Open tracheostomy in a suspect severe acute respiratory syndrome (SARS) patient: brief technical communication

Patient management in the setting of severe acute respiratory syndrome (SARS) is complicated by the controversies about transmissibility, a reliable diagnostic tool and a clinically proven cure.1,2,3,4 High-risk procedures are particularly problematic. Directives for high-risk procedures were published by Ontario's Ministry of Health and Long-Term Care in June 2003.5 Herein we describe the salient technical and essential infection-control principles6 (S. Abrahamson, unpublished data) learned from our experience with open tracheostomy in a SARS patient. We could find only 1 other report7 of tracheostomy in patients with or suspected of having SARS. High-risk procedures such as intubation, bronchoscopy and tracheostomy should be done in a negative-pressure isolation environment. However, the Canadian Standards Association requires that operating rooms (ORs) operate at positive pressure. At present, there are no negative-pressure isolation rooms in Toronto. A patient's clinical status or anatomy may warrant the greater anesthetic and surgical safety provided by ORs. If the patient's clinical status is expected to improve, it is prudent to wait; but difficult surgical anatomy is a more daunting problem, and should be given due consideration. The possibility of contamination in the OR of health care workers and other patients should be balanced against the potential for surgical mishap in the intensive care unit (ICU). If OR personnel are educated in and equipped with personal protective systems, and the procedure planned in advance in consultation with the hospital's infection prevention and control service, the risk to health care workers is likely to be small.