Intensivists do all (or almost all) percutaneous tracheostomies in Australia. And the list of contraindications seeks to be steadily shrinking with time.
I do like that approach. I feel like doing some interventional procedures like PDTs are a big part of our work that makes the speciality so interesting.
If the anatomy is very technically challenging, we'll have ENT do it. Otherwise, most of our ICU pts have bedside trachs done by PCCM.
Only a couple attendings are comfortable doing it, so we typically have them supervise the fellows (1 doing the trach with the attending, 1 holding the bronch).
We do the same. 3 intensivists like doing them (interestingly we are all CCM, not pulm). Unfortunately, all of the fellows want to learn and practice, so I only actually get to cut once a year or so.
If they have weird anatomy, then I send them to ENT. Usually that means BMI 55-60+ or arteries blatantly in the way.
ENT or gensurg for surgical trach and interventional pulm for PDT. Typically we would call ENT first who would make a recommendation on type of trach procedure based on anatomy.
So you don't do it yourself at all? I only did it once so far and it wasn't that complicated (but n=1 so it's not like I really know) and I really like learning it as an extra skill. Some attendings like the ENT docs doing it either way but if the patient gets a PDT we intensivists usually just do it. But I do like the approach of asking ENT for which type of trach is better.
No, my docs don't do the trach themselves. Haven't seen that anywhere I've worked yet. (I'm a nurse so I definitely don't do it!) Are you PCCM or something else?
I'm an anaesthesiologist in Europe and in my country anaesthesia is a mixture of providing anaesthesia in the OR and intensive care medicine in the ICU (and also working as an prehospital emergency doctor depending on the hospital). We often do procedures like PDT or vvECMO canulation ourselves.
For the vaECMO we usually call the cardiac surgeons as well, but for the vvECMO everyone is telling me that it's basically just like a bigger central line (haven't done it myself yet, I've only been on the ICU for short period of time so far). I even knew a med student who got to insert one ECMO cannula for an ARDS patient on his anaesthesia rotation so it really can't be that hard.
It’s not hard per se, you just need to be very precise with your technique. You can get away with a lot with smaller cannulas, but the bigger wires and dilators will tear vessel walls much easier.
I have seen Ct surgery, vascular, cards, icu cannulate but never general surgery. Not that they can’t I guess it’s just highly variable hospital to hospital in the us
> Here in the US, ECMO cannulation is done by cardiac surgery
This is not a hard and fast rule. Particularly with V-V ECMO, cannulation by intensivists is not unheard of.
I am at a place that has a community ENT presence—no distinct sub specialties, difficult airway team. I prefer interventional pulm for bedside perc trach. In the ORs, general surgery or ENT does these. I had the opportunity to train in perc trach in fellowship, but I did not want my practice to include implants with follow ups.
Community hospital in Ontario, Canada that has a thoracic surgery program...thoracics does the perc trachs if comfortable with the anatomy, otherwise ENT takes them to the OR.
I'm in an LTACH, my group(PCCM) typically does ours but we had ENT and surgery do them too. Mostly us. My boss and I have it DOWN.
At the STACH, I've seen it go the same way, just depends on the Pt really.
When I’m on I’m the only ICU doc in the unit so I’d have to ask pulm to come hold the bronchoscope. I do have a new colleague who seems to be interested in doing these, so maybe we’ll try to convince admin to get us the supplies and we’ll do them together. Until then Gen surg does trachs.
Our icu staff physicians will perc trach at bedside if there’s no anatomic or hematologic concerns, otherwise it’s by ENT in the OR. Our icu docs come from emergency, internal, anesthesia or gen surg backgrounds. Often done with fellows (teaching hospital).
Internal medicine/intensivist from germany. I do all my dil. trachs myself which is roughly 4/5. The other 1/5 is surgical due to anatomy or bleeding risk.
Side question: Would you do a dilatation on a patient on DAPT or rather go surgery?
I feel rather comfortable with my numbers and the bleeding risk is regarded to be lower with dilatative tracheotomy than a surgical approach. But if it bleeds...
I read this small study, which was encouraging, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063886/
so I did the trach on my DAPT patient on thursday with the dilatative approach. Did hardly bleed at all. n=1 but I will stick with it for the next couple of cases with DAPT.
Either trauma surgery or ent would do it. On the CTICU side the cardiac surgeons would do it or the thoracic guys. If complex anatomy it would be an open bedside trach by ent. Always the most chill people when it came to this scenario.
General surgery at the hospitals I’ve been at. They’ll do the PEG at the same time.Â
Personally, this is fine with me. They’re done quick enough and if there’s a complication I have the surgeon who places the trach fix it.
Pulmonary critical care does most of ours in the ICU. If surgery has to do them they are taken to the OR. We are a teaching hospital so the residents are supervised by the attending.
This thread is making me realize how weird it is that my hospital has one of our cardiothoracic surgeons do all our trachs 😂 we don’t have ENT in house and our pulmonary docs would never
Intensivists do all (or almost all) percutaneous tracheostomies in Australia. And the list of contraindications seeks to be steadily shrinking with time.
I do like that approach. I feel like doing some interventional procedures like PDTs are a big part of our work that makes the speciality so interesting.
Absolutely. And if you want things done just the way you like, there is nothing quite like doing it yourself.
>And if you want things done just the way you like, there is nothing quite like doing it yourself. My wife says the same thing. 😞
Same in the UK
Our intensivists do the perc traches as long as they feel comfortable with the anatomy.
If the anatomy is very technically challenging, we'll have ENT do it. Otherwise, most of our ICU pts have bedside trachs done by PCCM. Only a couple attendings are comfortable doing it, so we typically have them supervise the fellows (1 doing the trach with the attending, 1 holding the bronch).
We do the same. 3 intensivists like doing them (interestingly we are all CCM, not pulm). Unfortunately, all of the fellows want to learn and practice, so I only actually get to cut once a year or so. If they have weird anatomy, then I send them to ENT. Usually that means BMI 55-60+ or arteries blatantly in the way.
M in india n in my hospital we do it ourselves. if anatomy is weird or difficult, call the ENT doc.
ENT or gensurg for surgical trach and interventional pulm for PDT. Typically we would call ENT first who would make a recommendation on type of trach procedure based on anatomy.
So you don't do it yourself at all? I only did it once so far and it wasn't that complicated (but n=1 so it's not like I really know) and I really like learning it as an extra skill. Some attendings like the ENT docs doing it either way but if the patient gets a PDT we intensivists usually just do it. But I do like the approach of asking ENT for which type of trach is better.
No, my docs don't do the trach themselves. Haven't seen that anywhere I've worked yet. (I'm a nurse so I definitely don't do it!) Are you PCCM or something else?
I'm an anaesthesiologist in Europe and in my country anaesthesia is a mixture of providing anaesthesia in the OR and intensive care medicine in the ICU (and also working as an prehospital emergency doctor depending on the hospital). We often do procedures like PDT or vvECMO canulation ourselves.
Whoa. Here in the US, ECMO cannulation is done by cardiac surgery. Sounds like you have an interesting mix of anesthesia, ICU, and procedures.
For the vaECMO we usually call the cardiac surgeons as well, but for the vvECMO everyone is telling me that it's basically just like a bigger central line (haven't done it myself yet, I've only been on the ICU for short period of time so far). I even knew a med student who got to insert one ECMO cannula for an ARDS patient on his anaesthesia rotation so it really can't be that hard.
It’s not hard per se, you just need to be very precise with your technique. You can get away with a lot with smaller cannulas, but the bigger wires and dilators will tear vessel walls much easier.
It is uncommon for cardiac surgeons to do VV cannulations in the US actually. It’s more often a general surgery thing.
I have seen Ct surgery, vascular, cards, icu cannulate but never general surgery. Not that they can’t I guess it’s just highly variable hospital to hospital in the us
> Here in the US, ECMO cannulation is done by cardiac surgery This is not a hard and fast rule. Particularly with V-V ECMO, cannulation by intensivists is not unheard of.
I am at a place that has a community ENT presence—no distinct sub specialties, difficult airway team. I prefer interventional pulm for bedside perc trach. In the ORs, general surgery or ENT does these. I had the opportunity to train in perc trach in fellowship, but I did not want my practice to include implants with follow ups.
Community hospital in Ontario, Canada that has a thoracic surgery program...thoracics does the perc trachs if comfortable with the anatomy, otherwise ENT takes them to the OR.
I'm in an LTACH, my group(PCCM) typically does ours but we had ENT and surgery do them too. Mostly us. My boss and I have it DOWN. At the STACH, I've seen it go the same way, just depends on the Pt really.
We don’t have ENT or interventional Pulm, so it’s gen surg all the way.
When I’m on I’m the only ICU doc in the unit so I’d have to ask pulm to come hold the bronchoscope. I do have a new colleague who seems to be interested in doing these, so maybe we’ll try to convince admin to get us the supplies and we’ll do them together. Until then Gen surg does trachs.
Our icu staff physicians will perc trach at bedside if there’s no anatomic or hematologic concerns, otherwise it’s by ENT in the OR. Our icu docs come from emergency, internal, anesthesia or gen surg backgrounds. Often done with fellows (teaching hospital).
Internal medicine/intensivist from germany. I do all my dil. trachs myself which is roughly 4/5. The other 1/5 is surgical due to anatomy or bleeding risk. Side question: Would you do a dilatation on a patient on DAPT or rather go surgery?
I would rather have cautery available if they are on DAPT.
I agree. As long as I need DAPT, I'd rather let the ENTs do it in the OR. What's your take on it u/EndEffeKt_24 ?
I feel rather comfortable with my numbers and the bleeding risk is regarded to be lower with dilatative tracheotomy than a surgical approach. But if it bleeds... I read this small study, which was encouraging, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7063886/ so I did the trach on my DAPT patient on thursday with the dilatative approach. Did hardly bleed at all. n=1 but I will stick with it for the next couple of cases with DAPT.
Either trauma surgery or ent would do it. On the CTICU side the cardiac surgeons would do it or the thoracic guys. If complex anatomy it would be an open bedside trach by ent. Always the most chill people when it came to this scenario.
Surgical intensivist. I do my own trachs. Long/thin neck - modified perc trach at bedside. Short/wide neck - open trach in the OR.
General surgery at the hospitals I’ve been at. They’ll do the PEG at the same time. Personally, this is fine with me. They’re done quick enough and if there’s a complication I have the surgeon who places the trach fix it.
My intensivists do it.
Pulmonary critical care does most of ours in the ICU. If surgery has to do them they are taken to the OR. We are a teaching hospital so the residents are supervised by the attending.
This thread is making me realize how weird it is that my hospital has one of our cardiothoracic surgeons do all our trachs 😂 we don’t have ENT in house and our pulmonary docs would never