新型コロナウイルス（SARS–CoV–2）陽性患者に対し外科的気管切開術を施行した経験(Surgical tracheostomy for a patient positive for the novel coronavirus (SARS–CoV–2): a case report)

Abstract

新型コロナウイルス（SARS–CoV–2）患者に対する気管切開術を経験した。症例は69歳の男性。来院10日前に発熱と倦怠感が出現した。来院前日に近医で撮影した胸部X線写真で肺炎像を認め，SARS–CoV–2のPCRが陽性となり当院入院となった。第5病日に酸素化維持が困難となり経口気管挿管を施行したが，その後も急激に呼吸状態が悪化し，気管挿管から12時間後にveno–venous extracorporeal membrane oxygenationを導入した。挿管チューブが喀痰で狭窄したため，第15病日に気管切開術を施行した。手術に際し，エアロゾル曝露を考慮した個人防護具を装着した。手術は，物理的に隔離した集中治療室のベッドサイドで行った。筋弛緩薬を使用した全身麻酔で管理し，エアロゾル発生の観点から手術開始から人工呼吸器による換気を中止した。また，エアロゾル発生のリスクを考慮して外科的気管切開術を選択した。感染制御，手術のタイミング，術中管理について文献的考察を踏まえ報告する。We performed tracheostomy in a 69–year–old male patient with severe acute respiratory syndrome coronavirus–2 (SARS–CoV–2) infection. He presented with complaints of fever and malaise for the past 10 days. Chest radiographs taken at a local hospital on the previous day revealed pneumonia, and the RT–PCR test for SARS–CoV–2 was positive; therefore, the patient was admitted to our hospital. On the 5th day of hospitalization maintenance of oxygenation was found difficult; therefore, oral endotracheal intubation was performed. However, his respiratory conditions deteriorated rapidly; hence, veno–venous extracorporeal membrane oxygenation was initiated 12 hours after endotracheal intubation. The sputum had caused a narrowing of the endotracheal tube, and so tracheostomy was performed on the 15th day. Bedside surgery was performed in a physically isolated intensive care unit but considering the high–risks associated with aerosol exposure, appropriate personal protective equipment was used. The patient was managed under general anesthesia using muscle relaxants, but the use of ventilator was discontinued from the beginning of the surgery over concerns of aerosol generation. This report focuses on infection control, the timing of surgery, and intraoperative management followed by a discussion based on the review of available literature.