What the Anesthesiologist Should Know before the Operative Procedure
Pediatric patients who undergo tracheostomy do so for three primary indications:
(1) to bypass acute or chronic upper airway obstructions
(2) to facilitate long-term mechanical ventilation in patients with congenital or acquired lung disease, or in those with congenital or acquired abnormalities of central control of ventilation
(3) to facilitate tracheal suction of secretions in patients who cannot clear secretions themselves due to the nature of secretions or due to muscle weakness or neurologic impairment.
Examples of these conditions are listed in Table 1,Table 2, andTable 3.
Because many tracheostomies are performed in prematurely born infants with a history of prolonged endotracheal tube placement, with either the development of subglottic stenosis or the need for prolonged mechanical ventilation, most pediatric tracheostomies are performed during the first year of life.
|Pierre Robin sequence|
|Caustic substance ingestion|
|Vocal cord paralysis|
|Airway Obstruction (lower)|
|Subglottic stenosis after tracheal|
|Intubation (most often after premature birth)|
|Congenital diaphragmatic hernia|
|Lung disease of prematurity/|
|Tracheomalacia associated with trachea-|
|Complex congenital heart disease|
|Encephalitis (control of ventilation)|
|High spinal cord tumor|
|Central core disease|
|Central ventilatory failure (Ondine’s curse)|
|Cystic fibrosis (end stage)|
1. What is the urgency of the surgery?
In patients receiving chronic mechanical ventilation with an endotracheal tube in place, tracheostomy may be scheduled electively. In neonates, infants, or older children with airway obstruction who may have a difficult-to-impossible intubation, patients may come to the operating room emergently for airway evaluation under anesthesia (flexible and/or rigid bronchoscopy) immediately followed by airway management, which may result in endotracheal intubation or tracheostomy.
What is the risk of delay in order to obtain additional preoperative information?
Tracheostomy for intubated infants and children is elective, allowing for ample time for preoperative evaluation and laboratory studies. Patients with acute airway obstruction frequently need to come to the operating room emergently for airway evaluation (direct or fiberoptic laryngosocopy, flexible or rigid bronchoscopy) by ENT surgery. The endpoint of this evaluation may be intubation or tracheostomy, depending on the findings of examination.
In a recent report summarizing a single center’s three years of experience for 100 pediatric tracheostomies, 94% were elective and 6% were emergent. It is unlikely that any tracheostomies would fit into the category of urgent but not emergent. In multiple historical single center case series, 40% of tracheostomies were performed for upper airway obstruction and 50% for prolonged ventilation or to facilitate pulmonary toilet.
With recent innovations in technology for difficult intubation in infants and children (fiberoptic scopes, LMA, videolaryngoscopes), fewer tracheostomies are performed in children with craniofacial abnormalities than were done previously.
Emergent: Patients requiring emergency tracheostomy are those with acute upper airway obstruction whose airway cannot be secured with an endotracheal tube prior to coming to the operating room. These include patients in whom a foreign body may be partially obstructing the larynx and those in which supraglottic swelling (e.g., epiglottitis, angioneurotic edema) may prevent successful direct laryngoscopy and intubation.
Elective: Elective tracheostomy is performed as a scheduled surgery in patients whose airway has been secured with an endotracheal tube either recently or for a prolonged duration, giving the anesthesiologist and surgeon time for thorough discussion of the plans for airway evaluation and surgery.
2. Preoperative evaluation
The mainstay of preoperative evaluation is physical examination, including careful auscultation of the lungs with documentation of any rales or wheezing. Associated conditions that require evaluation in pediatric patients coming to the operating room for tracheostomy are those requiring tracheostomy because of prolonged mechanical ventilation. These patients may have progressive parenchymal lung disease, and careful documentation of preoperative condition is necessary to prepare for appropriate resources for ventilation in the operating room.
Evaluation of any concomitant condition which may be associated with coagulopathy (such as sepsis or congenital diseases of coagulation [e.g., hemophilia]) is necessary.
Patients with congenital static conditions (craniofacial abnormalities) need only review of prior airway management if not already intubated. Checking with a reliable resource (OMIM database) about associated abnormalities of organ structure or function (e.g., congenital heart disease in Apert syndrome) should guide investigation for presence of such abnormalities in the patient.
Medically unstable conditions warranting further evaluation include: cervical spine instability (congenital [e.g., some patients with Down syndrome or dwarfing syndromes] or acquired [traumatic]), increased intracranial pressure, coagulopathy, and sepsis/local infection. In patients with Down syndrome, flexion-extension films of the cervical spine, if available, should be evaluated for evidence of increased atlanto-axial distance. If films are not available, the head and neck of these patients should be stabilized with sandbags in as close as possible to the neutral position as is practical for successful performance of the tracheostomy.
Delaying surgery may be indicated if: Intubated patients with parenchymal lung disease who require high peak inspiratory pressures and/or high PEEP may require delay in tracheostomy until ventilatory pressures are in a more reasonable range. Use of high pressures after a fresh tracheostomy increases the risk of mediastinal and subcutaneous emphysema. Patients with anatomic abnormalities of the lower airway, such as thoracic dystrophy or dwarfing syndromes, may require a custom tracheostomy tube to be fashioned prior to the tracheostomy being performed. Patients with Down syndrome may have a smaller caliber trachea and require a smaller than expected tracheostomy tube, although the indwelling endotracheal tube size should be predictive.
3. What are the implications of co-existing disease on perioperative care?
Perioperative risk reduction strategies: The major concern for transport and operating room management occurs in patients with severe parenchymal lung disease requiring high inspired oxygen concentrations and high peak inspiratory and end-expiratory pressures. Such patients may have deterioration in the adequacy of their ventilation (de-recruitment) during transport with bag-tube ventilation by hand as well as during the procedure if the anesthesia machine ventilatory is incapable of delivering the same ventilatory pattern as the ICU ventilator. Such patients may benefit from delaying tracheostomy until ventilatory pressures are lowered, after which transport and the procedure may be associated with less hypoxia. There may also be a decrease in the risk of post-tracheostomy pneumothorax or pneumomediastinum.
b. Cardiovascular system
Acute/unstable conditions: If a patient is undergoing tracheostomy emergently after trauma or burns (facial/airway/chest), careful assessment and replacement of intravascular fluid volume should be performed.
Parenchymal lung disease requiring elevated inspired oxygen and/or high ventilating pressures
a. Perioperative evaluation- Physical examination with careful auscultation of the lungs is essential. Ventilator settings focusing on peak inspiratory pressure, PEEP, and FiO2 are important. Patients who require greater than 50% oxygen and high ventilatory pressures may experience severe oxygen desaturation during the interruption in ventilation that occurs during the transition from endotracheal tube to tracheostomy. Informed consent should be obtained after explanation of all risks, including hypoxia, bleeding, pneumothorax, and death.
b. Any imaging available, including chest X-ray and CT scan, should be evaluated to identify any atelactasis, pulmonary infiltrate, or emphysema. Preoperative tracheal suction and lung recruitment strategies should be employed to optimize ventilation at lowest possible inflation pressures.
Except in cases of extreme emergency, coagulation studies (PT, PTT, INR) should be performed to assess risk of bleeding during tracheostomy.
Acute issues: Patients with recent head trauma should be assessed for increased intracranial pressure. If the patient is or can be intubated, reduction and stabilization of intracranial pressure should be achieved before tracheostomy is performed.
Chronic disease: In a patient whose long standing neurologic disease is responsible for the necessity of mechanical ventilation, no intervention is necessary.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient's medications and how should they be managed in the perioperative period?
Patients who have been on chronic steroid therapy (such as patients with lung disease, neoplasms, or endocrine disease) should receive stress-dose steroids.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
i. What should be recommended with regard to continuation of medications taken chronically?
If bronchospasm has been a component of pulmonary disease, any prescribed bronchodilators, such as albuterol, should be administered prior to surgery
Patients with liver disease may have coagulation defects and should have PT, PTT, and INR determined.
j. How To modify care for patients with known allergies –
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
Children at higher risk for latex allergy include those with myelomeningocele and bladder exstrophy. Many children’s hospitals have a latex-free environment throughout the entire institution, including the operating room.
l. Does the patient have any antibiotic allergies? (common antibiotic allergies and alternative antibiotics)
Many children have a history of some reaction after the administration of penicillins (most commonly rash), but most are not truly allergic. In the setting of preoperative antibiotics for trachesostomy, the most common prophylactic antibiotic is cephazolin. If there is a history of prior reaction (maculopapular rash, urticaria, swelling) caution should be practiced and clindamycin administered (10 mg/kg up to a maximum of 600 mg).
m. Does the patient have a history of allergy to anesthesia?
Avoid all trigger agents, such as succinylcholine and inhalational agents. If case is not first case of the day, the anesthesia machine should be flushed in accordance with current recommendations to remove any traces of potent anesthetic vapors.
Proposed general anesthetic plan: Intravenous anesthesia using propofol or dexmedetomidine infusion and narcotic (remifentanil or fentanyl). A combination of propofol and ketamine may be used.
Ensure MH cart available:
Family history or risk factors for MH:
Patients who may present for tracheostomy who are at risk for malignant hyperthermia include some patients with neuromuscular disease, such as central core disease.
5. What laboratory tests should be obtained and has everything been reviewed?
Chest x-ray, CBC, and coagulation studies should be reviewed, and if not available, if time allows (elective tracheostomy), should be obtained. If the procedure is an emergency, chest x-ray should be obtained, especially after trauma, to rule out rib fractures and pneumothorax.
Common laboratory normal values will be same for all procedures, with a difference by age and gender.
Hemoglobin levels: Necessary, especially in trauma patients and chronically ill patients with prolonged ICU courses. Platelet count should also be determined.
Electrolytes: Unnecessary, unless there is a history of prior abnormalities.
Coagulation studies: If time allows.
Imaging: Chest x-ray; review CT if available
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
For tracheostomy in infants and children, general anesthesia is virtually the only option because of the need for motion control and the inability to utilize the local anesthesia plus sedation option that might be employed in adults. For general anesthesia, inhalation agent and/or intravenous anesthesia may be used.
Fundamental to the safe and successful anesthetic and surgical management of pediatric patients for tracheostomy, as in all airway surgery, is a thorough preoperative discussion between the anesthesiologist and surgeon about the plan for surgery, including the anesthetic plan (mask vs. intravenous induction, presence or absence of intravenous access, desire for maintenance of spontaneous ventilation vs. paralysis), plan for initial airway management (mask, ETT placed by surgery or anesthesia, LMA, immediate use of rigid bronchoscope by surgeon), concern for difficult ventilation or intubation (plan for management: fiberoptic with or without use of LMA, videolaryngoscope; patient may also be intubated by the surgeon with an endotracheal tube passed over a rigid bronchoscope), surgical equipment to be used (bronchoscope(s), possible need for jet ventilation, avoidance of cautery once tracheal incision is made, size of tracheostomy tube to be inserted).
If intubation is impossible, tracheostomy may be performed with the patient being ventilated via an LMA or with a rigid bronchoscope held in place manually by the anesthesiologist.
For patients coming to the operating room with an endotracheal tube in place, many have been receiving opioid and/or sedative infusions during mechanical ventilation. These infusions may be continued in the operating room along with an inhalation anesthetic. If a decision is made to discontinue opioid/sedative infusions, it is essential to provide adequate bolus doses of opiod to avoid withdrawal symptoms, especially in those who have been receiving these drugs for a prolonged period. This is also important at the end of surgery, as patients should be well sedated to prevent inadvertent decannulation of a fresh trachesotomy until the first tracheostomy change has been accomplished.
The administration of a muscle relaxant in addition to an opioid will facilitate positioning and airway manipulation required during the procedure. A muscle relaxant should be used only in patients who were intubated prior to or after arrival in the operating room. If intubation is impossible, pressure support with spontaneous ventilation should be used with an LMA. If the surgeon places a rigid bronchoscope, controlled ventilation may be utilized with muscle relaxation with the anesthesiologist securing the bronchoscope in place manually.
Tracheostomy in a child who is neither intubated with an endotracheal tube or rigid bronchoscope may be more difficult and prolonged (especially in small infants) because of the softness of the cricoid cartilage and tracheal rings. The presence of an ETT or bronchscope facilitates identification of the trachea because of their rigidity. Prior to skin incision, all devices should be removed from the esophagus (e.g., esophageal stethoscope, feeding tube, or other naso-ororogastric tubes). This is to prevent the surgeon from inadvertently incising the esophagus rather than the trachea.
After opening the trachea, the surgeon should place non-absorbable stay sutures through lateral tracheal walls with ends knotted loosely and left long and steri-stripped to chest (and correctly labeled “right” and “left” to allow traction to reopen trachea in case of inadvertent dislodgement of tracheostomy tube prior to establishment of a mature stomal passage (usually 5-7 days after placement).
Endotracheal tube tape ends should be loosened from the facial skin to enable withdrawal of ETT tip just proximal to tracheal incision with careful observation by the anesthesiologist and surgeon, allowing re-advance of the tube if the attempt to insert the tracheostomy tube is delayed. The anesthetic circuit is then attached to the tracheostomy tube.
The first breaths are gentle to confirm correct placement and avoid subcutaneous emphysema or dissection of a false passage in the event of malposition. Only after the trachesotomy tube is in place with confirmation of placement by the presence of expiratory pressure wave, end-tidal carbon dioxide wave form, and ausculatation of bilateral breath sounds, is the endotracheal tube completely removed.
Proper location of the tracheostomy tube is documented with location of tip above carina documented either by CXR or fiberoptic examination through tracheostomy tube lumen. The chest x-ray will detect pneumothorax or mediastinal emphysema, while use of the fiberoptic will only confirm tip placement above the carina.
The tracheostomy tube is secured with umbilical tape ties with the head in a neutral position after the shoulder roll has been removed. Prior to return to the intensive care unit, the trachea should be suctioned to avoid obstruction of the tube lumen, as there will most likely be blood and secretions present due to pulmonary disease and surgical trauma.
Most surgeons will inject localanesthetic (usually 0.25% bupivacaine with 1:200,000 epinephrine) toprovide analgesia and vasoconstriction prior to surgical incision.
a. General Anesthesia
Benefits: immobility, ease of positioning.
Drawbacks: Possible loss of airway in patients who cannot be intubated, but LMA will usually allow adequate ventilation.
Prior to induction of general anesthesia, an anti-cholinergic should be administered to reduce secretions (atropine 0.02 mg/kg or glycopyrrolate 0.01 mg/kg intravenously). This is important for all patients, but essential if ketamine is used as a component of the anesthetic because of its effect as a sialogogue.
Airway concerns:if ETT cannot be placed by any means, LMA or mask ventilation
Monitored Anesthesia Care
Similar to other procedures, it is unrealistic to expect that tracheostomy could be performed in a pediatric patient with monitored anesthesia care. The small size of structures and the positioning required mandates motion control which is not achievable with monitored anesthesia care in infants and children.
6. What is the author's preferred method of anesthesia technique and why?
What prophylactic antibiotics should be administered?
Cefazolin or clindamycin if history of allergy.
What do I need to know about the surgical technique to optimize my anesthetic care?
Proper positioning is fundamental to optimal performance of pediatric tracheostomy. Supine position is used with shoulder roll to extend the head as much as possible with tape across tip of mandible attached to the sides or head of the bed (or the anesthesiologists hand on the tip of the mandible) to maintain elevation of the jaw and neck extension and smooth any neck skin folds. Usually the child is maintained on 100% oxygen during procedure, as most of these children have increased oxygen requirements due to parenchymal lung disease. Because of the risk of fire, cautery is usually avoided once the trachea is opened. If bleeding is encountered and the surgeon insists cautery is necessary, the FiO2 should be reduced to as low as possible (21%) with sufficient time to wash out elevated oxygen concentration before bipolar cautery is used.
What are the most common intraoperative complications and how can they be avoided/treated?
The most common complications of tracheostomy include 1) pneumothorax, which may occur due to surgical invasion of the pleura at the apex of the lung during dissection around the trachea, or may be due to high pressure ventilation or dissection from false passage; 2) pneuomediastinum, or 3) subcutaneous emphysema. The incidence of all 3 is 3-9%. Pulmonary edema may occur if the tracheostomy relieves long standing airway obstruction. Bleeding may occur but is not likely to be substantial unless a major neck vessel is inadvertently violated. Hypoxia may occur, but should be minimized by careful coordination of slight withdrawal of the endotracheal tube to allow insertion of the tracheostomy tube, maintaining the ability to re-advance the ETT if the tracheostomy tube cannot be easily placed. The surgeon should not close the incision tightly around the tracheostomy tube to reduce the risk of subcutaneous emphysema.
b. If the patient is intubated, are there any special criteria for extubation?
c. Postoperative management
For postoperative analgesia and motion control, muscle relaxation may be maintained for transport along with continuation of any opioid and/or sedative infusions which had been used preoperatively in the intensive care unit. For patients who were not sedated preoperatively, opioids should be administered by either bolus or infusion along with propofol or benzodiazepine for amnesia if the patient is hemodynamically stable. Small patients may also be restrained with arm restraints or arm boards (no-no’s) to prevent elbow flexion.
The patient should be transported to an intensive care unit with cardiac monitor, pulse oximetry, and end tidal carbon dioxide monitoring (the latter if available). Ventilation should be supported or controlled during transport utilizing a bag and tracheostomy tube extension (Mapleson or Jackson Reese circuit if available, especially if the patient is breathing spontaneously).
Postoperative complications may include pneumothorax and, most importantly, tracheostomy tube obstruction by blood or secretions, or inadvertent decannulation.
What's the Evidence?
CONDITIONS LEADING TO PEDIATRIC TRACHEOSTOMY
Wrightson, F, Soma, M, Smith, JH. “Anesthetic experience of 100 pediatric tracheostommies”. Paediatr Anaesth.. vol. 19. 2009. pp. 659-66. (A recent single-center report of 100 pediatric tracheostomies (anesthesia perspective).)
Graf, JM, Montagnino, BA, Hueckel, R, McPherson, ML. “Pediatric tracheostomies: a recent experience from one academic center”. Pediatr Crit Care Med.. vol. 9. 2008. pp. 96-100. (A second single-center experience of 70 children and adolescents over a 24-month period (PICU perspective).)
Deutsch, ES. “Tracheostomy: pediatric considerations”. Respir Care.. vol. 55. 2010. pp. 1082-90. (Surgical technique and concerns for pediatric tracheostomy.)
Boss, EF. “Pediatric tracheostomy”. Oper Techn Otolaryngol. vol. 20. 2009. pp. 212-7.
Yoon, PJ. “The infant tracheostomy”. Oper Techn Otolaryngol. vol. 16. 2005. pp. 183-6.
Smith, LP, Roy, S. “Operating room fires in otolaryngology: risk factors and prevention”. Am J Otolaryngol.. vol. 32. 2011. pp. 109-14.
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI
- e. Neurologic:
- f. Endocrine:
- g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
- l. Does the patient have any antibiotic allergies? (common antibiotic allergies and alternative antibiotics)
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- a. Neurologic:
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management
- What's the Evidence?