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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type = General, local
| anesthesia_type = General, awake/local
| airway = ETT, tracheotomy
| airway = ETT, tracheotomy
| lines_access = PIV
| lines_access = PIV
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=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===


* Bleeding although EBL generally minimal
* Intraoperative
* Cellulitis / tracheitis
** Bleeding although EBL generally minimal
* Tracheal stenosis
** Pneumothorax
* Pneumothorax
*** Seen if low neck dissection of false passage formation
** Seen if low neck dissection of false passage formation
** Pneumomediastinum
* Pneumomediastinum
** Creation of false passage during procedure
* Creation of false passage during procedure
*** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)
** Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)
*** Signs include absent end tidal, increased PIP
** Signs include absent end tidal, increased PIP
*** If suspect, should attempt to reintroduce existing ETT
** If suspect, should attempt to reintroduce existing ETT
** Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications<ref name=":0">{{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}}</ref>


* Occlusion of tracheostomy tube
* Early postoperative complications (within 1 week):
** Secretions, mucus plug, blood, mainstem
** Cellulitis / tracheitis
** Occlusion of tracheostomy tube
*** Secretions, mucus plug, blood, mainstem
** Tracheostomy tube displacement
*** Re-intubate orally or through trach site


* Tracheostomy tube displacement
* Late complications (seen beyond 1 week):
** Re-intubate orally or through trach site
** Note early postoperative complications may also occur after 1 week
** Airway stenosis
*** Posterior glottic, subglottic, tracheal
*** Risk factors: inappropriately large ETT (>7.5), obese patients (often sized with inappropriately large ETT)<ref name=":0" />
**** Tracheal airway diameters do not correlate with body weight<ref name=":0" />
** Tracheocutaneous fistula


== Procedure variants<!-- 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 "Ω" tool in the editor). --> ==
== Procedure variants<!-- 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 "Ω" tool in the editor). --> ==
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!General
!General
!Awake
!Awake
!Bedside - Percutaneous
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|Unique considerations
|Unique considerations
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|Position
|Position
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|Surgical time
|Surgical time
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|EBL
|EBL
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|Postoperative disposition
|Postoperative disposition
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|Pain management
|Pain management
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|2.2x more likely to have early postoperative complications vs open<ref name=":0" />
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Revision as of 10:36, 22 February 2022

Tracheotomy
Anesthesia type

General, awake/local

Airway

ETT, tracheotomy

Lines and access

PIV

Monitors

Standard

Primary anesthetic considerations
Preoperative
Intraoperative
Postoperative
Article quality
Editor rating
In development
User likes
0

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.

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.

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic
Cardiovascular All patients possibly with significant cardiac risk factors, related to smoking, EtOH abuse, male gender, HLD, HTN.
Pulmonary Thorough airway exam, particularly for patients for who a tracheostomy is part of a scheduled procedure. Assess for possible recurrent aspiration.
Gastrointestinal
Hematologic If malignancy or chronic disease, coagulopathies or anemia may be present
Renal Assess for renal disease if chronic illness
Endocrine Consider adrenal suppression, hyperglycemia if ICU patient
Other Note nutritional status

Labs and studies

  • Head and Neck CT/MRI
  • CXR, ABG as indicated from H&P

Operating room setup

Patient preparation and premedication

  • Standard premedication if elective
    • Avoid if critically ill of symptoms upper airway obstruction

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

  • Standard monitors
    • Invasive monitors depending on condition
  • Avoid ECG pads in the prepped area

Induction and airway management

Intubated
  • Convert ICU sedation to GA with propofol/remifentanil or inhalational agent
Not intubated with plan for GETA
  • Standard IV induction
  • Consider awake FOI if airway problems anticipated
Awake Tracheostomy
  • Precedex

Positioning

  • Supine, head extended with shoulder roll
    • Note ETT cuff can migrate cephaled - risk of inadvertent perforation by surgeon; tape securely

Maintenance and surgical considerations

General
  • Consider TIVA with propofol/remifentanil
  • Muscle relaxation required, may use rocuronium
  • Normovolemia, normothermia
  • PONV prophylaxis with dexamethasone, ondansetron
  • To avoid ETT cuff puncture, may advance closer to carina before trachea opened
  • Slowly remove ETT under visualization of surgeon however do not remove completely
  • Once tracheostomy tube secured, connect to circuit/suction
  • Remove ETT once EtCO2 tracing confirmed and inflation pressures within normal limits
Awake

Emergence

Postoperative management

Disposition

  • Obtain CXR to assess tracheostomy tube position and check for evidence of pneumothorax / pneumomediastinum
Critically ill patients
  • Continue on ventilatory support in the ICU
  • Careful suctioning, humidified oxygen
  • Opioid sedation will minimize reaction to suctioning in early postoperative period
  • Do not remove for 5-7 days until track formed
Awake or as part of scheduled procedure

Pain management

  • Multimodal approach combining nonopioid (acetaminophen, NSAIDs), bolus/PCA opioids, peripheral local anesthetics

Potential complications

  • Intraoperative
    • Bleeding although EBL generally minimal
    • Pneumothorax
      • Seen if low neck dissection of false passage formation
    • Pneumomediastinum
    • Creation of false passage during procedure
      • Particularly true if increased mucosal swelling (edema, prolonged intubation) or increased tissue fragility (chronic steroid therapy)
      • Signs include absent end tidal, increased PIP
      • If suspect, should attempt to reintroduce existing ETT
    • Notably, nonotolaryngologists 9.1x more likely to have intraoperative complications[1]
  • Early postoperative complications (within 1 week):
    • Cellulitis / tracheitis
    • Occlusion of tracheostomy tube
      • Secretions, mucus plug, blood, mainstem
    • Tracheostomy tube displacement
      • Re-intubate orally or through trach site
  • Late complications (seen beyond 1 week):
    • Note early postoperative complications may also occur after 1 week
    • Airway stenosis
      • Posterior glottic, subglottic, tracheal
      • Risk factors: inappropriately large ETT (>7.5), obese patients (often sized with inappropriately large ETT)[1]
        • Tracheal airway diameters do not correlate with body weight[1]
    • Tracheocutaneous fistula

Procedure variants

General Awake Bedside - Percutaneous
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications 2.2x more likely to have early postoperative complications vs open[1]

References

  1. ↑ 1.0 1.1 1.2 1.3 Halum, Stacey L.; Ting, Jonathan Y.; Plowman, Emily K.; Belafsky, Peter C.; Harbarger, Claude F.; Postma, Gregory N.; Pitman, Michael J.; LaMonica, Donna; Moscatello, Augustine; Khosla, Sid; Cauley, Christy E. (2011-12-19). "A multi-institutional analysis of tracheotomy complications". The Laryngoscope. 122 (1): 38–45. doi:10.1002/lary.22364. ISSN 0023-852X.

Top contributors: Helen Heymann and Chris Rishel

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