Tracheostomy
Indications
Prolonged intubation with failure to extubate
Chronic ventilation requirement
Neuromuscular disease or injury
Chronic pulmonary disease requiring prolonged ventilation
Refractory OSA
Particularly common in patients with cranio-facial syndromes
Known difficult airway requiring prolonged or repeated intubations
Patient Considerations
Reason for trach? Will this complicate anesthetic?
Patients with severe pulmonary disease and pulmonary hypertension are less likely to tolerate the low FiO2s and the interrupted ventilation required for tracheostomy placement
Disease Specific Considerations
Poor lung function
Ventilation may be challenging
FiO2 requirement may be high
Neuro problems (spinal cord, HIE, etc)
Difficult airway?
Pulmonary HTN
How will the patient display signs of Pulmonary Hypertension?
Is there a shunt that will act as a pop-off?
Pulmonary hypertension may demonstrate as desaturation
If no pop-off, the right heart may fail
Associated Comorbidities/Syndromes
Pulmonary HTN 2/2 hypoxic pulmonary vasoconstriction
Hypoxia leads to hypoxic pulmonary vasoconstriction
Chronic hypoxia leads to vascular remodeling and a chronic increase in pulmonary vascular resistance
This increases the pressure the Right Ventricle is forced to overcome
The RV was not designed to function in a high-pressure system and may fail
Anesthetic Management:
Case Planning
Thorough Pre-Anesthetic Evaluation including identification and optimization of comorbid conditions (as allowed)
Patients are frequently already intubated (ICU Transport)
Specific or Unique Room Set-Up Requirements
Airway
Frequently patients arrive with an established airway
Children with chronic OSA presenting tracheostomy are at high risk for airway obstruction and may be a difficult airway
Drugs/Infusions
Consider paralytic and controlled ventilation
Narcotics such as fentanyl may help attenuate hemodynamic stress
Monitors
Standard ASA monitors
EtCO2 monitoring for transport
Blood Availability
Consider if anemia or coagulopathy is present at baseline
PICU Bed Availability
Patient should be taken to PICU intubated and well-sedated post-op
Anesthetic Considerations
Anesthesia Transport to OR (EtCO2, benzo, paralytic)
Limit FiO2 during cautery to avoid airway fire
Very ill patients may not tolerate prolonged decreases in FiO2
Communicate with surgeon if increased FiO2 is necessary
Surgeon will ask for ETT to be pulled back under visualization
Keep ETT at or below the cords until successful ventilation through tracheostomy is established
May leave ETT in trachea until successful arrival in PICU
Be ready to reintubate from above!!!
When surgeon enters trachea, they will place tracheostomy tube
Be prepared to hand anesthesia circuit over to surgeon
Have an accordion piece attached to the circuit for additional flexibility
Verify EtCO2 ASAP and notify surgeon IMMEDIATELY if ventilation is inadequate
Induction
IV (paralytic, benzo, narcotic)
Inhalational
Via existing ETT
Positioning
Supine, bed not turned
Maintenance
Inhalational plus additional paralytic and narcotic as indicated
Avoid Nitrous Oxide during dissection as it predisposes to airway fire
Hemodynamic/Physiologic goals
Avoid hypoxia
Limit increases in PA Pressures
Surgical Considerations (such as neuromonitoring, muscle relaxation, anticipated blood loss)
Close communication with surgeon is essential
Limit FiO2 during cautery to avoid airway fire
Surgeon will ask ETT to be pulled back under visualization
Be ready to reintubate from above if needed
When surgeon enters trachea, they will place trach
Be prepared to hand anesthesia circuit over to surgeon
Emergence/Disposition
Return to PICU with generous sedation
Post-Op Pain Management
IV narcotics
Case-Specific Complications
Hypoxia
May be due to inadequate oxygenation during dissection or existing pulmonary disease
Pulmonary HTN crisis
Nitric Oxide may be required to treat severe pulmonary hypertension
Bronchospasm
Patients requiring mechanical ventilation for pulmonary infectious processes are particularly likely to experience bronchospasm
Fistula formation
Traumatic TE Fistula may occur during tracheostomy tube placement
Loss of Airway/Trach Dislodgement
Attempting to replace a fresh trach may result in intubation of false passage
Fiberoptic guidance is likely to be unsuccessful in the setting of fresh bleeding
Intubate from above in an emergency