ABSTRACT
SESSION TITLE: Lessons from the ICU: What have We Learned about the Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: October 18-21, 2020 PURPOSE: Benefits of early tracheostomy (2-10 days after intubation) include decreased sedation, days on ventilator, ICU length of stay and long-term mortality. In addition, it helps improve patient’s comfort level, tracheal suctioning, oral hygiene and facilitates early mobility in comparison to delayed tracheostomy (7-14 days after intubation). With the recent COVID-19 pandemic, an unprecedented surge in patients requiring prolonged mechanical ventilation led to an increase in the need for tracheostomies. Tracheostomy is an aerosol-generating procedure that raises potential risk to the proceduralists. Therefore, international professional otolaryngology and surgical organizations published guidelines, which recommended delaying tracheostomy to after 21 intubation days in order to ensure viral clearance prior to the procedure. In the setting of these well-intended practice guidelines, intensivists are faced with a new dilemma;following the standard of care for tracheostomy planning vs. delaying the procedure without evidence to support the new recommended guidelines. METHODS: We utilized our previously established Institute for Critical Care Medicine Tracheostomy Team (ICCM-TT), with its multidisciplinary departments, which include Critical Care, General Surgery, Cardiac and Thoracic Surgery and Otolaryngology. In April 2020, throughout the nine ICUs dedicated to the management of COVID-19 patients, the ICCM-TT performed 111 tracheostomy procedures. Case selection involved a multidisciplinary team evaluation of patient’s clinical status and wishes after goals of care discussion. Median time from translaryngeal intubation to tracheostomy was 11 days. All cases were performed at bedside, using percutaneous dilatational technique with bronchoscopic guidance. Additionally, real-time ultrasound guidance was utilized in cases identified to have difficult anatomical landmarks. All of the 111 procedures were performed within 1 day of the tracheostomy request, unless medical instability deferred the procedure or revisiting goals of care was needed. RESULTS: Of the patients who received tracheostomy for COVID-19 prolonged respiratory failure: 35 (31.5 %) patients discharged home alive, 23 (20.7 %) weaned from mechanical ventilation (no ventilator support, downsized or decannulated) but remain hospitalized on non-ICU floors, 33 (29.7 %) expired and the remaining 20 (18 %) are either in the ICUs or undergoing active weaning in a designated weaning unit. Of note, none of the ICCM-TT proceduralists acquired COVID-19 infection, all have been tested negative for antibodies. This may be due to the thorough pre-procedural planning, adherence to ICCM-TT protocols and vigilance in maintaining infection control guidelines. CONCLUSIONS: Developing a dedicated tracheostomy team and following standard of care in timing of tracheostomy for COVID-19 patients avoided unnecessary delay of patient’s care without risk of viral transmission to the staff. This facilitated patient’s ventilator weaning and discharges, which improved ICU throughput. CLINICAL IMPLICATIONS: Our results support creating a dedicated tracheostomy team and following standard of care without the need to delay a necessary procedure for COVID-19 pneumonia patients. Furthermore, this deemed safe when infection control protocols were strictly followed. DISCLOSURES: No relevant relationships by Adel Bassily-Marcus, source=Web Response No relevant relationships by Ella Illuzzi, source=Web Response No relevant relationships by Roopa Kohli-Seth, source=Web Response No relevant relationships by Evan Leibner, source=Web Response No relevant relationships by Ahmed Mohammed, source=Web Response