Trach cancellations?

[anbuitachi]

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We are doing many trachs for covid patients in the OR.

Issue is, trachs are semi urgent? What criteria do you use to proceed vs cancel, to weigh risk vs benefit? Thought process?

Obviously many of these patients are very sick and have many abnormal labs/vitals. The issue is it seems like they are all over the place and it seems like everyone has their own practice. Some are on pressors, some on spiking fevers, some hypotensive, some high vent settings, abnormal lab values (eg BUN > 100, hypernatremia, significantly hypercarbic etc), some patients arrested multiple times in hospital stay. Surgeons also have their own reasons of wanting to do them.. eg get patient out of ICU, or hospital, or possibly to improve pulmonary recovery...
Thoughts?

 

[jeterfan]

Trachs are one of those dammed if you do/don’t type cases at my shop. They are fast..pay good..get patients out..of course they go bad with really sick patients..they get cancelled only if really high pressors, or ridiculous vent/peep requirements..almost all surgeons understand these reasons and won’t book such scenarios..other reasons not so much understanding ..we had some in the past get cancelled for electrolyte or ekg reasons and surgeons then decide to go do them at bedside. that becomes its own administrative minefield

 

[KENY1]

I am surprised you're doing so many trachs.
1.these patients are on a ventilator for weeks but typically not longer than that.
2. Turning prone has a high risk of trach dislodg.
3. Tracheostomy has a high risk of aerosol dispersion.
Am I missing something ?

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[IMGASMD]

I am surprised you're doing so many trachs.
1.these patients are on a ventilator for weeks but typically not longer than that.
2. Turning prone has a high risk of trach dislodg.
3. Tracheostomy has a high risk of aerosol dispersion.
Am I missing something ?

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Only asking. about 3. If they are paralyzed and you stopped the vent, are they aerosolized more than someone just breathing?

 

[KENY1]

Not sure what u mean.
Generally from.rhw Tran SARS reviews anything to do.qith the trachea is a high risk of infection. You open the area where Covid lives.
Yes during paralysis and no ventilation it's better but the air doesn't stand still. You're pushing the reach in - that stirs the air.

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[KENY1]

Not sure what u mean.
Generally from the Tran SARS reviews anything to do with the trachea is a high risk of infection. You open the area where Covid lives.
Yes during paralysis and no ventilation it's better but the air doesn't stand still. You're pushing the reach in - that stirs the air.

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[abolt18]

We are doing many trachs for covid patients in the OR.

Issue is, trachs are semi urgent? What criteria do you use to proceed vs cancel, to weigh risk vs benefit? Thought process?

Obviously many of these patients are very sick and have many abnormal labs/vitals. The issue is it seems like they are all over the place and it seems like everyone has their own practice. Some are on pressors, some on spiking fevers, some hypotensive, some high vent settings, abnormal lab values (eg BUN > 100, hypernatremia, significantly hypercarbic etc), some patients arrested multiple times in hospital stay. Surgeons also have their own reasons of wanting to do them.. eg get patient out of ICU, or hospital, or possibly to improve pulmonary recovery...
Thoughts?

Maybe I lack understanding but a trach is not really a life-saving procedure in an intubated patient. Those critically ill patients who are hypotensive, acute renal failure not yet recovering or dialyzed, or the severe resp failure still requiring intermittent proning, high PEEP and high FiO2, are not in urgent need of a trach in my mind. Those patients are in urgent need of recovery and a trach isn't going to get them there.

Save the trach for the recovering patient who is failing to wean from the vent but could otherwise leave the ICU. That's just my perspective but I look forward to hearing from others with more knowledge.

 

[jeterfan]

Definitely doing a lot more covid confirmed cases in the last week. Breast lumpectomies, hip fractures. Some symptomatic, some urgent others not so much. The paranoia on my end and most of the or has gradually waned. Not as many space suits as there were a week ago. Just secure fitting mask for sure.
should the 96 yo symptomatic covid hip fracture get a tube, or spinal and mask?. I stopped thinking about it from the headache and just do what would be best for the patient if it was a relative. it’s probably a little careless. But then again so is running up a burning building about to collapse. At the end of the day the quote from The Godfather always reminds me ...
“this is the business we’ve chosen”

 

[KENY1]

Not sure what u mean.
Generally from the Tran SARS reviews anything to do.qith the trachea is a high risk of infection. You open the area where Covid lives.
Yes during paralysis and no ventilation it's better but the air doesn't stand still. You're pushing the trach in - that stirs the air.

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[Mman]

Maybe I lack understanding but a trach is not really a life-saving procedure in an intubated patient. Those critically ill patients who are hypotensive, acute renal failure not yet recovering or dialyzed, or the severe resp failure still requiring intermittent proning, high PEEP and high FiO2, are not in urgent need of a trach in my mind. Those patients are in urgent need of recovery and a trach isn't going to get them there.

Save the trach for the recovering patient who is failing to wean from the vent but could otherwise leave the ICU. That's just my perspective but I look forward to hearing from others with more knowledge.

our ENTs and trauma surgeons have basically decided no covid patients are getting trached. As you point out it provides no mortality benefit to them and exposes OR staff to unnecessary risk.

 

[deleted875186]

I’m in an endemic area. Doing a lot of trachs.

Obviously only in stable patients, low vent settings. Have to do them. I would never cancel for electrolyte or EKG issues unless acutely dangerous. A lot of these severe Covid cases recover from the acute respiratory failure, but obviously end up quite sick and can’t be extubated for various reason. A lot of these severe Covid cases aren’t healthy to begin with. The ICU is doing palliative care on all patients, but still have a ton of people going out with trachs.

 

[IMGASMD]

Not sure what u mean.
Generally from.rhw Tran SARS reviews anything to do.qith the trachea is a high risk of infection. You open the area where Covid lives.
Yes during paralysis and no ventilation it's better but the air doesn't stand still. You're pushing the reach in - that stirs the air.

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So these patient are presumably days out, are they still shedding as much? Or are they still shedding. I understand there is airflow, but if you minimize airflow, no active ventilation with the fact they may actually “recovered” just lung took a hit. You take proper precautions, is it as dangerous as say an intubation in day 10 of their disease course?
I am only asking, not arguing for any points.

 

[KENY1]

1. This patient needs a vent = is not 'recovered'.
2. Shedding - not an ICU doc myself - but yes I'm sure they're shedding - it's eating up their alveoli.
3. I think the high danger to airway management is the closeness of our own airways to theirs. At this 1-2 yard distance - I imagine - airborne viruses can come from their airway to ours without having to take an aerosolized splutter/mist as carrier. Airborne particles are then sucked in by us despite the barriers such as an N-95 etc.
That's all my imagination, maybe somebody more knowledgeable in C19 transmission can set me straight here, it's fine by me, happy to learn.

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[dannyboy1]

I only cancel a trach if I think the patient won’t survive the procedure. Risk vs Benefit? What risk! The patient is already fu(led up .....

 

[abolt18]

I only cancel a trach if I think the patient won’t survive the procedure. Risk vs Benefit? What risk! The patient is already fu(led up .....

Risk to yourself and all the other OR staff and support staff who have to come in the room after.

 

[dannyboy1]

Risk to yourself and all the other OR staff and support staff who have to come in the room after.

COVID is here and is not going away. We are just going to have to live with it. Wear the N95 and face shield and get on with life.....

 

[KENY1]

I would wear a PAPR with just the cloth/plastic ortho hood over it, that's the best arrangement.
A gown, apron, booties, triple gloves, keep changing them, disinfectant wipes in-between glove changes for your hands and anything you may have touched.

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[KENY1]

N-95 under PAPR under Ortho hood

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[chocomorsel]

I would wear a PAPR with just the cloth/plastic ortho hood over it, that's the best arrangement.
A gown, apron, booties, triple gloves, keep changing them, disinfectant wipes in-between glove changes for your hands and anything you may have touched.

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Is this what you are actually doing when taking care of these patients? Every single day? With every patient?

 

[KENY1]

It makes me feel I am protecting myself and my family better and once you get used to it it's not really bad and people around you will also get used to you.

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[Arch Guillotti]

N-95 under PAPR under Ortho hoodView attachment 304765

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Way too much!

 

[KENY1]

The PAPR doesn't cover your neck where splashes can go and cause contact contamination. Ortho hood by itself doesn't filter the virus. This is a disease that can kill you. It's entirely up to you what you do, if you take off your mask nobody is going to force you to put it on.

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[deleted875186]

The PAPR doesn't cover your neck where splashes can go and cause contact contamination. Ortho hood by itself doesn't filter the virus. This is a disease that can kill you. It's entirely up to you what you do, if you take off your mask nobody is going to force you to put it on.

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If you guys have the resources go for it, it’s just a waste though. Practice good hand hygiene and wear the mask correctly, change your scrubs when leaving.

Where I am we have to wear the same N95 for multiple Covid patients, procedures, intubations, due to low inventory. Perspective.

 

[KENY1]

Sorry to hear that. PAPRs are reusable, there is no waste. If you wanted to I could also reuse the hood - if it doesn't get soiled. It's better than nothing. And then the N-95 - same as you have.
That way it's really no more waste then anything else. People everywhere are protesting they don't have enough protection - so when its available it should be used. What else would you be saving the protection for ?

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[nimbus]

The PAPR doesn't cover your neck where splashes can go and cause contact contamination. Ortho hood by itself doesn't filter the virus. This is a disease that can kill you. It's entirely up to you what you do, if you take off your mask nobody is going to force you to put it on.

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It’s too bad there isn’t a PAPR that provides the same coverage as an ortho hood.

 

[IMGASMD]

Sorry to hear that. PAPRs are reusable, there is no waste. If you wanted to I could also reuse the hood - if it doesn't get soiled. It's better than nothing. And then the N-95 - same as you have.
That way it's really no more waste then anything else. People everywhere are protesting they don't have enough protection - so when its available it should be used. What else would you be saving the protection for ?

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Not in an endemic area. So we don’t see crazy numbers that my other colleagues, co-residents saw.
We as a team have fortunately been doing okay with readily available N95. We do keep one for the whole day. We do gown up for all covid intubations, covid positive patients. Even PUI now, with rapid tests, you can get a result within hours to “know” to status. Quotes because we discuss the false negatives on a daily basis amongst ourselves. We do have staff who insist on using respirators, which we are very supportive of.

You do whatever you need to feel comfortable to perform your job well. I, as a of member of a minority group, do feel there is some social stigma (certainly also feel privileged as a doctor) when I get “proper” (whatever that really means) PPE but some of other staff may not.

But you’re absolutely right, this is a disease that kills and our priority should be to ourselves and our families. So if you have the resources, you do owe it to your loved one to get as protected as you feel necessary.

COVID is here and is not going away. We are just going to have to live with it. Wear the N95 and face shield and get on with life.....

The initial reason for stay home order is to flatten the curve. I feel that we’ve achieved that.

 

[Mman]

I’m in an endemic area. Doing a lot of trachs.

Obviously only in stable patients, low vent settings. Have to do them. I would never cancel for electrolyte or EKG issues unless acutely dangerous. A lot of these severe Covid cases recover from the acute respiratory failure, but obviously end up quite sick and can’t be extubated for various reason. A lot of these severe Covid cases aren’t healthy to begin with. The ICU is doing palliative care on all patients, but still have a ton of people going out with trachs.

so why doing a lot of trachs? It isn't lowering their mortality from the disease. Is it because we always trach people after a week or two on the vent? Because that seems like a bad reason. We have had a couple patients that were on the vent for > 21 days and got extubated and eventually sent home.

 

[Fart Daddy Smooth]

Sorry to hear that. PAPRs are reusable, there is no waste. If you wanted to I could also reuse the hood - if it doesn't get soiled. It's better than nothing. And then the N-95 - same as you have.
That way it's really no more waste then anything else. People everywhere are protesting they don't have enough protection - so when its available it should be used. What else would you be saving the protection for ?

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N95 is redundant under the PAPR, no?

 

[anbuitachi]

N95 is redundant under the PAPR, no?

technically pretty much. but people do what makes them comfortable. i also use n95 under papr for many reasons, a lot of it probably just in my head, but it makes me feel better!. one reason is bc so many covids in the hospital, and its questionably airborne, so when i take off papr i want n95 protection. also if for WHATEVER reason my papr isnt sealed well or stops working, at least i have n95 on. i dont mind extra precautions if i know me getting the disease can very well kill me

 

[chocomorsel]

It’s too bad there isn’t a PAPR that provides the same coverage as an ortho hood.

Is this sarcasm, because they are out there. That’s all I have seen.

 

[chocomorsel]

so why doing a lot of trachs? It isn't lowering their mortality from the disease. Is it because we always trach people after a week or two on the vent? Because that seems like a bad reason. We have had a couple patients that were on the vent for > 21 days and got extubated and eventually sent home.

People are tubed for three weeks and still not waking up. They weren’t doing them for anyone intubated less than three weeks where I was. Which I completely agreed with.
I would have preferred a head CT first but no one was doing that. Then possibly move them to the palliative unit if CT was bad. Who knows what’s going on in their brain.
Lots of strokes for sure as the initial symptoms for many patients.

 

[deleted171991]

We are doing many trachs for covid patients in the OR.

Issue is, trachs are semi urgent? What criteria do you use to proceed vs cancel, to weigh risk vs benefit? Thought process?

Obviously many of these patients are very sick and have many abnormal labs/vitals. The issue is it seems like they are all over the place and it seems like everyone has their own practice. Some are on pressors, some on spiking fevers, some hypotensive, some high vent settings, abnormal lab values (eg BUN > 100, hypernatremia, significantly hypercarbic etc), some patients arrested multiple times in hospital stay. Surgeons also have their own reasons of wanting to do them.. eg get patient out of ICU, or hospital, or possibly to improve pulmonary recovery...
Thoughts?

Trachs are semi-urgent procedures. The longer a patient has been on the vent, the higher the benefits for the patient, especially if the indication is being unable to wean. The risks include airway risks for the patient and infectious risks for the personnel.

The risks and benefits should be weighed individually. There is no clearcut rule. This is where having a good intensivist matters.

Without looking up evidence, I would bet that every day of intubation increases a patient's risk of dying, just because of all the extra fluids and pressors it requires. Nothing beats having the patient awake, and able to take PO.

Most trachs could and should be done at bedside, especially in Covid-19 patients. Except for potentially difficult airways or trachs, there is no reason to bring the patient to the OR. I haven't seen a trach in my OR for years (but I'm not in a big cacademic hospital).

 

[Arch Guillotti]

It’s too bad there isn’t a PAPR that provides the same coverage as an ortho hood.

Not all PAPR's are created equally. Some just cover the head and others also have a drape over your shoulders.

 

[Arch Guillotti]

Most trachs could and should be done at bedside, especially in Covid-19 patients. Except for potentially difficult airways or trachs, there is no reason to bring the patient to the OR. I haven't seen a trach in my OR for years (but I'm not in a big cacademic hospital).

All the surgeons I have ever worked with want them in the OR for lighting, room, equipment, etc.

 

[deleted171991]

All the surgeons I have ever worked with want them in the OR for lighting, room, equipment, etc.

I too would like a Ferrari instead of a family sedan.

They should grow up, especially in an epidemic. Trachs were done at bedside for decades, even daily abdominal washouts. Spoiled primadonnas.

There is no reason to risk spreading Covid to other hospital areas, for a simple procedure.

 

[anbuitachi]

Trachs are semi-urgent procedures. The longer a patient has been on the vent, the higher the benefits for the patient, especially if the indication is being unable to wean. The risks include airway risks for the patient and infectious risks for the personnel.

The risks and benefits should be weighed individually. There is no clearcut rule. This is where having a good intensivist matters.

Without looking up evidence, I would put my hand in fire that every day of intubation increases a patient's risk of dying, just because of all the extra fluids and pressors it requires. Nothing beats having the patient awake, and able to take PO.

Most trachs could and should be done at bedside, especially in Covid-19 patients. Except for potentially difficult airways or trachs, there is no reason to bring the patient to the OR. I haven't seen a trach in my OR for years (but I'm not in a big cacademic hospital).

you are a ICU person. what is your strategy on weaning patients off sedation? some of these patients they want to trach bc cant wean off sedation without being agitated. i see them being on like 15mg midaz/hr , 300 fent/hr, 1 of precedex, for week+ and the primary teams complain they cant wean them off sedation bc of agitation, therefore -> trach.

All the surgeons I have ever worked with want them in the OR for lighting, room, equipment, etc.

that's what is happening here in my hospital.

 

[anbuitachi]

I too would like a Ferrari instead of a family sedan.

They should grow up, especially in an epidemic. Trachs were done at bedside for decades, even daily abdominal washouts. Spoiled primadonnas.

There is no reason to risk spreading Covid to other hospital areas, for a simple procedure.

surgeons growing up?! what?!

 

[deleted171991]

you are a ICU person. what is your strategy on weaning patients off sedation? some of these patients they want to trach bc cant wean off sedation without being agitated. i see them being on like 15mg midaz/hr , 300 fent/hr, 1 of precedex, for week+ and the primary teams complain they cant wean them off sedation bc of agitation, therefore -> trach.



that's what is happening here in my hospital.

There is a reason critical care fellowships take at least a year. 😉

You have a systemic problem, which you should bring up with the ICU leadership.

 

[chocomorsel]

you are a ICU person. what is your strategy on weaning patients off sedation? some of these patients they want to trach bc cant wean off sedation without being agitated. i see them being on like 15mg midaz/hr , 300 fent/hr, 1 of precedex, for week+ and the primary teams complain they cant wean them off sedation bc of agitation, therefore -> trach.



that's what is happening here in my hospital.

That’s an insane and unnecessary amount of sedation. These patients are gonna have serious withdrawal and agitation coming off those insane amounts of drugs.
Before you get to such high levels of IV drugs, consider paralysis.
Only way to wean those people now it to transition to oral Benzos and oral pain meds and or psych meds. And it will still take a long time.
Totally insane.

 

[anbuitachi]

That’s an insane and unnecessary amount of sedation. These patients are gonna have serious withdrawal and agitation coming off those insane amounts of drugs.
Before you get to such high levels of IV drugs, consider paralysis.
Only way to wean those people now it to transition to oral Benzos and oral pain meds and or psych meds. And it will still take a long time.
Totally insane.

yea we recommended paralysis since the beginning, mainly bc a lot of our airways were due to unintended extubations. but medicine/specialty interns have no experience with paralysis so i guess they werent using.

but now its too late for many of these patients on these high doses. wondering if there are IV stuff we can recommend to help but im not experienced either with this long high dose sedations and weaning

 

[nimbus]

Is this sarcasm, because they are out there. That’s all I have seen.

No, wasn’t sarcastic. Didn’t know.

 

[chocomorsel]

yea we recommended paralysis since the beginning, mainly bc a lot of our airways were due to unintended extubations. but medicine/specialty interns have no experience with paralysis so i guess they werent using.

but now its too late for many of these patients on these high doses. wondering if there are IV stuff we can recommend to help but im not experienced either with this long high dose sedations and weaning

Time. Lots of it. With oral transition. Seems like they bought themselves a trach.
I hope they still aren’t doing this. They can look up how to paralyze.

 

[Mman]

Without looking up evidence, I would bet that every day of intubation increases a patient's risk of dying, just because of all the extra fluids and pressors it requires. Nothing beats having the patient awake, and able to take PO.

While that seems like it might be true, it's the sort of thing that we can't use experience to determine because by definition the patients that are extubated are doing better than the ones that we couldn't extubate yet. We all wish our patients were off the vent and doing better, but that's because their disease course had gotten better and not necessarily because the vent was making them worse.

Trachs decrease morbidity, not mortality.

 

[deleted171991]

Trachs decrease morbidity, not mortality.

That's absolutely false for late (but not very late) trachs, especially in patients who only have the tube because of failure to wean (and not because of bad lungs).

Beyond the respiratory care advantages, trachs decrease the need for sedation and IV fluids, both of which are long-term silent killers.

 

[CCM-MD]

you are a ICU person. what is your strategy on weaning patients off sedation? some of these patients they want to trach bc cant wean off sedation without being agitated. i see them being on like 15mg midaz/hr , 300 fent/hr, 1 of precedex, for week+ and the primary teams complain they cant wean them off sedation bc of agitation, therefore -> trach.



that's what is happening here in my hospital.

That is a **** ton of sedation.

We do our own trachs at the bedside. Waiting 3-4 weeks on COVIDs and only doing them to aid with weaning. We have run out of blue rhino kits.

We are doing many trachs for covid patients in the OR.

Issue is, trachs are semi urgent? What criteria do you use to proceed vs cancel, to weigh risk vs benefit? Thought process?

Obviously many of these patients are very sick and have many abnormal labs/vitals. The issue is it seems like they are all over the place and it seems like everyone has their own practice. Some are on pressors, some on spiking fevers, some hypotensive, some high vent settings, abnormal lab values (eg BUN > 100, hypernatremia, significantly hypercarbic etc), some patients arrested multiple times in hospital stay. Surgeons also have their own reasons of wanting to do them.. eg get patient out of ICU, or hospital, or possibly to improve pulmonary recovery...
Thoughts?

Many of my patients have hypernatremia and other abnormal lab values, they will probably be ok. But trach on a shocky, septic patient? Can probably wait.

 

[dannyboy1]

While that seems like it might be true, it's the sort of thing that we can't use experience to determine because by definition the patients that are extubated are doing better than the ones that we couldn't extubate yet. We all wish our patients were off the vent and doing better, but that's because their disease course had gotten better and not necessarily because the vent was making them worse.

Trachs decrease morbidity, not mortality.

Trachs are about placement. And remember
PLACEMENT COMES FIRST

 

[Mman]

That's absolutely false for late (but not very late) trachs, especially in patients who only have the tube because of failure to wean (and not because of bad lungs).

so for stroked out neuro patients?

 

[deleted171991]

so for stroked out neuro patients?

Obviously if a patient is a vegetable, a trach won't matter much. But I've seen many patients where a trach radically changed their prolonged ICU course.

Maintenance IV fluids and sedation for prolonged intubation make me .

 

[Mman]

Obviously if a patient is a vegetable, a trach won't matter much.

But I've seen many patients where a trach radically changed their prolonged ICU course.

so they would have died but now lived? Or they just got out of the ICU sooner?

 

[deleted171991]

so they would have died but now lived? Or they just got out of the ICU sooner?

They would have died.

Beyond the 2-week mark, many families and physicians will give up and go the CMO route. Many even earlier.

During fellowship, I had a few patients where I literally begged the families to let me trach the patient (they were afraid of the patient becoming vent-dependent), wake the patient up and go from there, instead of the CMO they wanted (based on advanced directives). All of them survived with (close to) baseline (i.e. good) QOL.

It's very hard to see the end of the tunnel when your loved one is sedated into oblivion, on pressors, with tons of tubes and monitors, possibly already f-ed up by fluid overload. Many people will get CMO'd unnecessarily by tired families and lazy/incompetent providers. I prefer the patient awake and able to make her own decisions.