When the ICU is the operating room

Piper, Greta L.; Maerz, Linda L.; Schuster, Kevin M.; Maung, Adrian A.; Luckianow, Gina; Davis, Kimberly A.; Kaplan, Lewis J.

doi:10.1097/ta.0b013e31827e9c52

Cited by 20 publications

(10 citation statements)

References 18 publications

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“…Accordingly, abdominal exploration is often considered as both diagnostic and potentially therapeutic for those with acute severe critical illness without a well-defined alternate etiology. Hemodynamically unstable patients who are unsafe to transport to the OR for whom an intra-abdominal catastrophe is believed to be the underpinning etiology may be explored at the bedside in the ICU [ 8 , 9 ]. Unsurprisingly, such patients are believed to have a rather poor outcome either with or without intervention, leaving exploration as an “intervention of last resort.” There is no well-defined metric by which the postoperative outcome may be predicted with sufficient certainty to inform surrogate decision makers, as well as the surgeon, in deciding on the advisability of undertaking bedside exploration with regard to outcome and quality of life.…”

Section: Discussionmentioning

confidence: 99%

Emergency Laparotomy in the Critically Ill: Futility at the Bedside

Martin

Patel

Chreiman

et al. 2018

Critical Care Research and Practice

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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.

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Section: Discussionmentioning

confidence: 99%

Emergency Laparotomy in the Critically Ill: Futility at the Bedside

Martin

Patel

Chreiman

et al. 2018

Critical Care Research and Practice

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“…Additionally, procedures are commonly performed in the ICU and may include operations that would be typically performed in the operating room, especially when the patient is unstable or there is no available operating room in a timely fashion. 12 The need to maintain operative productivity was made more clear by the finding that 56 per cent of the respondents also maintained an elective surgical practice. Moreover, 72 per cent covered the outpatient clinic or posted elective surgical cases while also attending in the ICU.…”

Section: Discussionmentioning

confidence: 99%

The Burden of the U.S. Crisis in the Surgical Critical Care Workforce and Workflow

Sarani

Toevs

Mayglothling

et al. 2015

The American Surgeon™

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There will be a 46 per cent shortage of intensivists by 2030. Currently, only 3 per cent of U.S. critical care is provided by surgeon-intensivists. Measurement of the current workload is needed to understand the ramifications of the expected shortage of surgeon-intensivists. The purpose of this study is to evaluate the self-reported workload of U.S. surgeon-intensivists. Over a 2-month period, a voluntary and anonymous survey of the surgery section of the Society of Critical Care Medicine was performed using Survey Monkey. Only surgeons were invited to participate. We assessed personnel resources and surgeon-intensivists workload in the intensive care unit (ICU) and on their postcall day. Two hundred sixty-two persons responded. Sixty-nine per cent had administrative responsibilities and 42 per cent covered bed allocation/transfer center duties while in the ICU. Seventy-six per cent covered trauma and general surgery call and 72 per cent covered the outpatient clinic or had elective surgery cases while responsible for the ICU. Only 14 per cent had no other responsibilities. Twenty-one per cent did not round with residents and 50 per cent did not round with a fellow. Thirty-six per cent did not work with advanced practitioners. The majority of surgeon-intensivists have significant responsibilities in addition to providing ICU care. This workload should be factored into the expected shortage of surgical intensivists relative to the expected increase in critical care demand.

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“…Examples of (semi-)elective bedside surgery are the percutaneous dilatational tracheostomy [20] and percutaneous endoscopic gastrostomy [21]. Many surgical centers increasingly perform routine laparotomies in critically ill patients [22]. …”

Section: Discussionmentioning

confidence: 99%

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

et al. 2014

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IntroductionThe 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).MethodsThis 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.ResultsA 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.ConclusionsThese 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.

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When the ICU is the operating room

Abstract: Epidemiologic study, level III.

Cited by 20 publications

References 18 publications

Emergency Laparotomy in the Critically Ill: Futility at the Bedside

Emergency Laparotomy in the Critically Ill: Futility at the Bedside

The Burden of the U.S. Crisis in the Surgical Critical Care Workforce and Workflow

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

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