Surgical Procedures - What It Means For The Intensive Care Unit
In recent years, intensive care unit (ICU) bedside surgical procedures have become more common.
Much of this is due to the acceptance of surgeons that procedures previously thought to be only performed in the operating room (OR) can now be done safely and easily in the ICU.
In many cases, it has been shown that performing these procedures in the ICU can save money while maintaining patient safety.
Furthermore, due to difficulties obtaining timely access to the OR, either due to patient instability or availability of the OR, bedside procedures have become a popular alternative that often results in more efficient care.
Most importantly, transporting critically ill patients carries inherent risks, with some studies showing that serious adverse events, including death, can occur in as many as 30%–45% of intra-hospital transports involving critically ill patients.
Certain procedures can be performed at the bedside in the ICU to reduce these risks.
For a variety of reasons, ICU care is similar to that in the OR. The ICU has nearly identical monitoring and equipment capabilities as the OR. In addition to standard OR ventilators, most ICU ventilators have mechanical ventilation capabilities. While inhaled anesthetics are not readily available, intravenous sedatives are commonly used and are relatively easy to obtain. In addition, ICU personnel are similar to OR personnel. Circulating nurses, anesthetists, and OR attendants are replaced with critical care nurses, respiratory therapists, and patient care assistants.
However, in the ICU, the scrub nurse has no natural counterpart. Many hospitals have created systems that connect the operating room to the intensive care unit. This usually entails the use of an OR crew to transport the necessary equipment and supplies from the OR to the ICU. This can be a difficult and time-consuming task, particularly in time-sensitive situations or at inconvenient times such as nights or weekends.
Some procedures that can be performed in the ICU have some limitations, and some procedures clearly belong in the OR. Risk of major bleeding, prosthetic implantation, and long, complex procedures are all contraindications to bedside surgery. As a general rule, bedside procedures should be reserved for two scenarios: minor procedures for which transport to the OR is not justified due to transportation difficulties, OR expense, or OR availability, and lifesaving, emergency procedures for patients who are too unstable to be transported.
For patients who need long-term mechanical ventilation or have an upper airway obstruction, a tracheostomy is the gold standard. Ciaglia's percutaneous dilational techniques, as well as subsequent modifications using the Ciaglia Blue Rhino® kit, have made percutaneous tracheostomy placement arguably the preferred method.
Percutaneous tracheostomy performed at the bedside has been shown to be a safe alternative to open surgical tracheostomy in the operating room on numerous occasions. In comparison to open tracheostomy, Higgins' meta-analysis revealed that percutaneous tracheostomy had lower wound infection rates, less scarring, and shorter case lengths. Percutaneous tracheostomy performed at home has been shown to be significantly less expensive than open tracheostomy in the operating room.
The combined endoscopic and percutaneous techniques have low risk and are relatively easy to perform at the bedside. The combined endoscopic and percutaneous techniques carry a low risk of complications and are relatively simple to perform at the bedside. Percutaneous feeding access can be achieved using a variety of techniques and devices, but the PEG is still the gold standard. 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 patients are all examples of indications for PEG.
Haemodynamic instability, recent esophageal or gastric surgery, coagulopathy, inability to oppose the gastric wall to the anterior abdominal wall, inability to pass a flexible endoscope, and gastric outlet obstruction are just a few of the potential contraindications to PEG. Gastric varices, diffuse gastric cancer, and a short life expectancy are examples of relative contraindications. Bankhead and colleagues compared gastrostomy techniques and found that PEG was superior to laparoscopic and open gastrostomies. The PEG group had a shorter procedure time, could start tube feedings faster, and had fewer complications. Patients with PEGs had lower rates of subsequent intervention failure (e.g., clogged tube, interruption of feedings, etc.) than patients with nasogastric tubes, according to a meta-analysis conducted by Gomes recently, with no difference in other complications such as mortality.
By virtue of exhibiting characteristics of Virchow's triad, such as venous stasis, hypercoagulability, and endothelial damage, critically ill patients are inherently at high risk of deep venous thrombosis (DVT). Certain patients are unable to receive adequate pharmacologic DVT prevention or treatment due to frequent diagnosis or injuries. In this high-risk group, IVCFs are a viable option for preventing venous thromboembolism (VTE). These procedures were originally done only in the operating room.
The IVCF procedure has evolved into a percutaneous technique that can be performed in angiography suites, thanks to advancements in filter design and delivery systems. Since then, it has spread to the intensive care unit (ICU). The IVCF procedure relies on the filter being placed in the proper infra-renal location of the vena cava. Image-guided placement, such as transabdominal or intravascular ultrasonography or C-arm fluoroscopy with iodinated contrast or carbon dioxide, allows for this. IVCF has extremely low complication rates, which are comparable to those seen in operating rooms and angiography suites. The IVCF procedure can save a lot of money when done in the ICU. Using IVCF in the ICU rather than angiography suites or the OR has been shown to save money.
In cases of abdominal compartment syndrome, severe abdominal trauma, and specific emergency general surgical conditions, a bedside laparotomy may be required. After trauma or sepsis, aggressive fluid resuscitation frequently results in abdominal compartment syndrome. As a result of the bowel and interstitial oedema, pulmonary compromise, reduced venous return, and decreased cardiac output may occur. Severe hypoventilation and combined cardiogenic and hypovolemic shocks occur as a result. The severe hemodynamic and respiratory instability that can result from abdominal compartment syndrome precludes safe transport to the operating room and necessitates immediate surgery in the form of a decompressive laparotomy.
In the setting of the so-called lethal triad of hypotension, acidosis, and coagulopathy, damage control operations involving temporary abdominal closure have been well established in patients with severe torso injuries. The first operation takes place in the operating room and is aimed at controlling hemorrhage and gaining sepsis source control. The patient may be transferred to the ICU for continued resuscitation and stabilization after a temporary abdominal closure system has been applied.
Orthopedic surgeons are occasionally required to perform operative procedures at the bedside, much like general surgeons perform bedside laparotomies as a damage control procedure. While there are few reports of bedside orthopedic procedures in the published literature, they are frequently used at our institution in certain situations. The indications for bedside orthopedic procedures are the same as for bedside laparotomy, with the exception of one.
The following are some of the reasons for bedside orthopedic procedures: compartment syndrome, hemorrhage control, wound debridement and irrigation, and temporary fracture stabilization in patients who are too unstable to be transported to the OR. The first series of bedside fasciotomies for compartment syndrome were recently published by Ebraheim et al. Their research looked at 34 patients who were treated at the bedside with fasciotomies under sedation and local anesthesia. The authors found a 9% infection rate, which was similar to previously published rates for fasciotomies performed in the operating room, and no deep infections, osteomyelitis, amputations, or death.
In patients with moderate-to-severe traumatic brain injuries, hemorrhage control of an open or badly mangled extremity is sometimes required, especially in patients with multiple injuries. Resuscitation with fluids and blood products may not always be enough to keep up with the ongoing losses from a severely injured extremity. To avoid secondary brain injury from hypotension caused by hemorrhagic shock, bedside exploration and washout are required in these rare cases. Formal irrigation and debridement should be done within six to eight hours, according to traditional orthopedic surgical principles. Irrigation and debridement can be performed at the bedside for patients who have experienced prolonged periods of instability that prevent safe transport to the OR.
Surgical procedures that were once reserved for the OR are increasingly being performed in ICUs. Advanced ventilation management could have an impact on where the surgery is performed. The intensive care unit (ICU) can be used safely as an operating room for critically ill and injured patients.
Critically ill patients are treated in the SICU by specialists from General Surgery, Orthopedics, Vascular Surgery, Gynecology-Obstetrics, Transplantation (liver, pancreas, bowel, and kidney), and Urology.
As previously stated, intensive care units are for critically ill patients who require close monitoring and supervision; larger hospitals will separate medical and surgical patients. Medical intensive care unit (MICU) and surgical intensive care unit (SICU) are two different types of ICUs.
Medical Surgical ICU Nurse – Provide direct care to ICU patients in order to stabilize their condition before and after surgery. Traumatic brain injuries, hip and knee replacements, and other ailments are common among patients who require this type of treatment.
It's important to keep in mind that the operating room is still the preferred location for the vast majority of surgical procedures. The operating room, on the other hand, is no longer the only place where operative procedures can be carried out safely and effectively. The ICU has evolved into an accessory theater where surgical procedures are now routinely performed, either out of necessity or for convenience. In fact, there are some benefits to having procedures done in the ICU. The advantages of performing select procedures in the ICU include avoiding the risks of transporting critically ill patients, avoiding OR availability issues, and cost savings. The safety and success of ICU procedures require proper training of ICU personnel, including a specially trained PSN or mobile OR personnel. To reduce the risk of negative outcomes in the ICU, proper patient and procedure selection is also critical.