Association of Tracheostomy with Changes in Sedation during COVID-19: A Quality Improvement Evaluation at the University of Michigan

Abstract

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

POINT: Tracheostomy in Patients With COVID-19

“…Numerous randomized trials attest to benefits of early tracheostomy in appropriately selected patients. Tracheostomy reduces the cumulative sedation dose 14 and allows for earlier participation in physical therapy and rehabilitation; this improvement in early mobility lessens the risk of critical illness myopathy and VTE. Early tracheostomy is also associated with earlier walking, talking, and eating.…”

Tracheostomy Practices and Outcomes in Patients With COVID-19 Supported by Extracorporeal Membrane Oxygenation: An Analysis of the Extracorporeal Life Support Organization Registry

“…Receiving a tracheostomy during ECMO support was associated with a greater proportion of patients achieving a level of mobilization of sitting and exercising in bed or higher in both cohorts. The potential benefits of a tracheostomy during ECMO may include improved patient comfort, facilitating a more awake state and improved rehabilitation ( 22 ). In the comparator cohort of pre-COVID-19 viral pneumonia, 28% of patients were mobilized (43% among those who received a tracheostomy on ECMO) compared with 24% (36% among those who received a tracheostomy on ECMO) of patients with COVID-19.…”

Review of the published literature to characterise clinical excellence in COVID-19 care

“…From a critical care perspective, it was seen early in the pandemic that patients with COVID-19 induced respiratory failure required high levels of sedative medication infusion and prolonged periods of mechanical ventilation. [39][40][41] On awakening, patients found themselves in unfamiliar environments without the support of family members, who were not allowed to visit the hospital. They also had limited ability to communicate due to the presence of an endotracheal tube.…”