Does a patient need to be under general anesthesia (GA) to undergo a tracheostomy?

Tracheostomy Anesthesia Options: General vs. Local

Tracheostomy can be safely performed under either local anesthesia or general anesthesia, with the choice depending on specific patient factors, with local anesthesia being preferred in patients with difficult airways or high risk of airway compromise. 1

Patient Factors Determining Anesthesia Choice

Local Anesthesia Preferred When:

• Patient has anticipated difficult airway 1
• History of failed intubation 1
• Unfavorable airway examination 1
• Upper airway obstruction 1
• Risk of significant placental hemorrhage (in obstetric cases) 1
• Anaplastic thyroid cancer with airway involvement 1

General Anesthesia May Be Appropriate When:

• Patient has stable airway
• No anticipated difficulty with intubation
• Pediatric patients (who may not tolerate an awake procedure) 1
• When complex surgical dissection is required

Technique for Local Anesthesia Tracheostomy

1. Preparation:

   • Position patient in supine position with neck extension
   • Apply standard monitoring (ECG, pulse oximetry, blood pressure)
   • Ensure oxygen supplementation
   • Prepare for possible emergency airway intervention 1

2. Topicalization:

   • Apply topical lidocaine to the airway
   • Consider transtracheal lidocaine injection
   • Maximum safe dose: 4-5 mg/kg of lidocaine 1

3. Procedural Sedation (Optional):

   • Consider minimal sedation while maintaining spontaneous ventilation
   • Avoid deep sedation that might compromise airway 1

4. Surgical Approach:

   • Standard surgical technique with careful dissection
   • Percutaneous dilatational technique can also be performed under local anesthesia 2

Technique for General Anesthesia Tracheostomy

1. Airway Assessment:

   • Thorough pre-anesthetic evaluation 3
   • Prepare difficult airway equipment

2. Induction:

   • Standard induction with secure endotracheal intubation
   • Consider videolaryngoscopy for first attempt if difficult airway anticipated 1

3. Maintenance:

   • Standard anesthetic maintenance
   • Position with neck extension

4. Tracheostomy Insertion:

   • Surgeon performs tracheostomy while patient remains intubated
   • ETT withdrawn under direct visualization as tracheostomy tube inserted

Special Considerations

Emergency Situations

• In "cannot intubate, cannot oxygenate" scenarios, emergency surgical airway under local anesthesia is indicated 1
• Consider awake tracheostomy if severe upper airway obstruction present 4

High-Risk Patients

• Patients with Ludwig's angina or other deep neck infections may require awake tracheostomy or careful induction with multiple backup airway plans 4
• Patients with anaplastic thyroid cancer often require tracheostomy under local anesthesia due to airway involvement 1

Obstetric Patients

• Pre-emptive tracheostomy under local anesthesia may be considered in pregnant patients with anticipated difficult airways 1

Post-Procedure Management

• Close monitoring for complications (bleeding, tube displacement, obstruction) 1
• Clear communication with recovery and ward staff regarding airway management plan 1
• Written airway management plan should be in place for high-risk cases 1

Common Pitfalls to Avoid

1. Inadequate Assessment:

   • Failure to recognize a difficult airway before induction
   • Not having a backup plan for failed intubation

2. Procedural Complications:

   • Bleeding and loss of airway are immediate complications 1
   • Short-term complications include blockage or displacement 1

3. Post-Procedure Issues:

   • Inadequate monitoring after procedure
   • Poor communication between teams regarding airway management plan 1

In conclusion, the decision between local and general anesthesia for tracheostomy should be based primarily on airway assessment and the risk of failed intubation. Local anesthesia is the safer option when there are concerns about securing the airway under general anesthesia.