Ever since a cluster of patients with pneumonia of an un-2 known cause was linked to a seafood wholesale market in 3 Wuhan, China in December 2019, an outbreak of the novel 4 coronavirus (severe acute respiratory syndrome coronavirus 5 2; SARS-CoV-2) has led to a pandemic of coronavirus dis- 6 ease 2019 (COVID-19) [1] . After the World Health Orga-7 nization (WHO) upgraded the status of the outbreak from 8 epidemic to pandemic on March 11, 2020, the number of pa- 9 tients with COVID-19 has rapidly increased in many countries 10 worldwide. Patients with severe COVID-19 are likely to be 11 considered for tracheal intubation and mechanical ventilation 12 to support potential recovery from the illness, and in 4 -5% 13 * Corresponding author.
E-mail address: hmariko@med.nagoya-u.ac.jp (M. Hiramatsu).
of such patients, invasive mechanical ventilation is required 14 [2 , 3] . 15 To avoid in-hospital infection with COVID-19 among 16 healthcare workers, appropriate and strict infection prevention 17 is essential, particularly in aerosol-generating medical proce-18 dures such as tracheal intubation, bronchoscopy, cardiopul-19 monary resuscitation, and tracheostomy [4] . When perform-20 ing tracheostomy in a patient with COVID-19, meticulous 21 attention should be paid to the details of anesthetic and sur-22 gical management of the tracheostomy to minimize cross-23 contamination and occupational infection among healthcare 24 workers in the hospital. Here, we report our experience with 25 anesthetic and surgical management in a patient with COVID-26 19 who underwent tracheostomy. To prevent aerosol generation of COVID-19 if the cuff 67 would be ruptured by surgical intervention, we examined the 68 chest radiograph before performing the tracheostomy and con-69 firmed that the intubation tube would be inserted up to 27 cm 70 deep from the mouth. After intravenous injection of 70 mg 71 rocuronium for muscle relaxation, 5 mg midazolam for seda-72 tion, and 100 -200 mg fentanyl for pain control, mechanical 73 ventilation was discontinued, and chest movement was con-74 firmed to stop by the anesthesiologist. Thereafter, the intu-75 bation tube was inserted up to 27 cm deep from the mouth, 76 and mechanical ventilation was immediately reinstated. Fi-77 nally, chest movement was confirmed without listening to 78 the patient's chest using a stethoscope. During tracheostomy, 79 0.2 mg/kg of rocuronium was added every half hour to prevent 80 patient movement and coughing. Before the tracheostomy, all members inside and outside 83 the isolation room confirmed that the equipment and surgical 84 devices were ready to use. By administering local anesthe-85 sia around the neck region, surgical tracheotomy was per-86 formed by two otolaryngologists. Before opening the trachea, 87 we confirmed that muscle relaxant action and oxygenation 88 were sufficient for the subsequent surgical procedures. The 89 ventilator was turned off immediately before tracheal incision 90 to avoid aerosol generation of blood or tracheal secretions. A 91 scalpel was used to incise the trachea to reduce the risk of air-92 way fire, and the trachea was opened between the second and 93 third trachea rings. After the trachea was opened, any elec-94 trosurgical device was not used to avoid the aerosolization of 95 Table 1 Tracheostomy protocol in a suspect or probable COVID-19 patient. the tracheostomy ranged from14 days-25 days [7 , 8] . The study was performed in accordance with the Helsinki 212 Declaration of 1975 and its amendments, and the laws and 213 regulations of the Japan. Written informed consent was ob-214 tained from the patients. 215 