Tracheostomy (percutaneous)

Anesthesia Implications

Position: Supine, arms tucked, head slightly extended
Time: 5-30 min (very short)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: No

ICU transport – In these cases, the patient is often transported from the ICU. How the patient is transported/maintained depends on what the patient’s baseline is in the ICU. Some will give paralytic/sedation if the patient is paralyzed/sedated. If the patient is awake, transport can be with airway support and minimal sedation. Once in the OR, sedate/paralyze as needed.

Loosen ETT – The patient’s head will be completely under the drape. This makes it difficult to loosen the tracheal tube already in place. Its recommended to get the straps/attachments loose prior to draping to make for an easy withdraw when the time comes.

Turn down O2 – the surgeon will more than likely use cautery at some point during the surgery. VERY IMPORTANT to have the 02 turned down or you may end up with an airway fire

Withdraw ETT – The surgeon will ask you to deflate the cuff and pull the ETT back. The physicians concern is puncturing the cuff when advancing the percutaneous needle. The idea is to withdraw the tube enough to avoid puncture of the ETT, but not so much that it is completely out. Do not pull the ETT completely until the surgeon has confirmed a secured airway.

Additional advice from the pros – Before withdrawing the ETT, introduce a boujie (eschmann stylet) so if something goes wrong, and for some reason the ETT becomes too far withdrawn, you have a direct conduit to the airway.

Once access is made, the surgeon will ask to have your circuit. The circuit will be attached, ETCO2 and volumes confirmed. After confirmation, the old ETT can be discontinued.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Once the patient is prepped and draped, the surgeon will find and mark the point of entry. Needle will be inserted with negative pressure, so when the trachea is accessed, air will be aspirated. The point of entry is then dilated and the tracheal tube is placed.