Cardiac arrest due to an unexpected inability to ventilate in a tracheostomy patient suggesting the need for a routine anesthesia checklist and an anesthesia relevant emergency pathway for tracheostomy management: a case report.

Background: Up to 30% of patients worldwide have a significant complication related to their tracheostomy. We report a case of a 'cannot ventilate' event resulting in cardiac arrest due to an unexpected airway occlusion in a patient with a pre-existing brain injury The following case report is unique as the patient had developed a mucus plug that turned into a crystal following a coronavirus disease 19 (COVID-19) infection. Case Description: The patient was a young adult who suffered a traumatic brain injury from a motor vehicle collision. He presented for elective cystoscopy to treat recurrent urinary tract infections. During induction of anesthesia, the patient became agitated, desaturated, and ventilation became impossible. With chest compressions underway the tracheostomy was removed, and the patient was quickly and successfully orally intubated using a video-laryngoscope. Subsequent inspection of the tracheostomy tube revealed a mucus plug in the distal portion which had hardened into a rock-like appearance. The inner cannula was also missing. Follow-up revealed that the patient recently had a COVID-19 infection and because of this received less frequent suctioning of his tracheostomy tube. Conclusions: Reviewing the literature, we recognized that there has been no case report documenting a mucus plug that turned into a stone. Reviewing guidelines for handling tracheostomy emergencies, we recognize that there are no anesthesia specific guidelines in the USA. We also recognize that there are no established checklists for patients with tracheostomy undergoing surgery. We therefore recommend establishing a routine checklist and anesthesia specific guideline for emergencies that follows every patient with a tracheostomy undergoing surgery.