Open Tracheostomy for COVID-19-Positive Patients: A Method to Minimize Aerosolization and Reduce Risk of Exposure

BACKGROUND: The COVID-19 virus is highly contagious, and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies. METHODS: This is a case series of 18 patients who were COVID-19-positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts. RESULTS: There were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7 years, body mass index was 32.6, and the pretracheostomy ventilator day was 20.4 days. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation. CONCLUSION: This report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals. LEVEL OF EVIDENCE: Therapeutic/care management, Level V

Open tracheostomy for COVID-19–positive patients: A method to minimize aerosolization and reduce risk of exposure

BACKGROUND: The COVID-19 virus is highly contagious, and thus there is a potential of infecting operating staff when operating on these patients. This case series describes a method of performing open tracheostomy for COVID-19 patients while minimizing potential aerosolization of the virus using typically available equipment and supplies. METHODS: This is a case series of 18 patients who were COVID-19-positive and underwent open tracheostomy in the operating room under a negative pressure plastic hood created using readily available equipment and supplies. Patients had to be intubated for at least 14 days, be convalescing from their cytokine storm, and deemed to survive for at least 14 more days. Other indications for tracheostomy were altered mental status, severe deconditioning, respiratory failure and failed extubation attempts. RESULTS: There were 14 men and 4 women with severe SARS-CoV2 infection requiring long-term intubation since March 23 or later. The mean age was 61.7 years, body mass index was 32.6, and the pretracheostomy ventilator day was 20.4 days. The indications for tracheostomy were altered mental status, severe deconditioning and continued respiratory with hypoxia. Failed extubation attempt rate was 16.7% and hemodialysis rate was 38.9%. All patients were hemodynamically stable, without any evidence of accelerating cytokine storm. To date there was one minor bleeding due to postoperative therapeutic anticoagulation. CONCLUSION: This report describes a method of performing open tracheostomy with minimal aerosolization using readily available equipment and supplies in most hospitals. LEVEL OF EVIDENCE: Therapeutic/care management, Level V

Echocardiography derived three-dimensional printing of normal and abnormal mitral annuli

Aims and Objectives: The objective of this study was to assess the clinical feasibility of using echocardiographic data to generate three-dimensional models of normal and pathologic mitral valve annuli before and after repair procedures. Materials and Methods: High-resolution transesophageal echocardiographic data from five patients was analyzed to delineate and track the mitral annulus (MA) using Tom Tec Image-Arena software. Coordinates representing the annulus were imported into Solidworks software for constructing solid models. These solid models were converted to stereolithographic (STL) file format and three-dimensionally printed by a commercially available Maker Bot Replicator 2 three-dimensional printer. Total time from image acquisition to printing was approximately 30 min. Results: Models created were highly reflective of known geometry, shape and size of normal and pathologic mitral annuli. Post-repair models also closely resembled shapes of the rings they were implanted with. Compared to echocardiographic images of annuli seen on a computer screen, physical models were able to convey clinical information more comprehensively, making them helpful in appreciating pathology, as well as post-repair changes. Conclusions: Three-dimensional printing of the MA is possible and clinically feasible using routinely obtained echocardiographic images. Given the short turn-around time and the lack of need for additional imaging, a technique we describe here has the potential for rapid integration into clinical practice to assist with surgical education, planning and decision-making

Impact of Three-Dimensional Echocardiography on Classification of the Severity of Aortic Stenosis

<p>Background. Owing to its elliptical shape, the left ventricle outflow tract (LVOT) area is underestimated by two-dimensional (2D) diameter-based calculations which assume a circular shape. This results in overestimation of aortic stenosis (AS) by the continuity equation. In cases of moderate to severe AS, this overestimation can affect intraoperative clinical decision making (expectant management versus replacement). The purpose of this intraoperative study was to compare the aortic valve area calculated by 2D diameter based and three-dimensional (3D) derived LVOT area via transesophageal echocardiography (TEE) and its impact on severity of AS.</p><p>Methods. The LVOT area was calculated using intraoperative 2D and 3D TEE data from patients undergoing aortic valve replacement (AVR) and coronary artery bypass graft (CABG) surgery using the 2D diameter (RADIUS), 3D planimetry (PLANE), and 3D biplane (pi . x . y) measurement (ELLIPSE) methods. For each method, the LVOT area was used to determine the aortic valve area by the continuity equation and the severity of AS categorized as mild, moderate, or severe.</p><p>Results. A total of 66 patients completed the study. The RADIUS method (3.5 +/- 0.9 cm(2)) underestimated LVOT area by 21% (p <0.05) compared with the PLANE method (4.1 +/- 0.1 cm(2)) and by 18% (p <0.05) compared with the ELLIPSE method (4.0 +/- 0.9 cm(2)). There was no significant difference between the two 3D methods, namely, PLANE and ELLIPSE. Seven AVR patients (18%) and 1 CABG surgery patient (6%) who had originally been classified as severe AS by the 2D method were reclassified as moderate AS by the 3D methods (p <0.001).</p><p>Conclusions. Three-dimensional echocardiography has the potential to impact surgical decision making in cases of moderate to severe AS. (c) 2013 by The Society of Thoracic Surgeons</p>