Optimizing Patient Care
Page 1 of 6
Critical review
Surgical procedures in the intensive care unit:
a critical review
Abstract
Introduction
Increasingly, surgical procedures are
performed at bedside in the intensive care unit (ICU). Cost savings and
gaining timely access to the operating room (OR) have helped to spur
this trend towards more ICU-based
procedures. Patient physiology and
the patient transport concerns have
made performing bedside procedures a more attractive option than
the OR in certain settings.
Discussion
ICUs have begun to adapt to accommodate these bedside surgical procedures. Specialized personnel have
been trained to facilitate and support
procedures in some hospitals.
Because the operating room remains
the best location for most surgical
procedures, there are only a few indications to perform bedside surgical
procedures.
These
indications
include lesser procedures for which
the OR costs and transport risks
are not justified or emergent procedures in patients are too unstable
for transport to the OR. The most
common procedures performed in
the ICU include percutaneous tracheostomy, percutaneous endoscopic
gastrostomy tube and inferior vena
cava filter. Performing these procedures in the ICU is equally safe and
more cost effective than performing
them in the OR. Procedures of a more
urgent nature can also be performed
in the ICU and include laparotomy
and damage control orthopaedics.
Patient instability often dictates
* Corresponding author
Email: bradley.m.dennis@vanderbilt.edu
Division of Trauma and Surgical Critical
Care, Vanderbilt University Medical Centre,
Nashville, TN, USA
the need for these procedures to be
performed in the ICU.
Conclusion
The operating room is no longer the
only location that surgical procedures can be performed. The ICU is
becoming a more common location
where selected bedside procedures
are being performed. Reasons to
perform bedside procedures in the
ICU rather than the operating room
include cost savings, elimination
of risks of transporting critically ill
patients, and avoidance of OR availability concerns. The operating room
remains the preferred location for
almost all surgical procedures, but
the ICU offers an attractive alternative for certain selected patients and
procedures.
Introduction
Bedside surgical procedures performed
in the intensive care unit (ICU) have
become more commonplace in recent
years. Much of this is because of the
acceptance by surgeons and intensivists that procedures once thought
to be performed exclusively in the
operating room (OR) may be safely
and easily performed in the ICU.
In many cases, it has been demonstrated that significant cost savings
can be achieved by performing these
procedures in the ICU without sacrificing patient safety1–5. Additionally,
difficulties gaining timely access to
the OR, either because of patient
instability or OR availability, have
made bedside procedures an attractive alternative that often allows for
more efficient care4,6. Most importantly, there are inherent risks to
transport critically ill patients and
some studies have demonstrated that
serious adverse events, including
death, can occur in up to 30%–45%
of intra-hospital transports involving
critically ill patients7–9. These risks
can be mitigated by performing select
procedures at bedside in the ICU.
Discussion
The authors have referenced some
of their own studies in this review.
These referenced studies have been
conducted in accordance with the
Declaration of Helsinki (1964) and
the protocols of these studies have
been approved by the relevant ethics
committees related to the institution
in which they were performed. All
human subjects, in these referenced
studies, gave informed consent to
participate in these studies.
ICU as an OR
Care in the ICU mirrors that in the
OR for a number of reasons. The
monitoring and equipment capabilities in the ICU are nearly identical
to the OR. Ventilators in most ICUs
have mechanical ventilation capabilities beyond standard OR ventilators. While inhaled anaesthetics are
not readily available, intravenous
sedatives are routinely used and are
easily accessible. Additionally, ICU
personnel are analogous to OR staff.
Critical care nurses, respiratory therapists and patient care assistants
replace circulating nurses, anaesthetists and OR attendants. The scrub
nurse, however, is a position without
a natural counterpart in the ICU. Many
hospitals have developed systems
that bring the OR to the ICU. This
typically involves an OR staff, which
brings the necessary equipment and
supplies from the OR to the ICU. This
can be an arduous and difficult task,
especially in time-sensitive situations or at inconvenient times, such
as nights or weekends. At our institution, we employ the use of specialised
procedure support nurses (PSNs) in
our trauma and surgical ICUs10. These
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.
Competing interests: none declared. Conflict of Interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
BM Dennis*, OL Gunter
Page 2 of 6
Figure 1: Surgical critical care team starting bedside percutaneous tracheostomy. Procedure support nurse is pictured in middle at the head of bed in order
to manage endotracheal tube.
and perform essential roles during
the various bedside procedures.
We have come to view the PSN role
as the lynchpin of bedside surgical
procedures. The PSNs are involved
in many aspects of the periprocedural care of the patient. The PSN can
confirm that appropriate informed
consent has been obtained by the
physicians and lead the pre-surgical
timeout. Similar to an OR scrub
nurse, the PSN ensures that all the
appropriate instruments are available and sterilised, and they play
integral roles during the various
procedures. For example, during
bedside percutaneous tracheostomy,
our PSN is expected to manage the
endotracheal tube during the procedure (Figure 1). We have intentionally
limited the number of PSNs to minimise the variability and maximise the
safety of the procedures. Their small
number and consistent presence for
procedures mean they have extensive
experience in the narrow spectrum of
procedures performed at bedside in
our hospital. In this regard, they are
invaluable in setting up and executing
bedside procedures in an efficient
and consistent manner, especially
important in emergent, time-sensitive situations. Furthermore, this
experience translates into being a de
facto bedside procedure expert, who
plays an important role in teaching
the techniques of bedside surgery to
many residents and fellows.
It is important to note that there
are certain limitations to procedures
that can be performed in the ICU,
and some procedures clearly belong
to the OR. Contraindications to
bedside surgery include risk of major
bleeding, insertion of prosthetics
and long, complex procedures. As
a general rule, bedside procedures
should be reserved for two situations
as follows: lesser procedures for
which transport to OR is not justified,
because of difficulties of transport,
OR expense or OR availability and
lifesaving, emergency procedures for
patients too unstable for transport11.
Low complexity procedures that
are ideal for the ICU setting, include
placement of percutaneous tracheostomy, percutaneous endoscopic
gastrostomy (PEG) and inferior vena
cava filters (IVCFs). More emergent
procedures, such as exploratory
laparotomy and damage control
orthopaedics are also possible at
the bedside. The aim of this critical
review was to discuss surgical procedures in the ICU.
Percutaneous tracheostomy
Tracheostomy is the gold standard for
patients requiring long-term mechanical ventilation or upper airway
obstruction. The percutaneous dilational techniques first described by
Ciaglia and the subsequent modification (Figure 2) employing the Ciaglia
Blue Rhino® kit (Cook Medical’s
Critical Care division, Bloomington,
IN) have made the percutaneous
technique arguably the procedure
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.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical review
Page 3 of 6
Figure 2: Dilation of tracheotomy using Ciaglia Blue Rhino® during bedside
percutaneous tracheostomy.
Figure 3: Standard equipment set up for bedside modified percutaneous
tracheostomy using Ciaglia Blue Rhino® kit.
of choice for tracheostomy placement12,13. Bedside percutaneous
tracheostomy (Figure 3) has been
shown repeatedly to be a safe alter-
native to open surgical tracheostomy in the OR2,5,10. Meta-analysis by
Higgins showed percutaneous tracheostomy to have lower wound infec-
tion rates, less scarring and shorter
case lengths when compared to open
tracheostomy5. Bedside percutaneous
tracheostomy has been shown to be
substantially more cost-effective than
open tracheostomy performed in
the OR. Studies have shown savings
between $1100 and $3400 per procedure1,14,15. The Johns Hopkins Percutaneous Tracheostomy Program Group
showed that a hospital-subsidised
multidisciplinary team performing
bedside percutaneous tracheostomies can decrease complications and
length of stay in ICU resulting in a net
increase in hospital revenue4,6. The
safety of bedside percutaneous tracheostomy even in high-risk groups, such
as the obese, was recently demonstrated in two large retrospective
studies. Complication rates in highrisk patients in these studies were
1.0% and 1.7%, respectively10,16.
Percutaneous endoscopic gastrostomy
Since its first description, PEG is a
procedure, which was an obvious
choice to be performed outside the
OR17. The combined endoscopic
and percutaneous techniques have
low risk and are relatively easy to
perform at the bedside (Figure 4).
Even in the initial cases, Ponsky
and colleagues used only local and
topical analgesia18. Other techniques
and devices exist for percutaneous
feeding access, but the PEG remains
the gold standard. Indications for
PEG are related to the requirement
for long-term feeding access and
include severe neurological injuries,
prolonged mechanical ventilation,
inability to swallow (e.g., head and
neck cancer, trauma, etc.), high risk of
aspiration, severe facial trauma and
severe malnutrition in debilitated or
demented patients19. Although few,
but some potential contraindications
to PEG are haemodynamic instability, recent oesophageal or gastric
surgery, coagulopathy, inability to
oppose the gastric wall to anterior
abdominal wall, inability to pass a
flexible endoscope and gastric outlet
obstruction. Relative contraindica-
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.
Competing interests: none declared. Conflict of Interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical review
Page 4 of 6
Critical review
Figure 4: Bedside percutaneous endoscopic gastrostomy tube placement.
Figure 5: Bedside laparotomy with abdominal washout. Procedure support
nurse (right) acts as scrub nurse. Critical care nurse (left) administers sedation
and monitors vital signs.
tions include gastric varices, diffuse
gastric cancer and limited remaining
life expectancy 19. Bankhead and
colleagues compared gastrostomy
techniques and concluded that PEG
was the preferred technique over
laparoscopic or open gastrostomies.
Procedure duration of PEG was
Inferior vena cava filter
Critically ill patients are inherently at
high risk of deep venous thrombosis
(DVT), by virtue of exhibiting characteristics of Virchow’s triad, including
venous stasis, hypercoagulability and
endothelial damage. Frequent, diagnoses or injuries preclude certain
patients from receiving appropriate
pharmacologic DVT prophylaxis or
treatment. To prevent venous thromboembolism (VTE) in this high-risk
group, IVCFs are a reasonable option.
Initially, these procedures were
exclusively performed in the OR.
With modernisation of filter design
and delivery systems, the IVCF procedure evolved into a percutaneous
technique that could be performed in
angiography suites. Since that time,
it has migrated into the ICU as well.
The key to the IVCF procedure is to
ensure deployment of the filter in
the proper infra-renal location of the
vena cava. This is made possible by
image-guided placement in the form
of ultrasonography (transabdominal
or intravascular) or C-arm fluoroscopy
with iodinated contrast or carbondioxide, either of which can be
performed at bedside3,22–24. Complication rates are exceedingly low in IVCF
and are comparable to those procedures performed in the OR and angiography suites23,24. Cost savings by
performing the IVCF procedure in the
ICU are tremendous. Multiple studies
have demonstrated significant cost
savings by placing IVCF in the ICU
rather than in angiography suites
or the OR3,23. Nunn and colleagues
reported that annual savings for IVCF
placed at bedside compared to angi-
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.
Competing interests: none declared. Conflict of interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
shorter, tube feedings were able to
be started sooner and complications
were fewer in the PEG group20. More
recently, a meta-analysis performed
by Gomes found that patients with
PEGs had lower rates of subsequent
intervention failure (e.g., clogged
tube, interruption of feedings, etc.)
compared to patients with nasogastric tubes with no difference in other
complications including mortality21.
Page 5 of 6
Figure 6: Instruments used at our institution for beside laparotomy, including
removal of packing and fascial closure. Additional instruments may be required
for more complex procedures, such as bowel anastomoses or ostomy creation.
ography suite and OR were nearly
$69,800 and $118,300, respectively3. Neither of these cost analyses
accounts for the hidden costs of the
time and personnel, required to
transport critically ill patients, nor do
they include the costs of the potential risks incurred in transport of this
high-risk population.
Laparotomy
Bedside laparotomy can be necessary in cases of abdominal compartment syndrome, severe abdominal
trauma and specific emergency
general surgical conditions. Abdominal compartment syndrome is
often the result of aggressive fluid
resuscitation after trauma or sepsis.
The resultant bowel and interstitial oedema may lead to pulmonary
compromise, diminished venous
return and decreased cardiac output.
The result is severe hypoventilation and combined cardiogenic and
hypovolemic shocks. The profound
haemodynamic and respiratory instability that can develop secondary to
abdominal compartment syndrome
obviates safe transport of the patients
to the OR and necessitates immediate
surgical intervention in the form of
decompressive laparotomy.
Damage control operations with
temporary abdominal closure have
been well established in patients with
severe torso injuries in the setting
of the so-called lethal triad of hypotension, acidosis and coagulopathy.
The initial operation is performed in
the OR and is primarily focused on
controlling haemorrhage and gaining
source control of sepsis. A temporary
abdominal closure system is typically applied, and the patient may be
transferred to the ICU for ongoing
resuscitation and stabilisation25. The
decision regarding when and where
to re-operate is dependent on factors,
such as operative complexity and
patient physiology. Simple procedures,
such as removal of intra-abdominal
packing and fascial closure may be
performed at the bedside in the ICU
(Figure 5), particularly for patients
with significant respiratory compromise requiring high levels of ventilator
support. More complex procedures,
such as restoration of bowel continuity may also be performed in the
ICU provided the appropriate equipment is available (Figure 6), and can
be considered on a case-by-case basis.
Care must be exercised to maintain
patient safety principles as would be
expected in the OR setting.
While there are many diagnoses
that may benefit from bedside laparotomy, there are few, if any, definite indications. Diaz reported the
use of a protocol for bedside laparotomy. As defined by the protocol,
the four primary clinical indications
for bedside laparotomy in patients
felt to be unsuitable for transport
to the OR were as follows: abdominal compartment syndrome, acute
haemodynamic instability caused
by intra-abdominal haemorrhage,
washout or closure of a previous
open abdomen and intra-abdominal
sepsis26. Damage control laparotomies had previously been shown to
carry higher rates of complications
than the more traditional exploratory laparotomy, particularly intraabdominal abscess and fistula27.
However, after employing the bedside
laparotomy protocol, Diaz demonstrated intra-abdominal abscess and
fistula rates that were equivalent to
studies involving damage control
laparotomies performed in the
OR26. Additionally, as with the previously discussed procedures, significant cost savings can be realised by
avoiding transport to the OR with
bedside laparotomy being shown to
save as much as $5300 per case27.
Damage control orthopaedic
procedures
Just as the bedside laparotomy is a
damage control procedure for general
surgeons, orthopaedic surgeons are
occasionally required to perform
operative procedures at bedside.
While there are sparse reports in the
published literature of bedside orthopaedic procedures, they are frequently
practiced at our institution in select
circumstances. Indications for bedside
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.
Competing interests: none declared. Conflict of Interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical review
Page 6 of 6
orthopaedic procedures reflect those
for bedside laparotomy with one additional indication. Reasons for bedside
orthopaedic procedures include the
following: compartment syndrome,
haemorrhage control, debridement
and irrigation of wounds and temporary fracture stabilisation in patients
too unstable for transport to the OR.
Ebraheim et al. recently reported the
first series of bedside fasciotomies
for compartment syndrome. Their
study investigated 34 patients, who
were treated with fasciotomies at
the bedside using sedation and local
anaesthetic. The authors observed
an infection rate of 9%, similar to
the published rates for fasciotomies
performed in the OR and no deep
infections, osteomyelitis, amputations or death were observed28.
Haemorrhage control of an open or
badly mangled extremity in unstable
patients, with multiple injuries, is
sometimes necessary, particularly
in patients with moderate-to-severe
traumatic brain injuries. Fluid and
blood product resuscitation may at
times be insufficient to keep up with
the ongoing losses from a severely
injured extremity. In these rare
instances, bedside exploration and
washout are required to prevent
secondary brain injury from hypotension due to haemorrhagic shock.
Traditional orthopaedic surgical principles would hold that formal irrigation and debridement should occur
within six to eight hours. For patients
with extended periods of instability
preventing safe transport to the OR,
irrigation and debridement can be
performed at the bedside with relative ease.
Fracture stabilisation may be also
performed at the bedside in a closed
technique or with skeletal traction
pins. However, stabilisation with
external fixation is possible in the
ICU as well, and our own orthopaedic
colleagues will employ this in select
cases. As with previous indications,
these patients usually have multiple
injuries and require significant critical
care supportive measures. A typical
scenario would include a patient, with
multiple long bone fractures that are
believed to contribute to a continued
systemic inflammatory response.
Conclusion
It is important to remember that OR
is still the preferred venue to perform
the vast majority of surgical procedures. However, the OR is no longer
the only location, in which operative
procedures can be safely and effectively performed. Because of either
necessity or convenience, the ICU
has become an accessory theatre, in
which surgical procedures are now
routinely performed. In fact, there
are some advantages to perform
procedures in the ICU. Eliminating
risks associated with transporting
critically ill patients, avoiding OR
availability issues and cost savings,
are all advantages to perform select
procedures in the ICU. Properly
training the ICU personnel, including
a specially trained PSN or mobile OR
personnel, is essential for the safety
and success of the ICU procedures.
Additionally, appropriate patient
and procedure selection for the ICU
setting are paramount to minimise
the risk of adverse outcomes.
Abbreviations list
DVT, deep venous thrombosis; ICU,
intensive care unit; IVCF, inferior
vena cava filter; OR, operating room;
PSN, procedure support nurse.
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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.
Competing interests: none declared. Conflict of interests: none declared.
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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.
Competing interests: none declared. Conflict of Interests: none declared.
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Critical review