Percutaneous and surgical tracheostomy is safe in critically ill patients requiring prolonged mechanical ventilation (1, 2, 3). However, existing trial data are inconclusive on optimal timing of tracheostomy (4, 5). This uncertainty has grown during the COVID-19 pandemic (6). Guidelines have recommended that tracheostomy be delayed later than most "late tracheostomy" arms of recent trials (1, 5, 7, 8, 9, 10, 11, 12). This delay arises from uncertainty of patient benefit as well as concern for healthcare workers during aerosol-generating procedures (5, 13). The relatively younger, less comorbid populations with COVID-19 may be more challenging to sedate or achieve ventilator synchrony (14). We reviewed our institution's experience with COVID-19 patients undergoing tracheostomy placement at the discretion of the attending intensivist, to evaluate whether tracheostomy was associated with a reduction in sedation and analgesia administration. Methods Patients were included if they were at least 18 years old; positive for COVID-19 on a reversetranscriptase polymerase chain reaction SARS-CoV-2 test; and did not have another indication for deep sedation. Timing of tracheostomy was determined by attending intensivist. Data were collected for the day of tracheostomy and five days pre-and post-procedure by two independent trained data abstractors blinded to each other's results; differences were reconciled. Drug dosages were obtained by a pharmacist via electronic data abstraction. Opioids included fentanyl, oxycodone, morphine, and hydromorphone. Opioid doses were converted into intravenous (IV) fentanyl equivalents (100 mcg [0.1 mg] IV fentanyl = 1.5 mg IV hydromorphone = 5 mg oral hydromorphone = 20 mg oxycodone = 30 mg oral morphine = 10
The use of extracorporeal membrane oxygenation (ECMO) in patients with COVID-19 has been supported by major healthcare organizations, yet the role of specific management strategies during ECMO requires further study. We sought to characterize tracheostomy practices, complications, and outcomes in ECMO-supported patients with acute respiratory failure related to COVID-19.
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