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Optimizing Patient Care

Critical review

Surgical procedures in the intensive care unit:
a critical review
BM Dennis*, OL Gunter

Abstract the need for these procedures to be critically ill patients7–9. These risks
Introduction performed in the ICU. can be mitigated by performing select
Increasingly, surgical procedures are Conclusion procedures at bedside in the ICU.
performed at bedside in the inten- The operating room is no longer the Discussion
sive care unit (ICU). Cost savings and only location that surgical proce- The authors have referenced some
gaining timely access to the oper- dures can be performed. The ICU is of their own studies in this review.
ating room (OR) have helped to spur becoming a more common location These referenced studies have been
this trend towards more ICU-based where selected bedside procedures conducted in accordance with the

All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
procedures. Patient physiology and are being performed. Reasons to Declaration of Helsinki (1964) and
the patient transport concerns have perform bedside procedures in the the protocols of these studies have
made performing bedside proce- ICU rather than the operating room been approved by the relevant ethics
dures a more attractive option than include cost savings, elimination committees related to the institution
the OR in certain settings. of risks of transporting critically ill in which they were performed. All
Discussion patients, and avoidance of OR avail- human subjects, in these referenced
ICUs have begun to adapt to accom- ability concerns. The operating room studies, gave informed consent to
modate these bedside surgical proce- remains the preferred location for participate in these studies.
dures. Specialized personnel have almost all surgical procedures, but ICU as an OR
been trained to facilitate and support the ICU offers an attractive alterna- Care in the ICU mirrors that in the
procedures in some hospitals. tive for certain selected patients and OR for a number of reasons. The
Because the operating room remains procedures. monitoring and equipment capabili-
the best location for most surgical ties in the ICU are nearly identical
procedures, there are only a few indi- Introduction to the OR. Ventilators in most ICUs
cations to perform bedside surgical Bedside surgical procedures performed have mechanical ventilation capa-
procedures. These indications in the intensive care unit (ICU) have bilities beyond standard OR ventila-

All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
include lesser procedures for which become more commonplace in recent tors. While inhaled anaesthetics are
the OR costs and transport risks years. Much of this is because of the not readily available, intravenous
are not justified or emergent proce- acceptance by surgeons and inten- sedatives are routinely used and are
dures in patients are too unstable sivists that procedures once thought easily accessible. Additionally, ICU
for transport to the OR. The most to be performed exclusively in the personnel are analogous to OR staff.
common procedures performed in operating room (OR) may be safely Critical care nurses, respiratory ther-
the ICU include percutaneous trache- and easily performed in the ICU. apists and patient care assistants Competing interests: none declared. Conflict of Interests: none declared.
ostomy, percutaneous endoscopic In many cases, it has been demon- replace circulating nurses, anaesthe-
gastrostomy tube and inferior vena strated that significant cost savings tists and OR attendants. The scrub
cava filter. Performing these proce- can be achieved by performing these nurse, however, is a position without
dures in the ICU is equally safe and procedures in the ICU without sacri- a natural counterpart in the ICU. Many
more cost effective than performing ficing patient safety1–5. Additionally, hospitals have developed systems
them in the OR. Procedures of a more difficulties gaining timely access to that bring the OR to the ICU. This
urgent nature can also be performed the OR, either because of patient typically involves an OR staff, which
in the ICU and include laparotomy instability or OR availability, have brings the necessary equipment and
and damage control orthopaedics. made bedside procedures an attrac- supplies from the OR to the ICU. This
Patient instability often dictates tive alternative that often allows for can be an arduous and difficult task,
more efficient care4,6. Most impor- especially in time-sensitive situa-
tantly, there are inherent risks to tions or at inconvenient times, such
transport critically ill patients and as nights or weekends. At our institu-
* Corresponding author
some studies have demonstrated that tion, we employ the use of specialised
serious adverse events, including procedure support nurses (PSNs) in
Division of Trauma and Surgical Critical
Care, Vanderbilt University Medical Centre, death, can occur in up to 30%–45% our trauma and surgical ICUs10. These
Nashville, TN, USA of intra-hospital transports involving nurses are specially trained to set up

Licensee OA Publishing London 2013. Creative Commons Attribution Licence (CC-BY)

FOR CITATION PURPOSES: Dennis B, Gunter O. Surgical procedures in the intensive care unit: a critical review. OA Critical
Care 2013 May 01;1(1):6.

It is important to note that there All authors contributed to the conception. are certain limitations to procedures that can be performed in the ICU. The PSNs are involved bedside percutaneous tracheostomy. bedside procedures should be reserved for two situations as follows: lesser procedures for which transport to OR is not justified. More emergent procedures. Contraindications to bedside surgery include risk of major bleeding. As a general rule. and some procedures clearly belong to the OR. complex procedures. Their small IN) have made the percutaneous nurse. Similar to an OR scrub safety of the procedures. Low complexity procedures that are ideal for the ICU setting. able and sterilised. Procedure support nurse is pictured in middle at the head of bed in order the bedside. time-sensi- tive situations. Conflict of interests: none declared. because of difficulties of transport. timeout. Figure 1: Surgical critical care team starting bedside percutaneous tracheos. as well as read and approved the final manuscript. placement of percutaneous trache- ostomy. Bloomington. The PSN can endotracheal tube during the proce. Page 2 of 6 Critical review procedures mean they have extensive experience in the narrow spectrum of procedures performed at bedside in our hospital. include All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure. Ciaglia and the subsequent modifica- confirm that appropriate informed dure (Figure 1). especially important in emergent. Furthermore. the PSN ensures that all the number and consistent presence for technique arguably the procedure Licensee OA Publishing London 2013.1(1):6. In this regard. Percutaneous tracheostomy the various bedside procedures. they are invaluable in setting up and executing bedside procedures in an efficient and consistent manner. such as exploratory laparotomy and damage control Competing interests: none declared. review was to discuss surgical proce- dures in the ICU. and they play Tracheostomy is the gold standard for We have come to view the PSN role integral roles during the various patients requiring long-term mechan- as the lynchpin of bedside surgical procedures. emergency procedures for patients too unstable for transport11. The percutaneous dila- in many aspects of the periproce. OA Critical Care 2013 May 01. who plays an important role in teaching the techniques of bedside surgery to many residents and fellows. For example. our PSN is expected to manage the tional techniques first described by dural care of the patient. Gunter O. OR expense or OR availability and lifesaving. percutaneous endoscopic gastrostomy (PEG) and inferior vena cava filters (IVCFs). during ical ventilation or upper airway procedures. Blue Rhino® kit (Cook Medical’s physicians and lead the pre-surgical mise the variability and maximise the Critical Care division. Surgical procedures in the intensive care unit: a critical review. design. orthopaedics are also possible at tomy. this experience translates into being a de facto bedside procedure expert. . Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Dennis B. insertion of prosthetics and long. obstruction. and preparation of the manuscript. and perform essential roles during appropriate instruments are avail. We have intentionally tion (Figure 2) employing the Ciaglia consent has been obtained by the limited the number of PSNs to mini. The aim of this critical to manage endotracheal tube.

13. obstruction. Ponsky and colleagues used only local and topical analgesia18. Bedside percutaneous tomy in the OR2. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Dennis B. Complication rates in high- Figure 2: Dilation of tracheotomy using Ciaglia Blue Rhino® during bedside risk patients in these studies were percutaneous tracheostomy. respectively10.14. coagulopathy. etc.5. Gunter O. Although few. All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.10. 1. oppose the gastric wall to anterior ment12. inability to swallow (e.6. Indications for Competing interests: none declared. head and neck cancer. Figure 3: Standard equipment set up for bedside modified percutaneous but some potential contraindications tracheostomy using Ciaglia Blue Rhino® kit. but the PEG remains the gold standard. . The safety of bedside percutaneous trache- ostomy even in high-risk groups. trauma. severe facial trauma and severe malnutrition in debilitated or demented patients19. prolonged mechanical ventilation.1(1):6.g. inability to of choice for tracheostomy place. was recently demon- strated in two large retrospective studies. design. such as the obese. and preparation of the manuscript. PEG are related to the requirement for long-term feeding access and include severe neurological injuries. to PEG are haemodynamic insta- bility.). Conflict of Interests: none declared. PEG is a procedure.15. recent oesophageal or gastric surgery.. Meta-analysis by abdominal wall. less scarring and shorter case lengths when compared to open tracheostomy5. The combined endoscopic and percutaneous techniques have low risk and are relatively easy to perform at the bedside (Figure 4). native to open surgical tracheos.16. Page 3 of 6 Critical review tion rates. increase in hospital revenue4. Studies have shown savings between $1100 and $3400 per proce- dure1. OA Critical Care 2013 May 01.7%. Surgical procedures in the intensive care unit: a critical review. Relative contraindica- Licensee OA Publishing London 2013. Bedside percutaneous tracheostomy has been shown to be substantially more cost-effective than open tracheostomy performed in the OR. high risk of aspiration. Other techniques and devices exist for percutaneous feeding access. Even in the initial cases. inability to pass a tracheostomy (Figure 3) has been Higgins showed percutaneous trache. Percutaneous endoscopic gastrostomy Since its first description. flexible endoscope and gastric outlet shown repeatedly to be a safe alter. as well as read and approved the final manuscript.0% and 1. which was an obvious choice to be performed outside the OR17. The Johns Hopkins Percuta- neous Tracheostomy Program Group showed that a hospital-subsidised multidisciplinary team performing bedside percutaneous tracheosto- mies can decrease complications and length of stay in ICU resulting in a net All authors contributed to the conception. ostomy to have lower wound infec.

etc.23. a meta-analysis performed by Gomes found that patients with PEGs had lower rates of subsequent intervention failure (e. Nunn and colleagues life expectancy 19. Frequent. OA Critical Care 2013 May 01. More recently. IVCFs are a reasonable option. This is made possible by image-guided placement in the form Competing interests: none declared. Surgical procedures in the intensive care unit: a critical review. interruption of feedings.. either of which can be performed at bedside3. the IVCF proce- dure evolved into a percutaneous technique that could be performed in angiography suites. Bankhead and laparoscopic or open gastrostomies.22–24.) compared to patients with nasogas- tric tubes with no difference in other complications including mortality21. Gunter O. The key to the IVCF procedure is to ensure deployment of the filter in the proper infra-renal location of the vena cava. . Complica- tion rates are exceedingly low in IVCF and are comparable to those proce- dures performed in the OR and angi- Figure 5: Bedside laparotomy with abdominal washout. All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure. it has migrated into the ICU as well.24. of ultrasonography (transabdominal or intravascular) or C-arm fluoroscopy with iodinated contrast or carbon- dioxide. these procedures were exclusively performed in the OR. hypercoagulability and endothelial damage. diag- noses or injuries preclude certain patients from receiving appropriate pharmacologic DVT prophylaxis or Figure 4: Bedside percutaneous endoscopic gastrostomy tube placement. tube feedings were able to be started sooner and complications were fewer in the PEG group20. Cost savings by nurse (right) acts as scrub nurse. teristics of Virchow’s triad. Inferior vena cava filter Critically ill patients are inherently at high risk of deep venous thrombosis (DVT). Procedure support ography suites23. Multiple studies have demonstrated significant cost savings by placing IVCF in the ICU tions include gastric varices. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Dennis B. including venous stasis. reported that annual savings for IVCF colleagues compared gastrostomy Procedure duration of PEG was placed at bedside compared to angi- Licensee OA Publishing London 2013. treatment.1(1):6. Critical care nurse (left) administers sedation performing the IVCF procedure in the and monitors vital signs. Since that time. ICU are tremendous. To prevent venous throm- boembolism (VTE) in this high-risk group. With modernisation of filter design and delivery systems. clogged tube. diffuse techniques and concluded that PEG rather than in angiography suites gastric cancer and limited remaining was the preferred technique over or the OR3. by virtue of exhibiting charac- All authors contributed to the conception. Page 4 of 6 Critical review shorter. Conflict of interests: none declared. Initially.g. design. and preparation of the manuscript. as well as read and approved the final manuscript.

resuscitation and stabilisation25. Abdom. Neither of these cost analyses surgical intervention in the form of tory laparotomy. The procedures The resultant bowel and intersti. of the so-called lethal triad of hypo. bedside laparotomy being shown to inal compartment syndrome is cally applied. patient physiology. after employing the bedside transport critically ill patients. As defined by the protocol. design. sepsis26. practiced at our institution in select abdominal compartment syndrome mise requiring high levels of ventilator circumstances. sary in cases of abdominal compart- ment syndrome. Additional instruments may be required open abdomen and intra-abdominal for more complex procedures. Conflict of Interests: none declared. Gunter O. severe abdominal controlling haemorrhage and gaining cant cost savings can be realised by trauma and specific emergency source control of sepsis. Figure 6: Instruments used at our institution for beside laparotomy.1(1):6. and the patient may be save as much as $5300 per case27. such as removal of intra-abdominal operative procedures at bedside. they are frequently bility that can develop secondary to with significant respiratory compro. such as restoration of bowel conti- nuity may also be performed in the ICU provided the appropriate equip- ment is available (Figure 6). Additionally. While there are many diagnoses that may benefit from bedside lapa- rotomy. The profound performed at the bedside in the ICU published literature of bedside ortho- haemodynamic and respiratory insta. Damage control laparoto- mies had previously been shown to ography suite and OR were nearly obviates safe transport of the patients carry higher rates of complications $69. acidosis and coagulopathy. Diaz demon- they include the costs of the poten. Care must be exercised to maintain patient safety principles as would be expected in the OR setting. and preparation of the manuscript. Surgical procedures in the intensive care unit: a critical review. Diaz reported the use of a protocol for bedside lapa- rotomy. studies involving damage control Laparotomy tension. Indications for bedside Licensee OA Publishing London 2013. nor do All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure. acute haemodynamic instability caused by intra-abdominal haemorrhage. decision regarding when and where Just as the bedside laparotomy is a tial oedema may lead to pulmonary to re-operate is dependent on factors. particularly intra- accounts for the hidden costs of the decompressive laparotomy. abdominal abscess and fistula27. (Figure 5). laparotomies performed in the The initial operation is performed in OR26. and can be considered on a case-by-case basis. signifi. there are few. as with the previ- Bedside laparotomy can be neces- the OR and is primarily focused on ously discussed procedures. abdominal closure system is typi.300. All authors contributed to the conception.800 and $118. Simple procedures. been well established in patients with strated intra-abdominal abscess and tial risks incurred in transport of this severe torso injuries in the setting fistula rates that were equivalent to high-risk population. required to Damage control operations with However. to the OR and necessitates immediate than the more traditional explora- tively3. orthopaedic surgeons are return and decreased cardiac output. damage control procedure for general compromise. if any. respec. . time and personnel. Competing interests: none declared. occasionally required to perform The result is severe hypoventila. A temporary avoiding transport to the OR with general surgical conditions. the four primary clinical indications for bedside laparotomy in patients felt to be unsuitable for transport to the OR were as follows: abdom- inal compartment syndrome. defi- nite indications. OA Critical Care 2013 May 01. Page 5 of 6 Critical review support. often the result of aggressive fluid transferred to the ICU for ongoing Damage control orthopaedic resuscitation after trauma or sepsis. diminished venous such as operative complexity and surgeons. particularly for patients paedic procedures. such as bowel anastomoses or ostomy creation. More complex procedures. as well as read and approved the final manuscript. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Dennis B. tion and combined cardiogenic and packing and fascial closure may be While there are sparse reports in the hypovolemic shocks. including washout or closure of a previous removal of packing and fascial closure. temporary abdominal closure have laparotomy protocol.

ostomy program. infections. A prospective. et al. Pierce R. Elective Competing interests: none declared. Eddy VA. tension due to haemorrhagic shock.1(1):6.91(4):882–6. there an infection rate of 9%. J Am Coll Surg. In fact. Percutaneous dilatational trache- ICU as well. avoiding OR 8. et al. Meta-anal- ysis comparison of open versus percuta- haemorrhage control. et al. Barba CA. similar to are some advantages to perform ill patients.30(8):1579–85. Naslund T. However. dures. washout are required to prevent Abbreviations list secondary brain injury from hypo.3(1):10. in patients with moderate-to-severe personnel. procedure support nurse. Schmieg RE Jr. 2004 Aug. Mirski MA. routinely performed. who necessity or convenience. the bedside using sedation and local which surgical procedures are now Wu AW. et al. Martin K. is essential for the safety Adverse events during intrahospital traumatic brain injuries. Conclusion 5.147(4):684–91. in 7. ciples would hold that formal irriga. Incidents relating anaesthetic. amputa. The authors observed to the intra-hospital transfer of critically All authors contributed to the conception. . Pronovost P. Intrahospital transfer of tions or death were observed28. management of tracheostomy patients. Moss C. and our own orthopaedic 3. is training the ICU personnel. randomized study tional tracheostomy. ostomy. For patients 12. osteomyelitis. 6. Because of either Otolaryngol Head Neck Surg. 15. Punthakee X. Cost-effective procedure. ICU. A safe. Halbig S. 2010 May. Angood PB. Berenholtz SM. Percutaneous tracheos- Fracture stabilisation may be also 2. Crit Care Med. Isabella K. vena cava filter. availability issues and cost savings. 3. Laryngoscope. Cobb JP. transport of critically ill patients: inci- blood product resuscitation may at Additionally. Van Natta TL. Ann Surg. Freeman BD. Breden- external fixation is possible in the Care Med. Licensee OA Publishing London 2013. Higgins KM. Miller CR. critically ill patients. stabilisation with comparing percutaneous with surgical Oct. Arch Surg. percutaneous tracheostomy in the instances.40(6):1827–34. Westphal K. with multiple injuries. Morris JA Jr. recently reported the the only location. inferior 11. May AK. 13. were treated with fasciotomies at has become an accessory theatre. Wilke HJ.43(5):752–8. References percutaneous dilatational tracheostomy. rary fracture stabilisation in patients the vast majority of surgical proce. However. Safety. Nunn CR. Latenser B. Winter MW. Favory sometimes necessary. injuries and require significant critical 1997 Nov. Page 6 of 6 Critical review orthopaedic procedures reflect those multiple long bone fractures that are efficiency. neous tracheostomy a safe. a prospective audit Haemorrhage control of an open or are all advantages to perform select within Flinders Medical Centre. too unstable for transport to the OR. Bass JG. 2007 and irrigation of wounds and tempo. An analysis of the reports the published rates for fasciotomies submitted to the Australian Incident procedures in the ICU.117(3):447–54. OR. Pandian V.227(5):618–24. Poissy J. these patients usually have multiple caval filters in trauma patients. as well as read and approved the final manuscript. Eckert MJ. Syniec C. particularly a specially trained PSN or mobile OR R. Onimus T. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Dennis B. setting are paramount to minimise injured extremity. the ICU Oct. 2000 Jan. 1985 Jun. the OR is no longer Schiavi AJ.87(6): irrigation and debridement can be Elective bedside surgery in critically 715–9. Gunter O. berg CE. Pandian V. Beckmann U. Morad AH. Gunter OL. Parmentier-Decrucq E. operating room. A typical 4. Ciaglia P. Lischke tive ease. 2000 pins. 2001 May. debridement It is important to remember that OR neous tracheostomy. et al. Mayberry JC.000 procedures. 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Eliminating performed in the OR and no deep Monitoring Study in Intensive Care. Chest. 1998 May.216(4):858–65. Gillies DM. Inten- risks associated with transporting sive Care Med. Crit Care Clin. A new simple bedside procedure. Bronchoscopic guidance makes percuta- scenario would include a patient. IVCF. V. Fluid and and success of the ICU procedures. Surgical procedures in the intensive care unit: a critical review. Safety of bedside the risk of adverse outcomes. Dennis BM. Reasons for bedside systemic inflammatory response. care supportive measures. Mirski MA. Bedside open abdominal Traditional orthopaedic surgical prin. Utility and wound management. Cobean R. Boyle tomy: ciaglia blue rhino versus the basic performed at the bedside in a closed WA 3rd. Neuzil D. patients. following: compartment syndrome. tracheostomy in critically ill patients.131(3): cases. design. Apr. 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Wellons ED.3:CD008096. Miller RS. ence with 112 patients. Surgery. Gastrostomy tube placement Surg. Mejia V. and preparation of the manuscript. One 21. Lai KM. 2000 ostomies in the surgical intensive care Percutaneous endoscopic gastrostomy Feb. Rolan. adults with swallowing disturbances. Bikk A. taneous endoscopic gastrostomy: a Ann Vasc Surg. Henderson VJ. Competing interests: none declared. Heniford BT. Ponsky JL. scopic. Gauderer MW. Subhawong AP. 2004 Spring. Kashuk JL. 2006 Jan.27(1):9–11. Licensee OA Publishing London 2013. J Orthop 20. Nine-year (Larchmt). 2001 May. a low return to the operating room. 24. 27. Subhawong T. Lustosa SA. Surgical procedures in the intensive care unit: a critical review. under local anesthesia for acute compart- of modern surgical practice. Am J heim MA. Smith LA. 1995 Nov. Matos D. . Kaufman HJ. Guy JS. Miller R. Townsend CM. 2012. and laparoscopic methods. 16. Ebraheim NA. Bankhead RR. Bedside laparotomy nonoperative technique for feeding 23. 1981 Kercher KW. J Trauma.118(5):879–83. et al. Jacobs DG. Feb. Percu. delli RH. Vacuum pack technique of temporary Haenel JB. Rosenthal D. 18. Fisher CA. endo. Burns RP. 19. Gastrointest Endosc. ment syndrome: a feasible and reliable PA: Elsevier Saunders. Philadelphia. Bedside insertion of inferior vena cava procedure in selected cases. Sabiston DC. Diaz JJ Jr. as well as read and approved the final manuscript. Kornblith LZ. 17. 1980 Dec. May AK. Sabiston filters in the intensive care unit. Biffl WL. Zerey M. abdominal closure: a 7-year experi- thousand bedside percutaneous trache. Barker DE. trauma and emergency general surgery: percutaneous endoscopic technique.192(6):795–800. O’Neill PJ. Abdelgawad AA. Am Coll Surg. filters in the intensive care unit. 2011 Feb. Bedside fasciotomy textbook of surgery: the biological basis Surg. J versus nasogastric tube feeding for 26. Ponsky JL. Page 7 of 6 Critical review and easy-to-teach procedure. Diaz JJ Jr. Moore EE. Clin Pract. design. Ebra- All authors contributed to the conception. OA Critical Care 2013 May 01.212(2):163–70.20(1):157–65. Heniford BT. Gauderer MW. Creative Commons Attribution Licence (CC-BY) FOR CITATION PURPOSES: Dennis B. J 22. Sing RF. Gunter O. Waisberg J. All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure. Jacobs DG.48(2):201–6. Paton BL. Izant R Jr.13(3):153–7. Gomes CA Jr.15(6):872–5. Burlew CC. Sing RF. Waisberg DR. 2012 Sep. Andriolo RB. for trauma: are there risks? Surg Infect gastrostomy.1(1):6. Am Pediatr Surg.71(11):986–91. 2012 Protocol for bedside laparotomy in Gastrostomy without laparotomy: a Mar. J Am Coll Traumatol.5(1):15–20. 2005 Nov.192(5):570–5. unit: time to change the gold standard. Cochrane Database Syst Rev. et al. Retrievable inferior Surg. Nutr Ciraulo DL.20(6):607–12. outcomes: comparison of surgical. 2006 Dec. Alla SR. 25. Morris JA Jr. vena cava filters: initial clinical results. Richart CL. experience with insertion of vena cava 28. Mauer A. Conflict of Interests: none declared. 2005 Dec.