Novel Technique Could Minimize COVID-19 Risk During Tracheostomy

By NAVEED SALEH, MD, MS

Surgeons at Berkshire Medical Center developed a novel barrier to potentially decrease the risk for COVID-19 transmission during tracheostomy. Details were published in a recent issue of the Journal of American College of Surgeons (2020; 230[6]:1102-1104).

“In addition to all the PPE gear, we wanted to create a means to contain COVID-19 as much as possible to minimize exposure,” said Michael DiSiena, DO, the lead author and a surgeon at Berkshire Medical Center, in Pittsfield, Mass.

Dr. DiSiena said the technique is functional and easy to assemble, and it could be useful for other operations that entail aerosolization risk or droplet exposure to OR personnel.

“We used a table retractor, a device called the Omni-Tract [Integra Lifesciences],” he said. “It allowed us to create a frame, … a plastic barrier similar to a tent, that allowed us to minimize respiratory secretions from being expelled from the trachea when you perform the tracheostomy.

“If the patient has COVID-19 and you perform a tracheostomy, a gush of air is released, and that air can obviously contain respiratory droplets and viruses,” Dr. DiSiena said. “So, we developed almost a sterile tent that allowed us to see through the clear plastic drape, which is sterile. We could put our hands underneath this tent and work in an operative field.”

To further minimize the risk for contamination due to aerosolization, the team used a novel filtration system. “We then used a suction apparatus that allowed us to evacuate the air so it would be filtered almost like an N95 mask filter system,” Dr. DiSiena added.

The team also used a simple, yet novel method for testing this filtration system. While testing the air to detect respiratory droplets was outside the capabilities of their institution, the team lit a cigarette and had a smoker on staff take a puff in the field to test whether the smoke cleared. “We could not detect the cigarette smoke,” Dr. DiSiena said.

Nevertheless, Dr. DiSiena readily acknowledges that the technique lacks experimental validation. “We do not have any experimental data to prove the efficacy of it, but intuitively it seems to work out well,” he said. “Whether it ultimately translates into decreased exposure, I am unsure.”

Immediate Potential, Immediate Need

To date, the staff at Berkshire Medical Center has employed the novel tracheostomy technique on two COVID-19 patients with positive outcomes. Dr. DiSiena also explained that the intervention requires approximately five to eight minutes of setup, and it did not render surgery unsafe in any way.

Looking forward, Dr. DiSiena anticipates that other surgeons and anesthesiologists could adopt the technique for improved ‘If the patient has COVID-19 and you perform a tracheostomy, a gush of air is released, and that air can obviously contain respiratory droplets and viruses. So, we developed almost a sterile tent that allowed us to see through the clear plastic drape, which is sterile.’ —Michael DiSiena, DO

safety. “We felt we came up with a great idea. We wanted to promote this technique as soon as possible given the crisis, and allow others to adapt to the technique, modify or improve upon it.” He also hopes that industry could use the idea to develop a commercial product with greater applicability.

In a separate interview, Jingping Wang, MD, PhD, an associate professor in the Department of Anesthesia, Critical Care and Pain Medicine at Massachusetts General Hospital, in Boston, provided his perspective.

“This instrument can be used as a physical shield, like wearing a mask. But we don’t know whether it functions like a surgical mask or N95 mask,” he said.

“It may or may not be a source of control for aerosols, unless supported by a validation test. Ideally, a device should be developed to function as not only a physical barrier but also a source of control for aerosol transmission, without interrupting surgery,” Dr. Wang said. We need better-designed devices to meet our clinical demands, not only in the OR but also in the ICU, ED, on the floor and during patient transportation.” ■

IV Vitamin C, Ozone Shown Effective Against COVID-19

By BOB KRONEMYER

Intravenous vitamin C and intravenous ozone are two simple, synergistic and low-cost adjuvant therapies that have been found to be effective for managing COVID-19 in patients who have just been hospitalized, according to an article in Revista Espanola de Anestesiologia y Reanimacion (2020 Apr 14. [Epub ahead of print]. S0034-9356(20)30075- X). There are virtually no side effects with this approach.

“Vitamin C has a long track record,” said co-author Peter Papadakos, MD, FCCM, FAARC, the director of critical care medicine at the University of Rochester Medical Center and a professor of anesthesiology, surgery, neurosurgery and neurology at the University of Rochester, in New York. As an example, he and his colleagues have been using vitamin C for its anti-inflammatory effects and for fluid modulating purposes in severe burn patients for many years. Others have used vitamin C to treat sepsis and acute respiratory distress syndrome.

“With the global pandemic of COVID19, we thought vitamin C would be an ideal agent to use in these patients,” Dr. Papadakos said. “Vitamin C has immunomodulating activity and reduces alveolar epithelial water in burns. It also has a very good safety profile.”

For IV administration of vitamin C, Dr. Papadakos recommended doses typically ranging from 0.2 to 0.5 g/kg, whereas central venous access is preferred for very high doses, sometimes over 50 g/kg (Table 1).

Other components are added to the IV solution, if possible: zinc sulfate (200 mg over 24 hours), thiamine (400 mg daily), vitamin D (5,000-10,000 IU over 24 hours), and vitamin E (1,600 IU over 48 hours).

“All of these elements have been shown to be helpful,” Dr. Papadakos said. Treatment can also be supplemented with calcium and magnesium by IV, if necessary.

Ozone Disrupts Coronavirus

As a treatment, ozone attacks the envelope of coronaviruses, according to Dr. Papadakos. “By affecting cysteine, ozone disrupts viral proteins, lipoproteins, lipids and glycolipids in the actual virus. As a result, ozone creates a dysfunctional virus, which cannot replicate.” Ozone therapy also affects certain coagulation parameters.

To prepare ozone for IV, the patient’s blood is saturated with ozone from a medically approved ozone machine, then the patient’s

Peter Papadakos, MD, FCCM, FAARC

blood containing the ozone molecule is infused into the patient (Table 2).

Peripheral venous access is favored, using a butterfly infusion set or cannula. The ozone/ oxygen mixture is adjusted to a 1:1 ratio, with a starting dose of 25 mcg/mL of blood, followed in subsequent days by up to 80 mcg/mL.

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Table 1. Protocol for IV Vitamin C Administration for COVID-19 Infection

• Central venous access preferable for very high doses (>50 g)

• Check: blood count, renal function, 1 electrolytes and G6PD

• Check IL-6; ferritin levels may be a useful indicator of therapeutic response and prognosis

• Use sterile water, PlasmaLyte or Lactated Ringer’s for mixture, or dextrose 5%-10%

• Doses: 0.2-0.5 g/kg vitamin C 2

• Administer daily until improvement, then every 2 days

• Infusion rate: adjust for 0.25-0.5 g/min (usually 1 to 4 h according to dose)

• Supplement with calcium and/or magnesium IV, if necessary

• If possible add zinc sulfate 220 mg/24 h, 3 thiamine 400 mg/d, vitamin D 5,000-10,000 IU/24 h, 4 vitamin E 1600 IU/48 h oral/NG, melatonin 6 mg/24 h oral at night

1 Caution with doses and frequency of administration. 2 If patient is in critical condition, suggest dose administration twice a day (every 12 hours). 3 220 mg of zinc sulfate contains 50 mg of elemental zinc. 4 Aim for 25(OH) level of 80-90 nmol/L.

Table 2. Ozone Auto hemotherapy Protocol For COVID-19 Infection

• Exclusive venous access for ozone administration. Peripheral venous access is preferable on the ward; use a central line for ICU patients

• Blood removal: 150-200 mL

• Anticoagulant to add in the sterile bottle or bag: - Heparin sodium: 1,000 IU for each 100 mL of blood removed; or - Sodium citrate 3.13%: 10 mL for each 100 mL of blood removed; or - ACD-A (Anticoagulant Citrate Dextrose A): 14 mL for each 100 mL blood removed

• Initial dose: 40 mcg/mL of ozone. Increasing dose is acceptable in ensuing days to a maximum of 70 mcg/mL

• Volume of gas O 2 /O 3 200 mL

• Shake the bottle gently once ozone is mixed with the blood and every 2 minutes during administration

• 2 sessions per day in non-critically ill patients and 4 sessions per day in critically ill patients until improvement