Elective bedside surgery in critically injured patients is safe and cost-effective

Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room?

Nonoperating room anesthesia (NORA) is a fast-growing field in anesthesiology, wherein anesthesia care is provided for surgical procedures performed outside the main operating room (OR) pavilion. Advances in medical science and technology have led to an increasing number of procedures being moved out of the operating room to procedural suites. One such NORA location is the intensive care unit (ICU), where a growing number of urgent and emergent procedures are being performed on medically unstable patients. ICU-NORA allows medical care to be provided to patients who are too sick to tolerate transport between the ICU and the OR. However, offering the same, high-quality, and safe care in this setting may be challenging. It requires special planning and a thorough consideration of the presence of life-threatening comorbidities and location-specific and ergonomic barriers. In this Pro-Con commentary article, we discuss these special considerations and argue in favor of and against routinely performing procedures at the bedside in the ICU versus in the OR.

Emergency Laparotomy in the Critically Ill: Futility at the Bedside

Background

Critically ill patients are often evaluated for an intra-abdominal catastrophe. In the absence of a preoperative diagnosis, abdominal exploration may be offered despite desperate circumstances. We hypothesize that (1) abdominal exploration for such patients is associated with a high mortality and (2) commonly obtained physiologic measures at laparotomy anticipate mortality.

Methods

All acute care surgery (ACS) patients undergoing emergency laparotomy at a quaternary referral center during a 3-year period were reviewed. Inclusion was defined by emergency laparotomy in the operating room (OR) in a patient with an American Society of Anesthesiologists (ASA) score ≥4 or bedside laparotomy in the ICU (BSL). Mortality was the primary endpoint and was stratified by demographics, admitting service, surgical findings, and physiology. Comparisons between OR and BSL were by Fisher's exact and Mann-Whitney tests.

Results

144 patients underwent emergency laparotomy (45 BSL vs. 99 OR). Overall mortality was 55.6% (77.8% BSL vs. 45.5% OR; p < 0.001). Mortality by admitting service was cardiac 71.4% (n=42), medical 70% (n=30), ACS 42% (n=50), and other 36.4% (n=22) services. Preoperative lactate levels were higher in nonsurvivors (2.7 vs. 8.5 mmol/L, p < 0.001), as was vasopressor use (62.5% vs. 97.5%, p < 0.001), acute kidney injury (51.6% vs. 72.5%, p < 0.01), leukocytosis (53.1% vs. 71.3%, p < 0.04), and anemia (45.3% vs. 71.3%, p < 0.01). The presence of any identifiable abdominal pathology established a 90% mortality rate.

Conclusions

The need for BSL portends an extremely high mortality rate and is likely useful in preintervention counselling. Emergency OR laparotomy leads to mortality in nearly half of such patients and is anticipatable based on concurrent abnormal physiology.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Bedside dressing changes for open abdomen in the intensive care unit is safe and time and staff efficient

Background

Patients with an open abdomen (OA) treated with temporary abdominal closure (TAC) need multiple surgical procedures throughout the hospital stay with repeated changes of the vacuum-assisted closure device (VAC changes). The aim of this study was to examine if using the intensive care unit (ICU) for dressing changes in OA patients was safe regarding bloodstream infections (BSI) and survival. Secondary aims were to evaluate saved time, personnel, and costs.

Methods

All patients treated with OA in the ICU from October 2006 to June 2014 were included. Data were retrospectively obtained from registered procedure codes, clinical and administrative patients’ records and the OR, ICU, anesthesia and microbiology databases. Outcomes were 30-, 60- and 90-day survival, BSI, time used and saved personnel costs.

Results

A total of 113 patients underwent 960 surgical procedures including 443 VAC changes as a single procedure, of which 165 (37 %) were performed in the ICU. Nine patients died before the first scheduled dressing change and six patients were closed at the first scheduled surgery after established OA, leaving 98 patients for further analysis. The mean duration for the surgical team performing a VAC change in the ICU was 63.4 (60.4–66.4) minutes and in the OR 98.2 (94.6–101.8) minutes (p < 0.001). The mean duration for the anesthesia team in the OR was 115.5 minutes, while this team was not used in the ICU. Personnel costs were reduced by €682 per procedure when using the ICU. Forty-two patients had all the VAC changes done in the OR (VAC-OR), 22 in the ICU (VAC-ICU) and 34 in both OR and ICU (VAC-OR/ICU). BSI was diagnosed in eight (19 %) of the VAC-OR patients, seven (32 %) of the VAC-ICU and eight (24 %) of the VAC-OR/ICU (p = 0.509). Thirty-five patients (83 %) survived 30 days in the VAC-OR group, 17 in the VAC-ICU group (77 %) and 28 (82 %) in the VAC-OR/ICU group (p = 0.844).

Conclusions

VAC change for OA in the ICU saved time for the OR team and the anesthesia team compared to using the OR, and it reduced personnel costs. Importantly, the use of ICU for OA dressing change seemed to be as safe as using the OR.

Bedside Tracheostomy and Percutaneous Endoscopic Gastrostomy on the Patient's Television

Bedside surgical procedures such as percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) placement in ICU settings are widely accepted; however, these procedures often require the addition of bulky equipment into the patient's room, which consumes valuable space and restrict workflow. A practice modification was developed in our trauma program, which reduces clutter in the patient's room, streamlines workflow, and results in better patient care and teaching. Simple and cost-effective, this has become the standard in our trauma center and could be of benefit to other institutions as well.

Patient variables impacting hospital costs from 2008 to 2010

BACKGROUND

Studying the variables associated with the increased costs of health care provides valuable insight.

METHODS

A review and analysis of the pertinent variables and information collected for 118.3 million hospital admissions recorded as Nationwide Inpatient Samples database was done for the years 2008 to 2010. We used hospital charges as an approximation of costs in the analysis of the patient variables and other factors contributing to hospital costs.

RESULTS

The top 5 factors with the most impact on charges were diagnostic category, length of stay, number of procedures, major operating room procedures, and ownership of the hospital.

CONCLUSION

The top 5 factors with the most impact on charges were length of stay, number of procedures, major diagnostic category, major operating room procedures, and ownership of the hospital.

Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room

INTRODUCTION

The prognoses of critically ill patients with a requirement for emergency laparotomy and severe respiratory and/or hemodynamic instability precluding transport to the operating room (OR) are often fatal without surgery. Attempting emergency surgery at the bedside might equally result in an adverse outcome. However, risk factors and predictors that could support clinical decision making have not been identified so far. This study describes the clinical characteristics, indicative pathophysiology and outcomes in patients undergoing resuscitative laparotomy in the intensive care unit (ICU).

METHODS

This was a retrospective observational study of all critically ill adult patients undergoing resuscitative laparotomy in the ICUs of a German university hospital from January 2005 to July 2013. Clinical characteristics, risk factors, and treatments were compared between survivors and non-survivors. The primary endpoint was 28-day survival.

RESULTS

A total of 41 patients with a median age of 64 (21 to 83) were included. The most frequent reasons for ICU admission were sepsis, pneumonia, and pancreatic surgery. All patients were mechanically ventilated, receiving vasopressors, and were in multiple organ failure. Twenty-nine patients (70.7%) were on renal replacement therapy and two patients (4.9%) on extracorporeal membrane oxygenation. The main reasons for surgery were suspected intra-abdominal bleeding (39.0%), suspected intestinal ischemia (24.4%) or abdominal compartment syndrome (24.4%). Twenty-eight-day, ICU and hospital mortalities were 75.6%, 80.5%, and 82.9%, respectively. In six out of ten patients (60%) who survived surgery for more than 28 days, bedside laparotomy was rated as a life-saving procedure by an interdisciplinary group of the investigators.

CONCLUSIONS

These findings suggest that in selected critically ill patients with a vital indication for emergency laparotomy and severe cardiopulmonary instability precluding transport to the OR, a bedside resuscitative laparotomy in the ICU can be considered as a rescue procedure, even though very high mortality is to be expected.

A simple alternative technique for harvesting split thickness skin grafts

AIM: To assess the use of a simple split skin graft harvesting technique, requiring only a scalpel and a swab.

METHODS: During the last 8 mo, we operated on a consecutive series of 52 patients (30 males, 22 females) with a mean age of 60 years (33-80). We used the technique we present in order to cover small skin defects. All procedures were performed under local anesthesia. Thirty-seven patients underwent bedside surgery, 8 patients were operated on in the outpatient department and the remaining 7 had their graft harvested in the operating room. After antiseptic preparation of the donor site, the margins of the graft were drawn by the use of a surgical marker. A No 15 scalpel was used for the graft elevation, under constant traction with a moist swab.

RESULTS: All procedures were completed successfully without immediate complications. The patients tolerated the procedure well. The mean operative time was 15 min. Twenty-four donor sites were left to heal by secondary intention, whereas 28 were sutured with interrupted 3/0 silk sutures in order to heal by primary intention. All 24 sites that were left to heal by secondary intention healed completely in approximately 14 d. For the sites that were sutured, the sutures were removed on the 10^th postoperative day. Out of the 52 operated cases, 6 patients (11%) developed complications. In 4 patients, the split thickness skin grafts were partially lost, whereas in 2 patients the grafts were completely lost. Wound dehiscence was observed in 2 patients, which were treated with local antiseptic and antibiotic therapy.

CONCLUSION: The skin graft technique described is simple, costless and effective and can be performed even on an outpatient basis, without the need for special equipment.

When the ICU is the operating room

BACKGROUND

The surgical intensive care unit (SICU) is increasingly used as a surrogate operating room (OR). This study seeks to characterize a Level I trauma center's operative undertakings in the SICU versus OR for trauma and emergency general surgery patients.

METHODS

Operative and ICU databases were queried for all operative procedures as a function of procedure type (CPT code) and location (OR, ICU) from August 2002 through June 2009. Mode of ventilation, type of anesthesia used, and adverse outcomes were recorded. Data were divided into 2002-2006 versus 2007-2009 because of MD staffing and service structure changes. Time frames were compared via Student's t-test or χ(2) as appropriate; significance for p < 0.05 (*) versus 2002-2006.

RESULTS

Trauma service-admitted patient volume increased from 2002-2003 (n = 1,293) to 2006-2007 (n = 1,577) and again in 2008-2009 (n = 1,825). Emergency general surgery total operative cases increased from 2002-2003 (n = 246) to 2005-2006 (n = 468). Case volume further increased in 2006-2007 (n = 767*), 2007-2008 (n = 1,071*), and 2008-2009 (n = 875*) compared with 2002-2003 or 2005-2006. Relaparotomy and temporary abdominal closure procedures were significantly increased in 2007-2008 (n = 109*) and 2008-2009 (n = 128*) versus 2002-2006 (n = 6) and 2006-2007 (n = 10). ICU cases were 11.5% of total cases (OR + ICU) spanning 2002-2006 and significantly increased to 24.3%* in 2007-2008 and 36%* in 2008-2009. Advanced ventilation was used in 15% of ICU cases in 2002-2003 and significantly increased to 40% in 2006-2007 and 78%* in 2008-2009. Neuromuscular blockade was rare; most cases (93.9%) were performed under deep sedation.

CONCLUSION

Our ICU is increasingly used for surgical procedures traditionally reserved for the OR. Advanced ventilation management may influence the choice of operative location. The ICU may be safely used as an operative location for the critically ill and injured.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Percutaneous dilational tracheostomy

Tracheostomy is a commonly performed intervention with several benefits in the treatment of patients with chronic respiratory failure. Percutaneous dilational tracheostomy techniques have allowed bedside tracheostomy placement in the modern intensive care unit. Percutaneous dilational tracheostomy can be safely performed by interventional pulmonologists, medical intensive care physicians, and surgical specialists. When performed with the assistance of adjuncts, such as flexible bronchoscopy, the percutaneous dilational method has a favorable complication rate, efficiency, and cost profile compared with surgical tracheostomy.

Safety of bedside percutaneous tracheostomy in the critically ill: evaluation of more than 3,000 procedures

BACKGROUND

Bedside percutaneous dilational tracheostomy has been demonstrated to be equivalent to open tracheostomy. At our institution, percutaneous dilational tracheostomy without routine bronchoscopy is our preferred method. My colleagues and I hypothesized that our 10-year percutaneous dilational tracheostomy experience would demonstrate that the technique is safe with low complication rates, even in obese patient populations.

STUDY DESIGN

We conducted a retrospective review of all bedside percutaneous dilational tracheostomy performed by the Division of Trauma and Surgical Critical Care faculty from 2001 to 2011, excluding patients younger than 18 years of age. All major airway complications and procedure-related deaths were evaluated during the early (≤48 hours postprocedure), intermediate (in hospital), and late (after discharge) periods. Incidence of post-tracheostomy stenosis was also evaluated.

RESULTS

There were 3,162 percutaneous dilational tracheostomies performed during the study period. Mean body mass index was 28 (16% with body mass index ≥35), mean Injury Severity Score was 32, and mean APACHE II score was 19. Major airway complications occurred in 12 (0.38%) patients, accounting for 5 (0.16%) deaths. Early major complications included 3 airway losses and 1 bleeding event requiring formal exploration with procedure-related deaths occurring in 3 patients. Intermediate major complications included 2 tube occlusion/dislodgement events with 2 related deaths. Late complications included 5 (0.16%) cases of tracheal stenosis requiring intervention without associated deaths.

CONCLUSIONS

Bedside percutaneous dilational tracheostomy is safe across a broad critically ill patient population. The safety of this technique, even in the obese population, is demonstrated by its low complication rate. Routine bronchoscopic guidance is not necessary. Specially trained procedure nurse and process improvement programs contribute to the safety and efficacy of this procedure.

Vena cava interruption

Anticoagulation has been proven to be effective in preventing and treating deep vein thrombosis and pulmonary embolus. However, many critically ill patients are unable to receive anticoagulation or suffer recurrent venous thromboembolism despite adequate treatment. This article examines the use of vena cava filters in the critically ill. Indications for, techniques, and complications of vena cava filter insertion are reviewed. The importance of vena cava filters with the option to be retrieved and bedside insertion in the intensive care unit is emphasized.

Common carotid artery surprise during percutaneous dilatational tracheostomy - A near miss, confirmed with ultrasound

The practice of percutaneous dilatational tracheostomy (PDT) has gained popularity and acceptance due to the ease in acquiring its skill and low probability of complications. Nevertheless, PDT is associated with a few complications, some really life-threatening. We present a case of an abnormally located common carotid artery encountered during PDT in our intensive care unit. The procedure was electively posted, in an old patient chronically ventilated after a revived cardiac arrest. While identifying the landmarks on palpation pulsation was felt similar to arterial pulsation. This was confirmed using bedside portable ultrasonography and found to be the right common carotid artery forming a loop anterior to the trachea at the level of the third and fourth tracheal rings. The patient had a past history of thyroidectomy and this was suspected to be the primary reason for the altered course of the right common carotid artery.

Percutaneous dilatational tracheostomy: review of technique and evidence for its use

Tracheostomy is a technique for airway management commonly used by surgeons who care for critically ill patients. Patients with traumatic facial injuries, severe odontogenic infections, and head and neck malignancies are often recipients of tracheostomies. As such, the oral and maxillofacial surgeon who frequently treats such patients should be well-trained in tracheostomy placement. For decades, the standard technique for tracheostomy was the open surgical technique. However, during the past 20 years, the use of percutaneous dilatational tracheostomy has increased. The purpose of the present report is to review the percutaneous dilatational tracheostomy technique, describe the use of intensive care units as proxies for the operating room, and review the available evidence comparing percutaneous dilatational tracheostomy to open tracheostomy.

Optional inferior vena cava filters in the trauma patient

Trauma patients are at exceedingly high risk of development of venous thromboembolism (VTE) including deep venous thrombosis and pulmonary embolism (PE). The epidemiology of VTE in trauma patients is reviewed. PE is thought to be the third major cause of death after trauma in those patients who survive longer than 24 hours after onset of injury. In fact, patients recovering from trauma have the highest rate of VTE among all subgroups of hospitalized patients. Various prophylactic and surveillance methods have been evaluated and found helpful in certain situations, but VTE complications can occur despite such measures. Therapeutic and prophylactic uses of inferior vena cava (IVC) filters in trauma patients are reviewed. Prophylactic IVC filter use is revealed to be a controversial subject with valid arguments on both sides of the issue. With the lack of prospective randomized trials of IVC filter use in trauma, it is impossible to make evidence-based recommendations. Unfortunately, two sets of guidelines are available for insertion of filters in trauma patients, with conflicting recommendations. The introduction of retrievable IVC filters seems to offer a unique solution for VTE protection in the trauma patient population, which often consists of younger members of our population. Lastly, current generations of FDA-approved retrieval filters are discussed.

Recommendations for the intra-hospital transport of critically ill patients

Introduction

This study was conducted to provide Intensive Care Units and Emergency Departments with a set of practical procedures (check-lists) for managing critically-ill adult patients in order to avoid complications during intra-hospital transport (IHT).

Methods

Digital research was carried out via the MEDLINE, EMBASE, CINAHL and HEALTHSTAR databases using the following key words: transferring, transport, intrahospital or intra-hospital, and critically ill patient. The reference bibliographies of each of the selected articles between 1998 and 2009 were also studied.

Results

This review focuses on the analysis and overcoming of IHT-related risks, the associated adverse events, and their nature and incidence. The suggested preventive measures are also reviewed. A check-list for quick execution of IHT is then put forward and justified.

Conclusions

Despite improvements in IHT practices, significant risks are still involved. Basic training, good clinical sense and a risk-benefit analysis are currently the only deciding factors. A critically ill patient, prepared and accompanied by an inexperienced team, is a risky combination. The development of adapted equipment and the widespread use of check-lists and proper training programmes would increase the safety of IHT and reduce the risks in the long-term. Further investigation is required in order to evaluate the protective role of such preventive measures.

Prospective implementation of an algorithm for bedside intravascular ultrasound-guided filter placement in critically ill patients

BACKGROUND

Although contrast venography is the standard imaging method for inferior vena cava (IVC) filter insertion, intravascular ultrasound (IVUS) imaging is a safe and effective option that allows for bedside filter placement and is especially advantageous for immobilized critically ill patients by limiting resource use, risk of transportation, and cost. This study reviewed the effectiveness of a prospectively implemented algorithm for IVUS-guided IVC filter placement in this high-risk population.

METHODS

Current evidence-based guidelines were used to create a clinical decision algorithm for IVUS-guided IVC filter placement in critically ill patients. After a defined lead-in phase to allow dissemination of techniques, the algorithm was prospectively implemented on January 1, 2008. Data were collected for 1 year using accepted reporting standards and a quality assurance review performed based on intent-to-treat at 6, 12, and 18 months.

RESULTS

As defined in the prospectively implemented algorithm, 109 patients met criteria for IVUS-directed bedside IVC filter placement. Technical feasibility was 98.1%. Only 2 patients had inadequate IVUS visualization for bedside filter placement and required subsequent placement in the endovascular suite. Technical success, defined as proper deployment in an infrarenal position, was achieved in 104 of the remaining 107 patients (97.2%). The filter was permanent in 21 (19.6%) and retrievable in 86 (80.3%). The single-puncture technique was used in 101 (94.4%), with additional dual access required in 6 (5.6%). Periprocedural complications were rare but included malpositioning requiring retrieval and repositioning in three patients, filter tilt >/=15 degrees in two, and arteriovenous fistula in one. The 30-day mortality rate for the bedside group was 5.5%, with no filter-related deaths.

CONCLUSIONS

Successful placement of IVC filters using IVUS-guided imaging at the bedside in critically ill patients can be established through an evidence-based prospectively implemented algorithm, thereby limiting the need for transport in this high-risk population.

Bedside placement of removable vena cava filters guided by intravascular ultrasound in the critically injured

BACKGROUND

Bedside placement of removable inferior vena cava filters (RVCF) is increasingly used in critically injured patients. The need for fluoroscopic equipment and specialized intensive care unit beds presents major challenges. Intravascular ultrasound (IVUS) eliminates such problems. The objective of the present study was to analyze the safety and feasibility of IVUS-guided bedside RVCF placement in critically injured patients.

METHODS

Between October 2004 and July 2006 47 IVUS-guided RVCF were placed at the bedside. Medical and trauma registry records were reviewed. Primary outcome was RVCF-related complications.

RESULTS

The mean patient age was 41 +/- 19 years, and the mean Injury Severity Score was 30 +/- 12. The right common femoral vein was chosen as the site of access in 40 patients, and the left common femoral vein was the access site in 7 patients. The insertion was performed 3.7 +/- 2.5 days after admission. Four patients (8.5%) developed common femoral deep vein thrombosis (DVT) and three (6%) developed a peripheral pulmonary embolism (PE). Complications related to technique were recorded in two patients (4%) and included one misplacement and one access site bleeding with no further associated morbidity. Five patients died during the hospital stay from issues unrelated to RVCF. Forty-one patients were eligible for follow-up. Removal of RVCF was offered only to 8 patients and was performed successfully in 4 (10%) at a mean of 130 days (range: 44-183 days).

CONCLUSIONS

In this study IVUS-guided bedside placement of RVCF was feasible but was also associated with complications. Follow-up was poor, and the rate of removal disappointingly low, underscoring the need for further exploration of the role of RVCF.

Ultrasound-guided interventional radiology in critical care

Ultrasound-guided intervention is becoming an increasingly popular and valuable tool in the critical care setting. In general, image-guided procedures can expedite wait times and increase the accuracy, safety, and efficacy of many procedures commonly performed within intensive care units. In the intensive care unit setting, ultrasound has particular advantages over other imaging modalities such as computed tomography and fluoroscopy, including real-time visualization, portability permitting bedside procedures, and reduced exposure to nephrotoxic contrast agents. We review the technical and procedural aspects of a number of ultrasound-guided interventions appropriate for critical care patients. These include central venous catheter deployment, thoracentesis, paracentesis, and drainage of a wide variety of abscesses, and percutaneous nephrostomy, percutaneous cholecystectomy, and inferior vena cava filter placement. Although we believe ultrasound is significantly underutilized in critical care today, we anticipate that with the improvement of ultrasound technology and the innovation of new ultrasound-guided procedures, the role of ultrasound in the intensive care unit will continue to expand, with bedside ultrasound-guided interventions increasingly becoming the norm.

Safety and efficacy of vena cava filters in trauma patients

Pulmonary embolism (PE), due to its sudden onset, notoriously difficult diagnosis, unpredictable nature and often fatal outcome, remains one of the most feared complications in surgical practice. Trauma patients with multisystem injuries, extremity or pelvic fractures and head or spinal cord injuries often pose a significant dilemma for the surgeon because of the inability to use conventional measures such as anticoagulation therapy and compression devices. On the other hand, the incidence of deep vein thrombosis (DVT) is high among trauma patients and the attendant risk of PE is an important cause of morbidity and mortality. Inferior vena cava (IVC) interruption by placement of diverse filtering devices has evolved over the past three decades. With the use of these devices, the risk of PE has been reduced dramatically. However, variable rates of complications are reported from their use. In this study, we review all the available data on IVC filter placement in trauma patients and we discuss the potential complications of IVC filters in order to understand better the risk/benefit ratio of their use.

Protocol for bedside laparotomy in trauma and emergency general surgery: a low return to the operating room

Bedside laparotomy (BSL) was introduced as a heroic procedure in trauma patients too unstable for safe transport to the operating room (OR). We hypothesize a BSL protocol would maintain patient safety while reducing OR use. Patients were prospectively entered into a BSL protocol from July 2002 to June 2003 and retrospectively reviewed. Protocol indications for BSL were abdominal compartment syndrome, decompensation due to hemorrhage, washout/closure, and sepsis in a patient too unstable for safe transport to the OR. Primary outcomes were mortality, emergent return to OR, and primary fascial closure (PFC). Trauma operating room charges and OR time were analyzed. One hundred thirty-three BSL were performed on 60 patients with an overall mortality of 23.3 per cent (14/60). There was an average of 2.2 BSL per patient (range 1-8). Indications for BSL were 1) explore/washout (n = 100, 75.2%), 2) decompression (n = 14, 10.5%), 3) infection/abscess (n = 12, 9.0%), 4) hemorrhage (n = 7, 5.3%). Five of 133 BSL (5.8%) were emergently returned to the OR because of perforation or compromised bowel. Trauma OR charges were dollar 5,300 per cases with 2.12 hours per cases. The protocol standardized the conduct of BSL procedure to allow for a low return to OR rate of 5.8 per cent and had an overall in-hospital mortality rate of 23.3 per cent. Primary fascial closure of the abdomen had a significantly reduced hospital stay. BSL allowed trauma OR charges of dollar 5,300 per cases with 2.12 hours per cases savings.

Bedside placement of inferior vena cava filters by using transabdominal duplex ultrasonography and intravascular ultrasound imaging

Bedside placement of inferior vena cava filters by using either transabdominal duplex ultrasonography or intravascular ultrasonography (IVUS) has been shown to be safe and effective. We review techniques for bedside filter placement with transabdominal duplex ultrasonography, IVUS with dual venous access, and IVUS with single venous access. Transabdominal duplex ultrasonography and IVUS remain our preferred techniques for filter placement when feasible, especially in critically ill and immobilized patients.

Peri-operative complications during percutaneous tracheostomy in obese patients

The safety of percutaneous tracheostomy in 73 obese patients (body mass index > or = 27.5 kg.m(-2)) in a cohort of 474 adults was studied. Four percutaneous techniques were employed (percutaneous dilational tracheostomy, n = 48; Ciaglia Blue Rhino, n = 157; guide wire dilating forceps, n = 62, translaryngeal tracheostomy, n = 207). The overall complication rate was 43.8% (n = 32) in the obese group compared to 18.2% (n = 73) in the control group (p < 0.001). Seven (9.6%) obese patients suffered life-threatening complications compared to three non-obese patients (0.7%, p < 0.001). Obese patients had a 2.7-fold increased risk for peri-operative complications, and a 4.9-fold increased risk for serious complications. The data suggest that percutaneous tracheostomy in obese patients is associated with a considerably increased risk for peri-operative complications, especially for serious adverse events.

Role of prophylactic temporary inferior vena cava filters placed at the ICU bedside under intravascular ultrasound guidance in patients with multiple trauma

OBJECTIVE

Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava (IVC) filters (IVCFs) offer protection against pulmonary embolism during the early immediate injury and perioperative period, when risk is highest, while averting potential long-term sequelae of permanent IVCFs. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound (IVUS) guidance in patients with multiple trauma.

INTERVENTIONS

Ninety-four patients with multiple trauma seen between July 1, 2002, and November 1, 2003, underwent placement of OptEase (Cordis Endovascular) retrievable IVCFs under real-time IVUS guidance. Mean (+/-SD) Injury Severity Score was 25.1 +/- 2.2). Abdominal x-ray films were obtained in all patients to verify filter location. Before IVCF retrieval all patients underwent femoral vein color-flow ultrasound scanning to rule out deep vein thrombosis (DVT), and pre-procedure and post-procedure vena cavography to identify possible IVCF thrombus entrapment and post-retrieval inferior vena cava injury.

RESULTS

Nineteen patients died of their injuries; no deaths were related to IVCF placement. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein DVT occurred. As verified on abdominal x-ray films, 96.8% (91 of 94) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 2 groin hematomas (2.1%) and 3 IVCFs misplaced in the right iliac vein (3.2%), early in our experience; the filters were uneventfully retrieved and replaced in the inferior vena cava within 24 hours. Thirty-one patients underwent uneventful retrieval of IVCFs after DVT or pulmonary embolism anticoagulation prophylaxis was initiated. Forty-four filters were not removed, 41 because severity of injury prevented DVT or pulmonary embolism prophylaxis and 3 because of thrombus trapped within the filter.

CONCLUSIONS

Prophylactic, temporary IVCF placement at the intensive care unit bedside under IVUS guidance in patients with multiple trauma is simple and safe, and serves as an effective "bridge" to anticoagulation therapy until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in patients with multiple trauma is warranted.

CLINICAL RELEVANCE

Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during the perioperative and immediate injury period, when risk is highest. Ninety-four patients with multiple trauma underwent prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein deep venous thrombosis occurred. Ninety-one of 94 IVCFs (96.8%) were placed without complication. Thirty-one patients underwent uneventful retrieval of IVCFs after anticoagulation prophylaxis was initiated. Forty-four filters were not removed, because of severity of injury (n = 41) or because of trapped thrombus within the filter (n = 3). Prophylactic, temporary IVCFs placed under intravascular ultrasound guidance at the bedside in patients with multiple trauma is simple, safe, and an effective bridge to anticoagulation therapy.

Bedside insertion of vena cava filters in the intensive care unit using intravascular ultrasound to locate renal veins

BACKGROUND

Historically, contrast venography has been used to determine renal vein location and assist with vena cava filter placement. This technique, however, exposes the patient to nephrotoxic contrast and radiation. For trauma patients in the intensive care unit (ICU), inferior vena cava filters should ideally be placed without contrast at the bedside to avoid nephrotoxic agents, radiation, and transport of a critically injured patient to the operating room or x-ray department. Previously, the authors have shown that intravascular ultrasound is a safe and accurate method for locating renal veins and assisting with vena cava filter placement. The purpose of this study was to evaluate bedside vena cava filter placement prospectively using only intravascular ultrasound for imaging.

METHODS

Between August 2000 and July 2003, 29 patients met trauma service criteria for prophylactic or therapeutic placement of a vena cava filter. The 7 females and 22 males had a mean age of 51.3 years (range, 20-92 years), a mean height of 177 cm (range, 160-218.4 cm), a mean weight of 101.9 kg (range, 59.1-186.4 kg), and a body mass index of 33 (range, 14.7-56.1). Fifteen patients (55.5%) had a body mass index exceeding 30. The mean Injury Severity Score was 25.4 (range, 12-45). Intravascular ultrasound was the sole imaging method, and no contrast or fluoroscopy was used. All procedures were performed in the ICU by trauma surgeons. Data collection was prospective and included demographics, injuries, vena caval anatomy, length of procedure, complications, and follow-up radiographic confirmation of appropriate deployment.

RESULTS

The location of the renal veins and vena cava diameter was imaged in all the patients. Three patients were noted to have accessory renal veins, and no patient had thrombus in the vena cava. The inferior vena cava diameter was less than 28 mm in all the patients, thus allowing standard filters to be deployed. Filter deployment was successful for all the patients. Of the 29 patients, 27 had abdominal computed tomography (CT) during their hospital stay. When the location of the renal veins identified by CT was compared with the level of the filter on abdominal x-ray, the filter tip was found to be at or below the level of the most caudal renal vein in 26 of the 27 patients (96.3%). In one patient, the filter tip was purposely placed 2 to 3 cm above an accessory caudal renal vein, but below the main right and left renal veins. The mean procedure time was 37.7 minutes (range, 12-86 minutes). No complications were associated with filter placement.

CONCLUSIONS

Intravascular ultrasound is a safe and effective imaging method that may be used for the bedside placement of vena cava filters in the ICU. This technique avoids the use of nephrotoxic intravenous contrast and eliminates the risk of transporting a critically injured patient to the operating room or x-ray department.

Percutaneous Tracheostomy Is Safe in Patients With Severe Thrombocytopenia

STUDY OBJECTIVES

Severe thrombocytopenia has been described as a contraindication for percutaneous tracheostomy (PT). The objective of this study was to assess the safety of PT in mechanically ventilated patients with severe thrombocytopenia (defined by a platelet count of < 50 x 10(9) cells/L).

DESIGN

Retrospective, single-center cohort study.

SETTING

Medical ICU of the University Hospital Hamburg-Eppendorf, Germany.

PATIENTS

Forty-two medical patients with acute respiratory failure and severe thrombocytopenia.

INTERVENTIONS

Bedside PT under bronchoscopic guidance using the Griggs guidewire forceps technique.

MEASUREMENTS AND MAIN RESULTS

The mean (+/- SD) intubation time prior to undergoing PT was 6.7 +/- 3.9 days (range, 1 to 20 days). The mean platelet count was 26.4 +/- 11.6 x 10(9) cells/L (range, 1 x 10(9) to 47 x 10(9) cells/L). The median transfusion of platelets before the procedure in 40 of the 42 patients was 6 +/- 2.5 U (range, 3 to 12 U). Twenty-two patients (52%) had an additional coagulopathy (activated partial thromboplastin time [APTT], > 40 s; international normalized ratio, > 1.5). PT was safely performed in all 42 patients. Only two (5%) patients developed major postprocedural bleeding complications that required suturing. Both of these patients had an elevated APTT due to heparin therapy.

CONCLUSIONS

When performed by experienced personnel, PT with bronchoscopic guidance has a low complication rate in patients with severe thrombocytopenia, provided that platelets are administered beforehand. However, in order to minimize bleeding complications heparin infusions should be temporarily interrupted during the procedure.

Real-Time Intravascular Ultrasound-Guided Placement of a Removable Inferior Vena Cava Filter

BACKGROUND

Reports have demonstrated the benefit of prophylactic inferior vena cava filter (IVCF) placement to prevent pulmonary embolism. This series evaluates the potential for the bedside placement of a removable IVCF under "real-time" intravascular ultrasound (IVUS) guidance.

METHODS

Twenty trauma patients underwent intensive care unit placement of a removable IVCF with IVUS guidance. All patients had ultrasonography of the femoral veins after placement to rule out postprocedure femoral vein thrombosis and radiographs to identify filter location.

RESULTS

Nineteen of 20 IVCFs were placed at approximately the L2 level as verified by radiography. One patient had a large IVC (34 mm) and underwent bilateral common iliac IVCF placement under IVUS. Within 3 weeks of placement, 12 IVCFs were retrieved. Of the remaining eight patients, six had indications for permanent implantation, two had contralateral deep venous thrombosis, and one had ipsilateral deep venous thrombosis.

CONCLUSION

Bedside insertion of a removable IVCF with IVUS guidance and its removal are simple, safe, and accurate.

Operating on critically ill neonates: the OR or the NICU

Advances in neonatal care have resulted in the survival of smaller infants with more complicated medical problems. From a surgical standpoint this has required novel approaches to patient care. Surgical care has evolved in many respects. Procedures performed on premature infants range from elective, minor procedures to major, emergent lifesaving interventions. The emergent nature of these surgical interventions has led to controversies in management. Certain conditions require surgical procedures that are commonly performed at the bedside by pediatric surgical specialists. Under other circumstances, the specific details of management are less uniform with wide variability in approach by different practitioners. The rationale in these cases is primarily driven by personal preference with a paucity of supportive data in the published literature to either support or contradict individual opinion. Nevertheless, the role of bedside procedures appears to be expanding. If these procedures are to be undertaken, significant planning is required to ensure a good outcome for the patient. Prospective data are needed determine which patients may benefit from this approach.

Expanding Options for Bedside Placement of Inferior Vena Cava Filters with Intravascular Ultrasound When Transabdominal Duplex Ultrasound Imaging Is Inadequate

Although bedside placement of inferior vena cava (IVC) filters by means of transabdominal duplex ultrasound is possible in most patients, those with inadequate visualization have traditionally required fluoroscopy. The purpose of this study was to assess the safety and efficacy of bedside IVC filter placement with intravascular ultrasound (IVUS) when transabdominal duplex ultrasound imaging is inadequate. Between January 1, 1999 and December 31, 2002, 256 IVC filter placements were performed (207 with transabdominal duplex ultrasound [81%], 21 with fluoroscopy [8%], and 28 with IVUS [11%]). IVC filter placement with IVUS was performed only if visualization with transabdominal duplex ultrasound was determined to be inadequate. Demographics, technical data, and outcome for patients undergoing IVC filter placement with IVUS were reviewed and form the basis of this report. Bedside IVC filter placement with IVUS was technically successful in 26 of 28 patients (93%). Post-procedure abdominal radiographs confirmed proper placement, based on bony landmarks in 24 of 26 patients (92%). Post-procedure complications included insertion site thrombosis in two patients and possible recurrent pulmonary embolism in one patient 2 months following filter placement. One patient died from causes unrelated to IVC filter placement. From these results we conclude that IVC filter placement with IVUS is technically feasible and safe. This may allow for expanded bedside IVC filter placement capabilities in patients with inadequate IVC visualization on transabdominal duplex ultrasound.

Bedside intravascular ultrasound-guided vena cava filter placement

OBJECTIVE

Several reports have demonstrated the efficacy of inferior vena cava filter (IVCF) placement with intravascular ultrasound guidance (IVUS). The majority of these procedures,however, have been done in concert with contrast venography and/or fluoroscopic guidance. The purpose of this report was to evaluate the potential for bedside IVCF placement with "real-time" IVUS guidance only.

DESIGN OF STUDY

In a phase I trial, 10 patients underwent IVUS interrogation of the IVC for diameter measurements and localization of the renal veins. Contrast venography verified the IVUS findings prior to filter deployment. In a phase II trial, another 35 patients underwent intensive care unit bedside placement of an IVC filter with only "real time" IVUS guidance using a double puncture technique in the same femoral vein. All patients underwent color-flow ultrasonography of the femoral veins after filter placement to rule out post procedure femoral vein thrombosis and plain radiographs of the abdomen to identify filter location.

RESULTS

In the phase I trial, all filters were placed within 15 mm of the most inferior renal vein identified by IVUS. There were no complications, and successful filter placement was verified by contrast venography. In phase II, 33 IVCFs were placed without complications at approximately the L2 level by plain radiograph. One patient had an IVCF deployed in the common iliac vein, which necessitated placement of an uneventful second IVCF at the infrarenal location by IVUS. This same patient had a femoral deep venous thrombosis identified by postoperative duplex ultrasonography. A second patient had IVC thrombus identified by IVUS, and placement was performed with contrast venography in the fluoroscopy suite. IVC measurements ranged from 18-28 mm in diameter.

CONCLUSIONS

IVUS accurately measures the IVC diameter and localizes the renal veins, allowing for exact placement of IVCFs. IVUS further avoids the need for contrast agents and for transport of critically ill patients. Bedside insertion of an IVcF with IVUS guidance is simple, safe, and accurate. Further assessment of this technique is warranted.

A Prospective Evaluation of a Bedside Technique for Placement of Inferior Vena Cava Filters: Accuracy and Limitations of Intravascular Ultrasound

Our objective was to evaluate the safety and accuracy of a bedside technique for placing vena cava filters with intravascular ultrasonography. We conducted a prospective case series of 36 patients requiring prophylactic vena cava filter placement. Intravascular ultrasound (IVUS) was used to assess the best location for inferior vena cava filter placement. Location of best filter placement was compared with a bedside technique using a fluoroscopic examination. Thirty-six patients underwent an IVUS examination. The 21 men and 15 women had a mean age of 51 years. Our bedside placement technique was successfully performed in 34 patients. Two patients did not undergo a bedside technique because of inadequate imaging. The difference between best filter placement and bedside technique was 1.22 ± 1.24 cm. In three patients our bedside technique differed from best filter placement by more than 3 cm. Excluding these three patients the difference between best filter placement and bedside technique was 0.92 ± 0.79 cm. This bedside IVUS technique for placement of inferior vena cava filters is established as safe and accurate; however, knowledge of the limitations involving the technique is important.

Translaryngeal tracheostomy: experience of 340 cases

OBJECTIVE

To describe the authors' initial experience with a new and innovative dilational translaryngeal tracheostomy bedside technique.

STUDY DESIGN

A prospective documentation of 340 patients who received an elective translaryngeal tracheostomy in a multidisciplinary, tertiary care intensive care unit during a 45-month period.

RESULTS

All translaryngeal tracheostomy procedures but one were completed successfully; one was aborted because of bleeding from a thyroid vein. Minor perioperative complications occurred in 42% of patients, which caused no adverse effects. The most common complication was arterial desaturation occurring in 17% of patients; this was short-lived, and the lowest saturation was 79%. Blood loss was minimal (<5 mL) in all but one case, despite an elevated international normalized ratio (INR) and partial thromboplastin time in 42% and 41% of patients, respectively, and a low platelet count in 13% of patients.

CONCLUSIONS

Translaryngeal tracheostomy is a safe and reliable technique and can also be used in patients with unstable cervical spines and bleeding diathesis. It has become the authors' procedure of choice for an elective bedside tracheostomy in the intensive care unit.

The impact of duplex scanning in phlebology

Chronic venous disease (CVD) is a tremendous medical and economic burden on society. In the past two decades the use of duplex ultrasound has emerged as the diagnostic method of choice for the diagnosis and management of CVD. In this article, we describe the specific techniques used in the assessment of the superficial, perforating, and deep venous systems. We also discuss the methods of ulcer bed and chronic obstruction evaluation. The contributions of the duplex ultrasound to the understanding of the pathophysiology and improvement of treatments for chronic venous disease are reviewed.

Percutaneous endoscopic gastrostomy: the preferred method of elective feeding tube placement in trauma patients

PURPOSE

The purpose of this study was to determine whether gastric feeding tubes placed by the percutaneous endoscopic route resulted in fewer and less severe complications than open surgical gastrostomy (SG).

METHODS

Charts for all trauma patients admitted 1/94 to 12/98, which had an electively placed feeding tube, were individually reviewed. All tube-related complications were recorded. Of 8119 patients screened, 158 (1.9%) met inclusion criteria. Percutaneous endoscopic gastrostomies (PEGs) were placed in 95 (60.1%) and surgical gastrostomies in 63 (39.9%). Most patients (79.1%) had AIS 3 or greater head or spinal cord injury as the primary diagnosis leading to tube placement.

RESULTS

Overall, SG patients were 5.4 times more likely than PEG patients to have a complication from their gastrostomy tube (95% CI, 2.1-13.8). They were 2.6 times more likely to have a major complication (internal leakage, dehiscence, peritonitis, and fistula), and 5.5 times more likely to have a minor complication (unplanned removal, dislodgment, external leak, skin infection, and nonfunction). The groups did not differ on ISS, ICU LOS, total LOS, or mortality (p > 0.05). Overall, a total of 39 individual complications related to tube placement were noted in 26 separate patients (PEG, 7; SG, 19). All four of the major complications requiring operative intervention were in the SG group. There were 31 minor complications, 8 in the PEG group and 27 in the SG group. Mean total charges for placement were also significantly lower in the PEG group than the SG group ($1271 vs. $2761, p < 0.001)

CONCLUSION

Gastrostomy tubes placed via the percutaneous endoscopic route had a significantly lower complication rate than surgically placed tubes. In addition, the charges incurred for their placement were also significantly less. Based on the findings of this study, PEG should be considered as the method of choice for gastric feeding tube placement for trauma patients who do not have specific contraindications to the procedure.

Percutaneous Endoscopic Gastrostomy in Patients with an Open Abdomen

Percutaneous endoscopic gastrostomy is a commonly performed procedure for enteral access. In the past decade surgeons have used the open abdomen technique with increased frequency for the treatment of intra-abdominal compartment syndrome. Because these patients often have associated malnutrition long-term enteral access is complicated by the massive ventral hernia. We reviewed the records of two patients with an open abdomen who needed long-term enteral access. Both patients had a large midabdominal soft tissue defect, which posed a concern about the technique for gastrostomy creation. Both patients underwent percutaneous endoscopic gastrostomy. In each case the entrance site was located on a portion of intact abdominal wall lateral to the open abdomen tissue defect. No intraoperative or postoperative complications were noted. We conclude that percutaneous endoscopic gastrostomy can be safely performed in patients with an open abdomen. Adherence to standard principles of performing percutaneous endoscopic gastrostomy allows for enteral access in these patients.

Accurate deployment of vena cava filters: comparison of intravascular ultrasound and contrast venography

BACKGROUND

The increasing use of vena cava filters by trauma surgeons has led to reports of filter placement using intravascular ultrasound (IVUS). Although attractive because of its ease of use and elimination of contrast and radiation, no studies have examined the accuracy of filter placement by IVUS as compared with contrast venography (CV). The purpose of this study was to compare the anatomic information obtained by both techniques during filter placement.

METHODS

Twenty-one patients meeting trauma service criteria for filter placement were studied (11 women and 10 men; mean age, 46.8 years). All procedures were performed in the operating room by trauma surgeons. Vascular access was obtained by percutaneous placement of an 8 French sheath in the right femoral vein. CV, IVUS, and bilateral selective renal venography were performed before deployment of a Greenfield filter. Localization and diameter measurements were made in reference to a radiopaque ruler placed on the patient's abdomen. We chose the "best location" for filter deployment as 1 cm below the junction of the lowest renal vein and the vena cava. Measurements by CV and IVUS were compared with the "gold standard" of selective renal venography.

RESULTS

As compared with selective renal venography, the difference between best location by CV and IVUS was 16.3 +/- 13.8 mm and 3.7 +/- 5.6 mm, respectively (p = 0.001). In four cases (19%) the CV missed best location by 3 cm or more. CV overestimated the diameter of the vena cava in all cases. Average vena cava diameter was 26.4 +/- 3.3 mm by venography and 20.6 +/- 3.1 mm by IVUS (p < 0.0001). CV incorrectly identified four patients as having vena cava diameters too large (>2.8 cm) for the placement of a Greenfield filter. The two renal vein anomalies (one double left renal vein and one absent left renal vein) were correctly diagnosed by IVUS.

CONCLUSION

IVUS is a more accurate method of localizing the renal veins and measuring vena cava diameter for placement of vena cava filters than contrast venography.

A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients

OBJECTIVE

To determine the relative cost-effectiveness of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) in critically ill patients.

DESIGN

Prospective randomized study.

SETTING

Medical, surgical, and coronary intensive care units at Barnes-Jewish Hospital, a tertiary care medical center.

PATIENTS

Eighty critically ill mechanically ventilated patients requiring elective tracheostomy.

INTERVENTIONS

Randomization to either PDT performed in the intensive care unit or ST performed in the operating room.

MEASUREMENTS AND MAIN RESULTS

Treatment groups were well matched with respect to age (PDT, 65.44 +/- 2.82 [mean +/- se] years; ST, 61.4 +/- 2.89 years, p = Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute Physiology and Chronic Health Evaluation II score: PDT, 16.87 +/- 0.84; ST, 17.88 +/- 0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1 +/- 2.0 mins; ST, 41.7 +/- 3.9 mins, p < .0001) and was associated with lower patient charges than ST (total patient charges: PDT, 1,569 dollars +/- 157 dollars vs. ST, 3,172 dollars +/- 114 dollars; equipment/supply charges: PDT, 688 dollars +/- 103 dollars vs. ST, 1,526 dollars +/- 87 dollars; professional charges: PDT, 880 dollars +/- 54 dollars vs. ST, 1,647 dollars +/- 50 dollars; p < .0001 for all). There were no differences in days intubated before tracheostomy (PDT, 12.7 +/- 1.1 days; ST, 15.6 +/- 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 +/- 2.5 days; ST, 28.5 +/- 3.1 days, p = .33), or hospital length of stay (PDT 49.7 +/- 4.2 days; ST, 43.7 +/- 3.5 days, p = .28) when we compared these two techniques.

CONCLUSIONS

PDT is a cost-effective alternative to ST. The reduction in patient charges associated with PDT in this study resulted from the procedure being performed in the intensive care unit, thus eliminating the need for operating room facilities and personnel. PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation.

The intensive care unit as an operating room

This article is an overview of the different procedures currently performed on the ICU patient and emphasizes percutaneous tracheostomy and percutaneous gastrotomy. The steps necessary to prepare the patient, the ICU staff, and intensivist to achieve a safe and successful procedure are described, as are the indications, technique, complications, safety, and advantages to perform these techniques in the ICU.