Concomitant tracheostomy and gastrostomy performed by intensivists using novel ultrasound-guided method enables safe and efficient airway and stomach access while limiting exposure to COVID-19 patients.

The PUMA-G System is a novel bedside product that utilizes point-of-care ultrasound to enable bedside gastrostomy for critically ill patients. Intensivists who perform gastrostomy using the PUMA-G System now dictate when their patients receive direct enteral access while benefiting from the safety and efficiency of performing in combination with percutaneous tracheostomy. Benefits of concomitant tracheostomy and gastrostomy include the elimination of an extra sedation event, increased patient mobility and comfort, shorter length of stay (LOS) in both ICU and hospital, reduced duration of mechanical ventilation, and others demonstrated in literature. There are obvious care delivery efficiencies, which are magnified under COVID-19 environments. Specifically, concomitant tracheostomy and gastrostomy limits the number of providers and time spent in the patient room, mitigating exposure and obviating concerns about transport.

In a small observational study (n=16), concomitant tracheostomy and gastrostomy were performed by intensivists on patients with COVID-19 and ARDS. Procedures were safely completed with 2 providers and 1 respiratory therapist in the room. Apnea during tracheal dilatation and tube insertion and minimal gastric insufflation were used to mitigate aerosolization. All providers later tested negative for SARS-CoV-2 antibodies, and only 1 major procedural complication was observed (pneumomediastinum associated with tracheostomy). 12/16 patients were transferred out of the ICU in 5 days or less. There were no patient mortalities associated with this group. (Olivieri 2020)

The safety and efficacy of concomitant tracheostomy and gastrostomy by intensivists was confirmed, albeit without a control arm. These results are especially significant given the increased requirement to maintain safe, long-term airway and enteral access for the critically ill COVID-19 patient population. The keystone to this approach was ultrasound-guided gastrostomy, in a procedure termed PUG (percutaneous ultrasound gastrostomy). PUG utilized existing intensivists’ skills – balloons, wires, ultrasound, and Seldinger technique, with no additional capital expense. Training and credentialing for PUG has been widely accepted by hospital administrations, with no surprises or unusual requirements. Concomitant percutaneous tracheostomy and gastrostomy procedures have been shown to reduce hospital costs by $35,000 per patient in neurocritical care settings (Nobleza 2017). Additional financial analysis is needed to confirm cost savings using this model in other hospital settings.