creation of false passage during procedure&lt;br /&gt;
** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)&lt;br /&gt;
** Signs include absent end tidal, increased PIP&lt;br /&gt;
** If suspect, should attempt to reintroduce existing ETT&lt;br /&gt;
&lt;br /&gt;
* Occlusion of tracheostomy tube&lt;br /&gt;
** Secretions, mucus plug, blood, mainstem&lt;br /&gt;
&lt;br /&gt;
* Tracheostomy tube displacement&lt;br /&gt;
** Re-intubate orally or through trach site&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3847</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3847"/>
		<updated>2022-02-18T19:33:17Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General, local&lt;br /&gt;
| airway = &lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard&lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Provide a brief summary of this surgical procedure and its indications here.&lt;br /&gt;
&lt;br /&gt;
A tracheotomy is done un&lt;br /&gt;
&lt;br /&gt;
A tracheotomy should be performed following emergent cricothyrotomy to reduce the incidence of subglottic stenosis and cricoid chondritis. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head and Neck CT/MRI &lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3846</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3846"/>
		<updated>2022-02-18T19:28:20Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation&lt;br /&gt;
Electrocautery and risk of airway fire&lt;br /&gt;
Tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema&lt;br /&gt;
PONV prophylaxis&lt;br /&gt;
Smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
'''Glossectomy''' refers to the surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, [[obstructive sleep apnea]], and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and flap reconstruction may be performed for glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider [[Coronary artery disease|CAD]]/vascular disease/HTN if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]]&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/[[Gastroesophageal reflux disease|GERD]]&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|Consider DVT risk if smoking/cancer history&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider history of alcohol abuse in head and neck cancers, assess nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, equipment for surgical airway&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider acetaminophen 500-1000 mg PO as part of multimodal regimen&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags/lip retractors per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication&lt;br /&gt;
* Administration of antisialogogue (glycopyrrolate) may improve operating conditions&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation&amp;lt;ref&amp;gt;{{Cite journal|last=Kheterpal|first=Sachin|last2=Martin|first2=Lizabeth|last3=Shanks|first3=Amy M.|last4=Tremper|first4=Kevin K.|date=2009-04-01|title=Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics|url=https://doi.org/10.1097/ALN.0b013e31819b5b87|journal=Anesthesiology|volume=110|issue=4|pages=891–897|doi=10.1097/ALN.0b013e31819b5b87|issn=0003-3022}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
** Consider high flow nasal cannula for pre-oxygenation&lt;br /&gt;
* Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference&lt;br /&gt;
* Consider awake fiberoptic intubation if large tumor at the tongue base&lt;br /&gt;
* If nasal/airway landmarks effaced, consider awake tracheostomy&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
** Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol and remifentanil or sufentanil&lt;br /&gt;
** Opioid infusion useful for smooth extubation&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* Complete muscle relaxation essential, may use rocuronium&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;30% to prevent airway fire from electrocautery use&lt;br /&gt;
* Goal euvolemia&lt;br /&gt;
** Patients may be volume depleted prior to surgery and require fluid boluses&lt;br /&gt;
* Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins &amp;lt;ref&amp;gt;{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation&lt;br /&gt;
** Reintubation may be impossible if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure&lt;br /&gt;
** Graft hematomas are the primary cause of skin graft failure&amp;lt;ref&amp;gt;{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Extubate after recovery of protective airway reflexes&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location of resection, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus opioid analgesics&lt;br /&gt;
* Consider opioid PCA if subtotal/total glossectomy&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction due to airway edema&lt;br /&gt;
** May require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
* Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Aspiration&lt;br /&gt;
* Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Dysphagia&lt;br /&gt;
* Bleeding &lt;br /&gt;
** Manipulation of mass&lt;br /&gt;
** Lingual artery/veins&lt;br /&gt;
** Consider external jugular/carotid if neck dissection&lt;br /&gt;
* Salivary fistula&lt;br /&gt;
* Osteonecrosis if mandibulotomy&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Graft failure&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|May require prolonged intubation or tracheostomy care&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3845</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3845"/>
		<updated>2022-02-18T15:24:55Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation&lt;br /&gt;
Electrocautery and risk of airway fire&lt;br /&gt;
Tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema&lt;br /&gt;
PONV prophylaxis&lt;br /&gt;
Smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
'''Glossectomy''' refers to the surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, [[obstructive sleep apnea]], and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and flap reconstruction may be performed for glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider [[Coronary artery disease|CAD]]/vascular disease if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]]&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/[[Gastroesophageal reflux disease|GERD]]&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|Consider DVT risk if smoking/cancer history&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider history of alcohol abuse in head and neck cancers, assess nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, equipment for surgical airway&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider acetaminophen 500-1000 mg PO as part of multimodal regimen&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags/lip retractors per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication&lt;br /&gt;
* Administration of antisialogogue (glycopyrrolate) may improve operating conditions&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation&amp;lt;ref&amp;gt;{{Cite journal|last=Kheterpal|first=Sachin|last2=Martin|first2=Lizabeth|last3=Shanks|first3=Amy M.|last4=Tremper|first4=Kevin K.|date=2009-04-01|title=Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics|url=https://doi.org/10.1097/ALN.0b013e31819b5b87|journal=Anesthesiology|volume=110|issue=4|pages=891–897|doi=10.1097/ALN.0b013e31819b5b87|issn=0003-3022}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
** Consider high flow nasal cannula for pre-oxygenation&lt;br /&gt;
* Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference&lt;br /&gt;
* Consider awake fiberoptic intubation if large tumor at the tongue base&lt;br /&gt;
* If nasal/airway landmarks effaced, consider awake tracheostomy&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
** Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol and remifentanil or sufentanil&lt;br /&gt;
** Opioid infusion useful for smooth extubation&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* Complete muscle relaxation essential, may use rocuronium&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;30% to prevent airway fire from electrocautery use&lt;br /&gt;
* Goal euvolemia&lt;br /&gt;
** Patients may be volume depleted prior to surgery and require fluid boluses&lt;br /&gt;
* Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins &amp;lt;ref&amp;gt;{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation&lt;br /&gt;
** Reintubation may be impossible if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure&lt;br /&gt;
** Graft hematomas are the primary cause of skin graft failure&amp;lt;ref&amp;gt;{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Extubate after recovery of protective airway reflexes&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location of resection, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus opioid analgesics&lt;br /&gt;
* Consider opioid PCA if subtotal/total glossectomy&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction due to airway edema&lt;br /&gt;
** May require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
* Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Aspiration&lt;br /&gt;
* Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Dysphagia&lt;br /&gt;
* Bleeding &lt;br /&gt;
** Manipulation of mass&lt;br /&gt;
** Lingual artery/veins&lt;br /&gt;
** Consider external jugular/carotid if neck dissection&lt;br /&gt;
* Salivary fistula&lt;br /&gt;
* Osteonecrosis if mandibulotomy&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Graft failure&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|May require prolonged intubation or tracheostomy care&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3844</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3844"/>
		<updated>2022-02-18T15:23:06Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation&lt;br /&gt;
Electrocautery and risk of airway fire&lt;br /&gt;
Tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema&lt;br /&gt;
PONV prophylaxis&lt;br /&gt;
Smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
'''Glossectomy''' refers to the surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, [[obstructive sleep apnea]], and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and flap reconstruction may be performed for glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|Consider stroke risk if smoking history, tongue direction if prior surgeries or hypoglossal nerve involvement&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider [[Coronary artery disease|CAD]]/vascular disease if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Assess compliance of airway including neck mobility, mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Check patency of each nare. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]]&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/[[Gastroesophageal reflux disease|GERD]]&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|Consider DVT risk if smoking/cancer history&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider history of alcohol abuse in head and neck cancers, assess nutritional status&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, high flow nasal cannula, equipment for surgical airway&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider acetaminophen 500-1000 mg PO as part of multimodal regimen&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags/lip retractors per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication&lt;br /&gt;
* Administration of antisialogogue (glycopyrrolate) may improve operating conditions&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Decreased compliance due to neck radiation is the most significant predictor of difficult mask ventilation&amp;lt;ref&amp;gt;{{Cite journal|last=Kheterpal|first=Sachin|last2=Martin|first2=Lizabeth|last3=Shanks|first3=Amy M.|last4=Tremper|first4=Kevin K.|date=2009-04-01|title=Prediction and Outcomes of Impossible Mask Ventilation: A Review of 50,000 Anesthetics|url=https://doi.org/10.1097/ALN.0b013e31819b5b87|journal=Anesthesiology|volume=110|issue=4|pages=891–897|doi=10.1097/ALN.0b013e31819b5b87|issn=0003-3022}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
** Consider high flow nasal cannula for pre-oxygenation&lt;br /&gt;
* Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference&lt;br /&gt;
* Consider awake fiberoptic intubation if large tumor at the tongue base&lt;br /&gt;
* If nasal/airway landmarks effaced, consider awake tracheostomy&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
** Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol and remifentanil or sufentanil&lt;br /&gt;
** Opioid infusion useful for smooth extubation&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* Complete muscle relaxation essential, may use rocuronium&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;30% to prevent airway fire from electrocautery use&lt;br /&gt;
* Goal euvolemia&lt;br /&gt;
** Patients may be volume depleted prior to surgery and require fluid boluses&lt;br /&gt;
* Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins &amp;lt;ref&amp;gt;{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation&lt;br /&gt;
** Reintubation may be impossible if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure&lt;br /&gt;
** Graft hematomas are the primary cause of skin graft failure&amp;lt;ref&amp;gt;{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Extubate after recovery of protective airway reflexes&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location of resection, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus opioid analgesics&lt;br /&gt;
* Consider opioid PCA if subtotal/total glossectomy&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction due to airway edema&lt;br /&gt;
** May require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
* Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Aspiration&lt;br /&gt;
* Dysarthria, from loss of musculature or post-operative changes such as tongue tethering from scar tissue&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Dysphagia&lt;br /&gt;
* Bleeding &lt;br /&gt;
** Manipulation of mass&lt;br /&gt;
** Lingual artery/vein, deep lingual vein&lt;br /&gt;
** Consider external jugular/carotid if neck dissection&lt;br /&gt;
* Salivary fistula&lt;br /&gt;
* Osteonecrosis if mandibulotomy&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Graft failure&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|May require prolonged intubation or tracheostomy care&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3843</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3843"/>
		<updated>2022-02-18T01:00:44Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation&lt;br /&gt;
Electrocautery and risk of airway fire&lt;br /&gt;
Tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema&lt;br /&gt;
PONV prophylaxis&lt;br /&gt;
Smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
'''Glossectomy''' refers to the surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, [[obstructive sleep apnea]], and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and flap reconstruction may be performed for glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider [[Coronary artery disease|CAD]] if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Consider pulmonary pathology related to smoking history. Consider OSA and possible related [[pulmonary hypertension]]&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/[[Gastroesophageal reflux disease|GERD]]&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider history of alcohol abuse in head and neck cancers&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including video laryngoscope, fiberoptic, equipment for surgical airway&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider acetaminophen 500-1000 mg PO as part of multimodal regimen&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication&lt;br /&gt;
* Administration of antisialogogue (glycopyrrolate) may improve operating conditions&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Nasal intubation may be required depending on tumor location (e.g. side versus base of tongue) and surgeon preference&lt;br /&gt;
* Consider awake fiberoptic intubation if large tumor at the tongue base&lt;br /&gt;
* If nasal/airway landmarks effaced, consider awake tracheostomy&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
** Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol and remifentanil or sufentanil&lt;br /&gt;
** Opioid infusion useful for smooth extubation&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* Complete muscle relaxation essential&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;30% to prevent airway fire from electrocautery use&lt;br /&gt;
* Surgical manipulation at the base of the tongue can cause vagally mediated bradycardia and hypotension&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins &amp;lt;ref&amp;gt;{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation&lt;br /&gt;
** Reintubation may be impossible if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure&lt;br /&gt;
** Graft hematomas are the primary cause of skin graft failure&amp;lt;ref&amp;gt;{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Extubate after recovery of protective airway reflexes&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus/PCA opioid analgesics &lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction due to airway edema&lt;br /&gt;
** May require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
* Altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation)&lt;br /&gt;
* Aspiration&lt;br /&gt;
* Dysarthria&lt;br /&gt;
* Dysphagia&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Salivary fistula&lt;br /&gt;
* Osteonecrosis if mandibulotomy&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
* Skin graft failure&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|May require prolonged intubation or tracheostomy care&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3832</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3832"/>
		<updated>2022-02-18T00:11:41Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = Extent of tumor and airway history including history of head and neck radiation&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema, smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and reconstruction may be performed for glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider CAD if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, presence of trismus, tongue fixation / mass obstruction of the airway. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/GERD&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider history of alcohol abuse in head and neck cancers&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider pre-op acetaminophen 500-1000 mg PO as part of multimodal regimen&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication, pre-op administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference&lt;br /&gt;
* Consider awake fiberoptic if large tumor at the tongue base &lt;br /&gt;
* If nasal/airway landmarks effaced, consider awake tracheostomy&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
* Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* Complete muscle relaxation essential&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;0.3 to prevent airway fire as electrocautery used &lt;br /&gt;
* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins &amp;lt;ref&amp;gt;{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation - may be impossible to reintubate if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure)&amp;lt;ref&amp;gt;{{Cite journal|last=Llanos|first=Sergio|last2=Danilla|first2=Stefan|last3=Barraza|first3=Cristina|last4=Armijo|first4=Eugenia|last5=Pi??eros|first5=Jose L.|last6=Quintas|first6=Maria|last7=Searle|first7=Susana|last8=Calderon|first8=Wilfredo|date=2006-11|title=Effectiveness of Negative Pressure Closure in the Integration of Split Thickness Skin Grafts: A Randomized, Double-Masked, Controlled Trial|url=http://journals.lww.com/00000658-200611000-00014|journal=Annals of Surgery|language=en|volume=244|issue=5|pages=700–705|doi=10.1097/01.sla.0000217745.56657.e5|issn=0003-4932|pmc=PMC1856589|pmid=17060762}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Extubate after recovery of protective airway reflexes&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus/PCA opioid analgesics &lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction second to airway edema - may require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Infection&lt;br /&gt;
* Aspiration&lt;br /&gt;
* Specific to glossectomy: dysarthria, dysphagia, altered tongue sensation (lingual nerve trauma or neuropathic/phantom sensation), salivary fistula, osteonecrosis if mandibulotomy &amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|Supine&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|&amp;lt;-- May require prolonged intubation or tracheostomy care&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|Multimodal&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|Bleeding, infection, aspiration&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3831</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3831"/>
		<updated>2022-02-17T23:47:58Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = History of head and neck radiation, extent of tumor and airway history&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation/PONV prophylaxis, electrocautery and risk of airway fire, tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema, smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and reconstruction may be performed for glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider CAD if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, tongue fixation / mass obstruction of the airway, presence of trismus. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/GERD&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider history of alcohol abuse in head and neck cancers&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Head CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref name=&amp;quot;:2&amp;quot;&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider pre-op acetaminophen 500-1000 mg PO&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication, preop administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon&amp;lt;ref name=&amp;quot;:1&amp;quot;&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference&lt;br /&gt;
* Consider awake fiberoptic if large tumor at the tongue base &lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
* Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)&amp;lt;ref name=&amp;quot;:2&amp;quot; /&amp;gt;&lt;br /&gt;
* Complete muscle relaxation essential&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;0.3 if lasers are used to prevent airway fire&lt;br /&gt;
* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP&amp;lt;ref name=&amp;quot;:1&amp;quot; /&amp;gt;&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation - may be impossible to reintubate if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure) &lt;br /&gt;
* Extubation after recovery of protective airway reflexes&lt;br /&gt;
* If extubated, may require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus/PCA opioid analgesics &lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction second to airway edema&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Infection&lt;br /&gt;
* Aspiration&lt;br /&gt;
* If neck dissection, consider risk of bleeding (external jugular/carotid artery), dysrhythmias if compression of the carotid sinus, venous air embolism if open veins &amp;lt;ref&amp;gt;{{Cite book|last=Feldman|first=MA|title=Anesthesia for eye, ear, nose, and throat surgery. In: Miller RD, ed. Miller's Anesthesia, 7th edition|last2=Patel|first2=A|publisher=Elsevier|year=2010|isbn=|location=Philadelphia|pages=2357-88}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|Supine&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|&amp;lt;-- May require prolonged intubation or tracheostomy care&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|Multimodal&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|Bleeding, infection, aspiration&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3830</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3830"/>
		<updated>2022-02-17T23:35:31Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT, consider awake&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = History of head and neck radiation, airway history&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = Assess degree of airway edema, smooth extubation&lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and reconstruction can be performed for all glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider CAD if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, tongue fixation / mass obstruction of the airway, presence of trismus. Consider pulmonary pathology related to smoking history. Consider OSA and possible related pHTN&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia/GERD&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supplemental equipment for a possible difficult airway including glidescope, fiberoptic, equipment for surgical airway&lt;br /&gt;
* If oral intubation, reinforced ETT and bite block recommended&lt;br /&gt;
* Assistance should be immediately available during induction&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider preoperative endoscopic or laryngoscopic airway exam to assess tumor extension&amp;lt;ref&amp;gt;{{Cite book|last=Nekhendzy|first=V|url=http://worldcat.org/oclc/983210379|title=Airway management in head and neck surgery. In: Hagberg's Benumof Airway Management, 4th edition|last2=Biro|first2=P|publisher=Elsevier Saunders|year=2018|isbn=978-0-323-42881-1|location=Philadelphia|pages=668-91|oclc=983210379}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Consider preop acetaminophen 500-1000 mg PO&lt;br /&gt;
* Consider aprepitant 40-80 mg for patients with history of severe PONV&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard premedication, preop administration of antisialogogue (glycopyrrolate) may improve operating conditions - check with surgeon&amp;lt;ref&amp;gt;{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|publisher=Lippincott Williams &amp;amp; Wilkins (LWW)|year=2019|isbn=978-1-49-637125-6|location=|pages=233-235}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference&lt;br /&gt;
* Consider awake fiberoptic if large tumor at the tongue base &lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
* Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* TIVA with propofol/remifentanil or propofol/sufentanil useful for smooth extubation (opioid blunting tracheal response)&lt;br /&gt;
* Complete muscle relaxation essential&lt;br /&gt;
* Maintaining lower MAP not mandatory but can decrease bleeding&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
* PONV prophylaxis with dexamethasone and ondansetron&lt;br /&gt;
* Maintain FiO2 &amp;lt;0.3 if lasers are used to prevent airway fire&lt;br /&gt;
* Of note, surgical manipulation at the base of the tongue can cause vagally mediated ↓ HR, ↓ BP&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Assess degree of upper airway obstruction prior to extubation - may be impossible to reintubate if obstruction occurs&lt;br /&gt;
* Smooth extubation important if skin graft used for closure (graft hematomas are the primary cause of skin graft failure) &lt;br /&gt;
* Extubation after recovery of protective airway reflexes&lt;br /&gt;
* If extubated, may require treatment with humidified oxygen or nebulized bronchodilators&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Inpatient admission depending on size/location, free flap, tracheostomy&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Intraoperative infiltration with local anesthetic&lt;br /&gt;
* Multimodal including non-opioid and bolus/PCA opioid analgesics &lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction second to airway edema&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Infection&lt;br /&gt;
* Aspiration&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Partial&lt;br /&gt;
!Subtotal/Total Resection&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|Supine&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|1-3 hr&lt;br /&gt;
|3-8 hr&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|50-150 mL&lt;br /&gt;
|100-300 mL&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|Inpatient depending on degree of resection / neck dissection / flap&lt;br /&gt;
|&amp;lt;-- May require prolonged intubation or tracheostomy care&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|Multimodal&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|Bleeding, infection, aspiration&lt;br /&gt;
|&amp;lt;--&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3829</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3829"/>
		<updated>2022-02-17T15:13:29Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = History of head and neck radiation, airway history&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and reconstruction can be performed for all glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider CAD if smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, mass obstruction of the airway, presence of trismus, tongue fixation, consider pulmonary pathology related to smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider preoperative flexible laryngoscopy to assess tumor extension&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
* Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Maintain FiO2 &amp;lt;0.3 if lasers are used&lt;br /&gt;
* Prophylactic steroids for airway edema&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Encourage early nutrition, foley removal, mobilization&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal including nonopioid and bolus/PCA opioid analgesics with peripheral local anesthetic &lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction second to airway edema&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Infection&lt;br /&gt;
* Aspiration&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3828</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3828"/>
		<updated>2022-02-17T15:10:09Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = History of head and neck radiation, airway history&lt;br /&gt;
| considerations_intraoperative = Adequate muscle relaxation, electrocautery and risk of airway fire, tracheostomy may be indicated&lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&amp;lt;ref name=&amp;quot;:0&amp;quot;&amp;gt;{{Citation|last=Bigcas|first=Jo-Lawrence M.|title=Glossectomy|date=2022|url=http://www.ncbi.nlm.nih.gov/books/NBK560636/|work=StatPearls|place=Treasure Island (FL)|publisher=StatPearls Publishing|pmid=32809471|access-date=2022-02-17|last2=Okuyemi|first2=Oluwafunmilola T.}}&amp;lt;/ref&amp;gt;&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and reconstruction can be performed for all glossectomy procedures.&amp;lt;ref name=&amp;quot;:0&amp;quot; /&amp;gt; &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|Consider CAD from smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, mass obstruction of the airway, presence of trismus, tongue fixation, consider smoking history&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|Assess for dysphagia&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* CT/MRI&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Consider preoperative flexible laryngoscopy to assess tumor extension&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Standard monitors, PIV&lt;br /&gt;
* Mouth gags per surgeon&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Nasal intubation may or may not be required depending on tumor location (for example, side versus base of tongue) and surgeon's preference&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Supine, arms tucked&lt;br /&gt;
* Arm positioning may differ if radial free flap&lt;br /&gt;
* If neck dissection, avoid neck over-rotation and brachial plexus stretch injuries&lt;br /&gt;
* Table often 180°&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Maintain FiO2 &amp;lt;0.3 if lasers are used&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Multimodal including nonopioid and bolus/PCA opioid analgesics with peripheral local anesthetic &lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
* Airway obstruction second to airway edema&lt;br /&gt;
* Bleeding&lt;br /&gt;
* Infection&lt;br /&gt;
* Aspiration&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3825</id>
		<title>Glossectomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Glossectomy&amp;diff=3825"/>
		<updated>2022-02-16T22:10:04Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = General&lt;br /&gt;
| airway = Nasal ETT, Oral ETT&lt;br /&gt;
| lines_access = PIV&lt;br /&gt;
| monitors = Standard, 5-lead ECG&lt;br /&gt;
| considerations_preoperative = History of head and neck radiation, airway history&lt;br /&gt;
| considerations_intraoperative = Nasal intubation, adequate paralysis&lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Glossectomy refers to surgical removal of part or all the tongue. It is primarily performed for excision of malignant lesions in addition to benign neoplasms of the tongue, obstructive sleep apnea, and macroglossia. Excisional or incisional biopsies of tongue lesions of undetermined etiology are also performed.&lt;br /&gt;
&lt;br /&gt;
There are several approaches to performing a glossectomy, most commonly transorally (through the mouth) for smaller and shallower tumors. Larger tumors or those with significant depth may require resection of the lower lip and mandible (&amp;quot;lip-split mandibulotomy&amp;quot;), or opening the sublingual or submental compartments for improved visualization of the inferior tongue (&amp;quot;transcervical pull-through&amp;quot;). Neck dissection and reconstruction are often performed for all glossectomy procedures. &lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|Mouth opening, mass obstruction of the airway, presence of trismus, tongue fixation&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|Consider preoperative flexible larynoscopy/imaging to assess tumor extension &lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
	<entry>
		<id>https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3824</id>
		<title>Tracheotomy</title>
		<link rel="alternate" type="text/html" href="https://wikianesthesia.org/w/index.php?title=Tracheotomy&amp;diff=3824"/>
		<updated>2022-02-16T02:12:57Z</updated>

		<summary type="html">&lt;p&gt;Helen.Heymann: &lt;/p&gt;
&lt;hr /&gt;
&lt;div&gt;{{Infobox surgical procedure&lt;br /&gt;
| anesthesia_type = &lt;br /&gt;
| airway = &lt;br /&gt;
| lines_access = &lt;br /&gt;
| monitors = &lt;br /&gt;
| considerations_preoperative = &lt;br /&gt;
| considerations_intraoperative = &lt;br /&gt;
| considerations_postoperative = &lt;br /&gt;
}}&lt;br /&gt;
&lt;br /&gt;
Provide a brief summary of this surgical procedure and its indications here.&lt;br /&gt;
&lt;br /&gt;
== Preoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Patient evaluation&amp;lt;!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --&amp;gt; ===&lt;br /&gt;
{| class=&amp;quot;wikitable&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!System&lt;br /&gt;
!Considerations&lt;br /&gt;
|-&lt;br /&gt;
|Neurologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Cardiovascular&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Respiratory&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Gastrointestinal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Hematologic&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Renal&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Endocrine&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Other&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
=== Labs and studies&amp;lt;!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Operating room setup&amp;lt;!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Patient preparation and premedication&amp;lt;!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Regional and neuraxial techniques&amp;lt;!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Intraoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Monitoring and access&amp;lt;!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Induction and airway management&amp;lt;!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Positioning&amp;lt;!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Maintenance and surgical considerations&amp;lt;!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Emergence&amp;lt;!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Postoperative management ==&lt;br /&gt;
&lt;br /&gt;
=== Disposition&amp;lt;!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Pain management&amp;lt;!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
=== Potential complications&amp;lt;!-- List and/or describe any potential postoperative complications for this case. --&amp;gt; ===&lt;br /&gt;
&lt;br /&gt;
== Procedure variants&amp;lt;!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the &amp;quot;Ω&amp;quot; tool in the editor). --&amp;gt; ==&lt;br /&gt;
&lt;br /&gt;
{| class=&amp;quot;wikitable wikitable-horizontal-scroll&amp;quot;&lt;br /&gt;
|+&lt;br /&gt;
!&lt;br /&gt;
!Variant 1&lt;br /&gt;
!Variant 2&lt;br /&gt;
|-&lt;br /&gt;
|Unique considerations&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Position&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Surgical time&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|EBL&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Postoperative disposition&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Pain management&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|-&lt;br /&gt;
|Potential complications&lt;br /&gt;
|&lt;br /&gt;
|&lt;br /&gt;
|}&lt;br /&gt;
&lt;br /&gt;
== References ==&lt;br /&gt;
&lt;br /&gt;
[[Category:Surgical procedures]]&lt;/div&gt;</summary>
		<author><name>Helen.Heymann</name></author>
	</entry>
</feed>