Page 1 of 6
Optimizing Patient Care
Surgical procedures in the intensive care unit:
BM Dennis*, OL Gunter
Abstract
Introduction
Increasingly, surgical procedures are
performed at bedside in the inten-
sive care unit (ICU). Cost savings and
gaining timely access to the oper-
ating room (OR) have helped to spur
this trend towards more ICU-based
procedures. Patient physiology and
the patient transport concerns have
made performing bedside proce-
dures a more attractive option than
the OR in certain settings.
Discussion
ICUs have begun to adapt to accom-
modate these bedside surgical proce-
dures. 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 indi-
cations to perform bedside surgical
procedures. These indications
include lesser procedures for which
the OR costs and transport risks
are not justified or emergent proce-
dures in patients are too unstable
for transport to the OR. The most
common procedures performed in
the ICU include percutaneous trache-
ostomy, percutaneous endoscopic
gastrostomy tube and inferior vena
cava filter. Performing these proce-
dures 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
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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.
a critical review
the need for these procedures to be
performed in the ICU.
Conclusion
The operating room is no longer the
only location that surgical proce-
dures 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 avail-
ability concerns. The operating room
remains the preferred location for
almost all surgical procedures, but
the ICU offers an attractive alterna-
tive 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 inten-
sivists 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 demon-
strated that significant cost savings
can be achieved by performing these
procedures in the ICU without sacri-
ficing patient safety15. Additionally,
difficulties gaining timely access to
the OR, either because of patient
instability or OR availability, have
made bedside procedures an attrac-
tive alternative that often allows for
more efficient care4,6. Most impor-
tantly, 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
Critical review
critically ill patients79. 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
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
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 capabili-
ties in the ICU are nearly identical
to the OR. Ventilators in most ICUs
have mechanical ventilation capa-
bilities beyond standard OR ventila-
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
tors. 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 ther-
apists and patient care assistants Competing interests: none declared. Conflict of Interests: none declared.
replace circulating nurses, anaesthe-
tists 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 situa-
tions or at inconvenient times, such
as nights or weekends. At our institu-
tion, we employ the use of specialised
procedure support nurses (PSNs) in
our trauma and surgical ICUs10. These
nurses are specially trained to set up

Figure 1: Surgical critical care team starting bedside percutaneous tracheos-
tomy. 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 periproce-
dural 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
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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.
appropriate instruments are avail-
able 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 proce-
dure (Figure 1). We have intentionally
limited the number of PSNs to mini-
mise the variability and maximise the
safety of the procedures. Their small
number and consistent presence for
Page 2 of 6
Critical review
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-sensi-
tive 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
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
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
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
placement of percutaneous trache-
ostomy, percutaneous endoscopic
gastrostomy (PEG) and inferior vena
cava filters (IVCFs). More emergent
procedures, such as exploratory
laparotomy and damage control Competing interests: none declared. Conflict of interests: none declared.
orthopaedics are also possible at
the bedside. The aim of this critical
review was to discuss surgical proce-
dures in the ICU.
Percutaneous tracheostomy
Tracheostomy is the gold standard for
patients requiring long-term mechan-
ical ventilation or upper airway
obstruction. The percutaneous dila-
tional techniques first described by
Ciaglia and the subsequent modifica-
tion (Figure 2) employing the Ciaglia
Blue Rhino kit (Cook Medicals
Critical Care division, Bloomington,
IN) have made the percutaneous
technique arguably the procedure

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 place-
ment12,13. Bedside percutaneous
tracheostomy (Figure 3) has been
shown repeatedly to be a safe alter-
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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.
risk patients in these studies were
to PEG are haemodynamic insta-
native to open surgical tracheos-
tomy in the OR2,5,10. Meta-analysis by
Higgins showed percutaneous trache-
ostomy to have lower wound infec-
Page 3 of 6
Critical review
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 proce-
dure1,14,15. The Johns Hopkins Percuta-
neous Tracheostomy Program Group
showed that a hospital-subsidised
multidisciplinary team performing
bedside percutaneous tracheosto-
mies can decrease complications and
length of stay in ICU resulting in a net
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
increase in hospital revenue4,6. The
safety of bedside percutaneous trache-
ostomy even in high-risk groups, such
as the obese, was recently demon-
strated in two large retrospective
studies. Complication rates in high-
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).
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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 Competing interests: none declared. Conflict of Interests: none declared.
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
bility, 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-

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
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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.
techniques and concluded that PEG
was the preferred technique over
laparoscopic or open gastrostomies.
Procedure duration of PEG was
Page 4 of 6
Critical review
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 nasogas-
tric tubes with no difference in other
complications including mortality21.
Inferior vena cava filter
Critically ill patients are inherently at
high risk of deep venous thrombosis
(DVT), by virtue of exhibiting charac-
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
teristics of Virchows triad, including
venous stasis, hypercoagulability and
endothelial damage. Frequent, diag-
noses or injuries preclude certain
patients from receiving appropriate
pharmacologic DVT prophylaxis or
treatment. To prevent venous throm-
boembolism (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 proce-
dure evolved into a percutaneous
technique that could be performed in
angiography suites. Since that time,
All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
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 Competing interests: none declared. Conflict of interests: none declared.
of ultrasonography (transabdominal
or intravascular) or C-arm fluoroscopy
with iodinated contrast or carbon-
dioxide, either of which can be
performed at bedside3,2224. Complica-
tion rates are exceedingly low in IVCF
and are comparable to those proce-
dures performed in the OR and angi-
ography 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-

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, respec-
tively3. 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 poten-
tial risks incurred in transport of this
high-risk population.
Laparotomy
Bedside laparotomy can be neces-
sary in cases of abdominal compart-
ment syndrome, severe abdominal
trauma and specific emergency
general surgical conditions. Abdom-
inal compartment syndrome is
often the result of aggressive fluid
resuscitation after trauma or sepsis.
The resultant bowel and intersti-
tial oedema may lead to pulmonary
compromise, diminished venous
return and decreased cardiac output.
The result is severe hypoventila-
tion and combined cardiogenic and
hypovolemic shocks. The profound
haemodynamic and respiratory insta-
bility that can develop secondary to
abdominal compartment syndrome
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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.
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 hypo-
tension, 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 typi-
cally 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 compro-
mise requiring high levels of ventilator
Page 5 of 6
Critical review
support. More complex procedures,
such as restoration of bowel conti-
nuity may also be performed in the
ICU provided the appropriate equip-
ment 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 lapa-
rotomy, there are few, if any, defi-
nite indications. Diaz reported the
use of a protocol for bedside lapa-
rotomy. As defined by the protocol,
All authors contributed to the conception, design, and preparation of the manuscript, as well as read and approved the final manuscript.
the four primary clinical indications
for bedside laparotomy in patients
felt to be unsuitable for transport
to the OR were as follows: abdom-
inal compartment syndrome, acute
haemodynamic instability caused
by intra-abdominal haemorrhage,
washout or closure of a previous
open abdomen and intra-abdominal
sepsis26. Damage control laparoto-
mies had previously been shown to
carry higher rates of complications
than the more traditional explora-
tory laparotomy, particularly intra-
abdominal abscess and fistula27.
However, after employing the bedside
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laparotomy protocol, Diaz demon-
strated intra-abdominal abscess and
fistula rates that were equivalent to
studies involving damage control
laparotomies performed in the
OR26. Additionally, as with the previ-
ously discussed procedures, signifi- Competing interests: none declared. Conflict of Interests: none declared.
cant 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 ortho-
paedic procedures, they are frequently
practiced at our institution in select
circumstances. Indications for bedside

orthopaedic procedures reflect those
for bedside laparotomy with one addi-
tional indication. Reasons for bedside
orthopaedic procedures include the
following: compartment syndrome,
haemorrhage control, debridement
and irrigation of wounds and tempo-
rary 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, amputa-
tions 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 hypo-
tension due to haemorrhagic shock.
Traditional orthopaedic surgical prin-
ciples would hold that formal irriga-
tion 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 rela-
tive 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
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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.
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 proce-
dures. However, the OR is no longer
the only location, in which operative
procedures can be safely and effec-
tively 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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All authors abide by the Association for Medical Ethics (AME) ethical rules of disclosure.
Competing interests: none declared. Conflict of Interests: none declared.