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

KEY POINTS

Question: Should procedures in critically ill patients be performed routinely at the bedside or in the operating room? Findings: There are advantages and disadvantages of routinely performing procedures on critically ill patients both at the bedside and in the operating room. Meaning: Patient and procedure characteristics as well as resource availability should be considered when making such a decision.

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Nonoperating room anesthesia (NORA) involves the provision of anesthetic care for diagnostic or therapeutic procedures that are performed outside the main operating room (OR). Convenience, cost-effectiveness, efficiency, and continued advancements in procedural technology have all contributed to an increasing number of procedures being performed in non-OR locations. The proportion of NORA cases in the United States has increased from 28.3% in 2010 to 35.9% in 2014, and is projected to increase further as the population ages.1–3 One location where NORA may be provided is the intensive care unit (ICU). While procedures performed in the ICU may, in some instances, be more cost-effective,4,5 providing safe anesthesia care in this context requires the anesthesiologist to overcome unique challenges. Table 1 lists some of the procedures commonly performed in the ICU. In this Pro-Con commentary article, we discuss the advantages and disadvantages of performing procedures on critically ill patients at the bedside versus performing those same procedures in the OR.

PRO: PROCEDURES SHOULD BE PERFORMED AT THE BEDSIDE IN THE ICU WHENEVER POSSIBLE

ICU-NORA allows the opportunity to provide care to patients who may be too clinically tenuous and/or for whom the risks of transport outweigh the benefits of performing the same procedure in the OR. Performing procedures at the bedside may be beneficial for the following reasons: (1) ability to provide high value care, and (2) avoidance of risks associated with intrahospital transfer.

High-Value Care

In many hospitals, scheduled and outpatient procedures are often prioritized over nonemergent procedures in hospitalized patients. The result is that these latter procedures are often “added on” to the OR schedule and performed after previously scheduled cases have been completed. This “after-hours” scheduling increases operative risk in an already high-risk surgical population and may delay the provision of timely patient care.6 Performing some procedures at the bedside, in the ICU, may mitigate some of these issues. In a “before-and-after” study, the Johns Hopkins Hospital, in Baltimore, MD, was able to demonstrate a significant reduction in the time from formal request to performance of a bedside tracheostomy (5.2 ± 5.3 vs 1.3 ± 1.9 days) by implementing a dedicated, percutaneous tracheostomy program. The overall duration of the procedure and total anesthesia care time were also significantly lower,7 and the ICU length of stay was shorter for patients receiving tracheostomy for nonpulmonary reasons (eg, airway protection). Increased familiarity with performing procedures in the ICU will allow the ICU team to administer procedural sedation at the bedside for procedures such as feeding tube placement, tunneled central line insertion, dressing changes, etc. This additional capacity will decrease the demands on the already stretched anesthesiology personnel and allow for better utilization of anesthesiology resources. Hence, performing select procedures in critically ill patients at the bedside may provide timely and efficient care while also expediting hospital discharge for suitable patients, further contributing to cost savings.

Table 1. - Surgical Procedures Commonly Performed in the ICU Tracheostomy Percutaneous placement of enteral feeding tubes Application or realignment of external fixation of fractures Surgical dressing changes Endoscopic interventions Occult bleeding Hemorrhage control Pancreato-biliary pathologies Exploratory laparotomy Washout and/or closure of open cavities Invasive diagnostic procedures Insertion or removal of invasive life-support equipment (ECMO, IABP, etc) Fasciotomy for compartment syndrome Wound debridement Pericardiocentesis

Abbreviations: ECMO, extracorporeal membrane oxygenation; IABP, intra-aortic balloon pump; ICU, intensive care unit.

Procedures such as tracheostomy and percutaneous endoscopic gastrostomy (PEG) creation may be performed at the bedside with minimal risks while conserving resources and costs. Given the growing concerns with health care spending and the push toward bundled care, cost-saving measures will continue to gain traction over the coming years. Van Natta et al 4 demonstrated positive revenue margins of 450% and 400%, respectively, when tracheostomy and PEG procedures were performed at the bedside. Similarly, a 2021 study from Europe was able to show a significant reduction both in the personnel required and in the overall cost of performing open surgical tracheostomy at the bedside versus in the OR.8 Based on these data, hospitals may incentivize viable bedside procedures. However, further studies are needed to comprehensively review the safety outcomes and costs (including personnel) associated with performing a wider range of procedures at the bedside in the ICU.

Transport of Critically Ill Patients

Critically ill patients are at increased risk of morbidity and mortality during within-hospital transport.9 Patients with respiratory failure, central nervous system injury, or hemodynamic instability have the highest risk of transport-related complications.10 Adverse events such as cardiac dysrhythmias, hypotension, dislodgement of indwelling tubes and catheters, increased intracranial pressure, and inappropriate mechanical ventilation settings have been described during patient transport.11 Human errors in drug dosing, accidental tracheal extubation, and technical failures of life-support devices may also occur, causing potentially fatal complications.12 Interruptions in care (eg, loss of positive pressure due to transferring mechanical ventilation from a dedicated ICU ventilator to a transport ventilator, or cessation of renal replacement therapy) are also relevant complications of patient transportation. Another consideration relevant to the intrahospital transport of critically ill patients is the risk of transmission of highly contagious infectious agents, as highlighted by the coronavirus disease 2019 (COVID-19) pandemic.13 Moreover, transporting a critically ill patient is time-consuming and labor-intensive. Bringing the OR to the ICU patient will avoid some of the complications and concerns mentioned above.

CON: PROCEDURES SHOULD BE PERFORMED IN THE OR WHENEVER POSSIBLE

While performing procedures at the bedside may have the potential to improve efficiency and value, issues such as location, space, staffing, and equipment are likely, and may prevent those efficiencies from being realized.

Spatial and Ergonomic Challenges

Space within ICU rooms is often limited by life-support devices such as the mechanical ventilator, hemodialysis machine, infusion pumps, balloon pumps, extracorporeal membrane oxygenation circuits, and ventricular assist devices. ICU rooms are not designed to act as ORs, and thus, lighting, space, and storage may all be inadequate. Equipment must be arranged to ensure both continued functionality and accessibility for procedural and anesthesia teams. The lack of “standard” equipment, such as anesthesia machine and drug/supply carts can be an additional source of error for anesthesia providers. Access to drugs/equipment that might be needed during the procedure may also be limited in an ICU. Access to the patient’s airway and intravenous (IV) catheters may be difficult due to space limitations. Furthermore, integrating data collected from ICU monitors with established anesthesia information management systems can distract anesthesiologists from providing care to their patients. Occasionally, ICUs may be equipped with a special procedure room organized similarly to a mini-OR. However, these are not widely available.

Personnel and Staffing

For most minor procedures in the ICU, sedation is usually provided by the ICU team, and anesthesia care is requested when the procedures are complex and/or the ICU team is occupied. The decision to involve a dedicated anesthesia team is often made in conjunction with the proceduralist and the ICU teams, considering the patient’s comorbidities, the complexity of the procedure, and the availability of the ICU team throughout the procedure. It is unclear whether establishing a predefined set of patient- and procedure-specific criteria for anesthesia involvement can improve patient outcomes. Also, studies are needed to assess the financial implications, as well as the impact on patient outcomes when a dedicated anesthesia team provides anesthesia care versus provision of sedation by the ICU team. The remote location of many ICUs, the critical illness of patients undergoing emergent procedures, and infectious isolation precautions all create challenges when attempting to implement the traditional OR care team model in the ICU. Specifically, while supervising anesthesiologists can medically direct 2 to 4 certified registered nurse anesthetists/certified anesthesiologist assistants or 2 residents in the operating suite, these guidelines may no longer be safe when applied in the ICU setting. A 1:1 supervision model would reduce the efficiency of anesthesiologists who otherwise might cover more rooms in the OR and negate many potential gains from transport and timing. By tying up an anesthesia team in an off-site location, ICU-NORA may worsen the efficiency of anesthesia providers. Nursing and technician staffing must also be considered when procedures are performed in the ICU. Most ICU nurses are not trained as OR scrub or circulating nurses and may not be as efficient or anticipate issues as well as trained OR nurses.12 Anesthesia and surgical technologists may not be readily available in these locations, further limiting the qualified help that is available at hand.

Limited or nonexistent surgical and anesthesia equipment and drugs in the ICU (such as volatile anesthetics) adds to these challenges. Institutional variability in the ease of availability of surgical equipment at the bedside also favors the performance of such procedures in the OR. Furthermore, certain interventional radiology procedures cannot be performed in the ICU because of lack of radiologic imaging. While newer ICU rooms are better able to accommodate anesthesia machines,14 and the AnaConDa (Sedana Medical, Uppsala, Sweden) orMIRUS (Pall Medical, Dreieich, Germany) systems are now able to use anesthetic gas for ICU sedation (not yet approved in the United States), there remains the need for personnel appropriately trained in their safe use. Although nonanesthesiologist intensivists may be trained to deliver volatile anesthetics, currently few nonanesthesiologists are familiar with how to deliver an inhaled anesthetic.

Concerns With Sterility

Another concern with performing procedures at the bedside in the ICU is the potential lack of sterility and the increased risk of surgical site infections (SSIs). ICUs are not designed with the same high airflow requirements as ORs. Although the risk of SSIs in commonly performed procedures at the bedside in the ICU is not higher than for those performed in the OR,15 current evidence is unclear regarding the risk of postoperative infections in patients undergoing tracheostomy in the ICU versus in the OR.16,17 For patients undergoing emergency, lifesaving procedures in the ICU, the risk of contamination of the surgical field remains high, necessitating a careful risk–benefit analysis. While further studies are needed to assess the risk of SSIs following bedside procedures in the ICU, insertion of long-term medical implants (such as pacemakers) is likely not yet indicated in the ICU.

Table 2. - Advantages of Performing Surgical Procedures at the Bedside in the ICU Pro Considerations Timely care The teams may be busy and not available Cost-effective care Cost savings may be reduced if an OR team is pulled out of circulation to perform the procedure in the ICU Maintenance of patient isolation/containment measures Potential lapses in implementation of isolation measures Avoidance of interruption in care Planning in advance for the procedure may alleviate this concern Avoidance of risks associated with patient transport A team-based, standardized approach may be helpful

Abbreviations: ICU, intensive care unit; OR, operating room.

Table 3. - Disadvantages of Performing Surgical Procedures at the Bedside in the ICU Con Considerations Limited space for clinicians and equipment, poor lighting Design of larger ICU rooms can mitigate this limitation Lack of equipment (surgical/anesthesia/imaging) Preparation and planning may help secure the necessary equipment Personnel and staffing challenges (anesthesia, nursing, surgical/anesthesia technologists) Efficient scheduling may help with judicious utilization of personnel Ergonomic challenges (inadequate access to airway, IV access, etc) Design of larger, ergonomically efficient ICU rooms can mitigate this limitation Concerns with sterility Current evidence does not show increased risk of infection

Abbreviations: ICU, intensive care unit; IV, intravenous.

Tables 2 and 3 summarize the arguments for and against routine performance of surgical procedures at the bedside in the ICU.

PATIENT AND PROCEDURE SELECTION

Because both pros and cons of performing procedures at the bedside in the ICU exist, identifying which procedures can be safely performed at the bedside in the ICU and which patients are more likely to benefit is a reasonable starting point for ICU-NORA. For certain procedures, such as tracheostomy and PEG placement, the OR costs and the risks associated with intrahospital transport are perhaps not justified, and performing these procedures in the ICU is likely cost-effective. Additionally, emergent damage-control procedures in unstable patients, such as laparotomy for abdominal compartment syndrome, hemorrhage control in an exsanguinating patient, debridement and irrigation of surgical wounds and temporary fracture stabilization, may be time-sensitive and can be performed at the bedside. Multidisciplinary discussions between the proceduralist and the ICU, anesthesia, and nursing teams will help determine the suitability of procedures for the ICU. Unique institutional protocols should be developed that consider the resources available and the input of all medical and nonmedical stakeholders. Only then can safe and cost-effective care be delivered in this unique practice setting. The Figure provides a flowchart that can serve as a decision aid in this process.

Figure.:

Flowchart to help decision-making around the location of procedures performed in critically ill patients in the ICU. ICU indicates intensive care unit; OR, operating room.

In summary, current technological advancements and the development of innovative, minimally invasive procedures have allowed for an increasing number of procedures to be performed in the ICU instead of in the OR. These are often emergency procedures being performed in medically unstable patients. While bringing the “OR to the ICU” allows for delivery of timely and efficient care, avoids intrahospital transport in high-risk patients, and potentially decreases the strain on valuable operating suite resources, it also presents a host of challenges to the safe delivery of patient care. Personnel and equipment availability, spatial and ergonomic limitations, as well as lack of sterility preclude routine performance of procedures at the bedside in the ICU. Selection of appropriate procedures and patients, multidisciplinary development of predefined plans, and meticulous planning and preparation can help mitigate most of these challenges and improve outcomes in this vulnerable patient population. Further studies are needed to assess the overall impact of performance of procedures in the ICU on patient outcomes as well as health economics.

DISCLOSURES

Name: Kunal Karamchandani, MD, FCCP, FCCM.

Contribution: This author conceptualized, and helped draft, review, and edit the manuscript.

Conflicts of Interest: K. Karamchandani is on the scientific advisory board of Eagle Pharmaceuticals and is a research advisor for Philips.

Name: Matthew Evers, BS.

Contribution: This author helped perform a literature search, and draft, review, and edit the manuscript.

Conflicts of Interest: None.

Name: Travis Smith, MD.