Position: Supine, arms tucked, head slightly extended
Time: 30-60 min (short)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: No

ICU transport – In these cases, the patient is often transported from the ICU. How the patient is transported/maintained depends on what the patient’s baseline is in the ICU. Some will give paralytic/sedation if the patient is paralyzed/sedated. If the patient is awake, transport can be with airway support and minimal sedation. Once in the OR, sedate/paralyze as needed.

Loosen ETT – The patient’s head will be completely under the drape. This makes it difficult to loosen the tracheal tube already in place. Its recommended to get the straps/attachments loose prior to draping to make for an easy withdraw when the time comes.

Turn down O2 – the surgeon will be dissecting down to the trachea with cautery. VERY IMPORTANT to have the O2 turned down or you may end up with an airway fire

Withdraw ETT – The surgeon will dissect down to the trachea. When he/she is ready, they will ask you to withdraw the ETT to just cephalad to the incision. Do not pull the ETT completely until the surgeon has confirmed a secured airway.

Once access is made, the surgeon will ask to have your circuit. The circuit will be attached, ETCO2 and volumes confirmed. After confirmation, the old ETT can be discontinued.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

Airway Fire Risk (general considerations): Keep the inspired oxygen concentration (FIO2) below 30% in the breathing circuit to prevent airway fires. It is crucial to note that even after adjusting to the “safe” FIO2 range, the expiratory oxygen concentration can remain above 30% for a considerable amount of time, presenting an ongoing risk of airway fire. The inspired and expired oxygen concentrations in the circuit are influenced by various factors including the circuit’s length, the fresh gas flow rate, and the starting oxygen concentration, potentially taking several minutes to decrease to below 30%.

Once the patient is prepped and draped, the surgeon will find and mark the incision site. Cautery will be utilized to cut down to the trachea. Once accessed, the surgeon will request the ETT tube to be pulled out slightly until the end of the ETT is cephalad to the incision. The tracheal tube will then be accessed, and the old ETT discontinued.