SURGICAL PROCEDURES IN THE SURGICAL INTENSIVE CARE UNIT

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CHAPTER 102 SURGICAL PROCEDURES IN THE SURGICAL INTENSIVE CARE UNIT

Bedside procedures are an integral part of the care delivered to critically ill patients. Whether performed for diagnostic or therapeutic purposes, bedside procedures have specific indications and complications. With the pressure of more effective utilization of the operating rooms (ORs), bedside procedures in the surgical intensive care unit (SICU) have become more frequent.

This chapter is not intended to provide a comprehensive review of all the bedside procedures and monitoring that can be performed in the SICU. Rather, we will illustrate the indications, management, and complications of common surgical procedures that can be performed outside of the OR at the patient’s bedside.

HISTORICAL PERSPECTIVE

The basic concept of bringing the surgeon to the site of the injured patient is not a novel one. During the Korean War, mobile army surgical hospitals (MASH) units allowed injured soldiers to receive essential surgical care close to the battlefield before they could be transported to hospitals for definite care. This concept is widely used today by the military around the world, and more recently has been adopted by humanitarian organizations to provided medical care to injured civilians. It has also been recently modified and used in response to new challenges of trauma care.

Critically injured patients are more likely to survive their injuries today due to a multitude of improvements in trauma systems and critical care.¹ As a result, “diseases of survivorship” have become more prevalent and are posing new and complex challenges to the trauma surgeon. Clearly, surgeons are most comfortable operating in the OR where conditions are optimal. However, the safe performance of bedside elective surgical procedures has already been demonstrated with tracheostomy and percutaneous feeding access. Currently, there are now circumstances where it is not safe to transport the patient to the OR, and the surgeon is forced to operate under less optimal conditions, in the patient’s best interest, in the SICU. This situation arises if the patient is too critical to travel to the OR but needs urgent or emergent surgery, or if the patient needs an emergent surgery but the OR is not immediately available due to other emergencies. This chapter will provide indications and management of both elective and emergent bedside procedures.

SURGICAL PROCEDURES

Bedside Tracheostomy

Patients with persistent respiratory failure following major trauma frequently require tracheostomy since the complications related to the presence of an endotracheal tube for more than 7 days increases and can be life threatening. Patients who have a high likelihood of requiring prolonged mechanical ventilation undergo tracheostomy at the earliest possible time when conditions are stable and optimal. Some of the theoretic and proven benefits of tracheostomy include reduction of dead space and airway resistance, facilitation of weaning, improved pulmonary toilet and oral care, and better toleration by the patient, and establishing a secure long-term airway.²

Indications

The indications for tracheostomy include (1) prolonged mechanical ventilation (>7 days); (2) an inability to protect airway such as in severe traumatic brain injury, severe maxillofacial trauma, extensive neck, or vocal cord edema/trauma/injury; (3) complex tracheal repair; (4) cervical spinal cord injuries; and (5) respiratory failure and the need for multiple and frequent trips to the OR.

Procedure Options, Contraindications, and Preparation

Bedside tracheostomy can be performed via an open or percutaneous technique based on the surgeon’s preference. Tracheostomy is not recommended at times when respiratory complications related to the procedure will be poorly tolerated by the patient. These include situations such as severe hypoxemia, severe hypercarbia, or respiratory acidosis. Redo tracheostomies in patients with difficult anatomy (short neck, goiter) should preferably be performed in the OR under more favorable conditions with optimal lighting. Specific relative contraindications to the percutaneous tracheostomy include a redo tracheostomy, moderate to severe coagulopathy, and unstable cervical spine injuries or an inability to extend the neck.

Adequate preparation for this procedure is critical, as errors can quickly lead to major complications. A complete surgical tracheostomy set and percutaneous tracheostomy kit are present at the bedside (Table 1). Lighting in the SICU should be optimized or surgeons may prefer using a headlight. Assisting personnel include a surgical team with an operating surgeon attending and one or two assistant surgeons, one respiratory therapist, one anesthesiologist, and a nurse. All personnel in the room have protective headwear, masks, and gloves, and the surgeons also wear sterile gowns and gloves.

Table 1 Equipment Required for Bedside Tracheostomy

Bedside Tracheostomy	Equipment
Tracheal set	Retractors
	Hemostats
	Right-angle clamps
	Metzenbaum and suture scissors
	Tracheal hook and dilator
	Electrocautery
	#11- and #15-blade scalpels
Airways	8F tracheostomy and 6F tracheostomy
	Lubricating gel
	Capnometer
	Anesthesia kit with endotracheal tubes
Sutures	Nylon skin sutures
Sutures	Silk sutures and silk ties
Anesthesia	Paralytic and sedatives
Anesthesia	1% lidocaine anesthetic
Field	Sterile drapes and Betadine prep
Field	Sterile towels
Percutaneous Tracheostomy
	Percutaneous tracheostomy kit
	Bronchoscope

Open Tracheostomy Technique

Once the patient is paralyzed and sedated, the neck is prepped and draped. Local anesthetic is injected at the surgical site, and then a 2-cm vertical midline incision is made below the cricoid. The platysma is divided and the strap muscles are retracted laterally. The second to fourth tracheal rings are exposed by retracting the isthmus of thyroid superiorly (using a vein retractor) or by dividing the isthmus of the thyroid. Stay sutures can be placed at the lateral aspect of trachea; note that the balloon of endotracheal tube should be deflated while placing stay sutures. Before the procedure begins, the surgeon should test the balloon of the tracheostomy, and ensure that the anesthesiologist suctions the endotracheal tube and mouth and that all equipment works and is within reach. A tracheotomy is performed using an 11-blade scalpel, the opening is dilated, and under direct vision the endotracheal tube is pulled back to just above the tracheotomy site. The tracheostomy is inserted, the inner cannula is placed, and the balloon is inflated. Then capnography is performed, adequate return of tidal volume is assessed, and chest wall movement is visualized. When placement is confirmed, the tracheostomy is sutured to the skin and secured with tracheal ties, and then the endotracheal tube is removed (Figure 1).

Figure 1 Tracheostomy tube insertion.

(From Velmahos GC: Bedside tracheostomy. In Shoemaker WC, Velmahos GC, Demetriades D, editors: Procedures and Monitoring in the Critically Ill. Philadelphia, WB Saunders, 2001, figure 5-4, p. 34.)

Percutaneous Dilatation Technique

There are several kits available today with various modifications for the percutaneous tracheostomy using the Ciaglia technique. The authors recommend the following percutaneous technique, which includes making a 2-cm vertical midline incision below the cricoid, and gentle dissection and retraction of the strap muscles with the ability to identify the thyroid and palpate the tracheal rings. With or without the use of a bronchoscope in the endotracheal tube, the endotracheal tube is pulled back superiorly so that a 10-ml saline-filled syringe is inserted into the trachea just below the endotracheal tube at about the second or third tracheal ring. Once air bubbles enter the syringe, the syringe is removed and a guidewire is advanced into the tracheal lumen. The needle is removed and the tract is dilated with the short dilator. With the use of a guiding catheter, either serial dilation (12–36 Fr) or a single tapered dilation is performed. The 28-Fr dilator within a #8 tracheostomy tube is placed over the guiding catheter and the entire unit is inserted into the trachea (Figure 2). Once in place, the guidewire, the guiding catheter, and the 28-Fr dilator are removed; the inner cannula is placed; and the balloon is inflated. Placement is confirmed and securing of the tracheostomy is performed as previously explained.

Figure 2 Percutaneous dilation technique (up to 36FR). FR, French.

Mortality, Morbidity, and Complications

Bedside tracheostomy is considered a safe procedure when performed meticulously and using the suggestions stated above. It has a low mortality rate (0.1%–1%) and minimal morbidity (up to 3%).³ Complications related to tracheostomy occur intraoperatively, early postoperatively, and late postoperatively. Intraoperative complications include bleeding, perforation of posterior wall of the trachea or anterior wall of esophagus, hypoxia, and loss of the airway. Early postoperative complications include bleeding, hematoma, pneumothorax, and tracheoesophageal fistula. Late postoperative complications include subglottic stenosis, laryngeal nerve injury, tracheal granulation, and tracheoinnominate fistula.

A meta-analysis comparing open surgical and percutaneous tracheostomies found that the rate of serious complication was similar in the two groups.⁴ The authors also noted that perioperative complications occurred more often with the percutaneous technique, but that postoperative complications were more frequent with the open surgical tracheotomy. However, most of the differences in complication rates were attributed to minor complications. Another meta-analysis by Freeman et al.⁵ found no difference in overall operative complication rates, but found lower postoperative complications and bleeding in the percutaneous technique. Currently, there are no prospective data to support the use of bronchoscopy to reduce complications related to percutaneous tracheostomy, but using it is advocated during the learning curve.

Percutaneous Feeding Catheters

Seriously injured patients are at risk for malnutrition and all of its complications. In addition, failure to use the gastrointestinal tract for a prolonged period leads to atrophy of the intestinal mucosa and bacterial translocation.⁶ Short-term enteral nutrition is often provided via a naso- or oro-gastric tube. Due to the high incidence of patient discomfort, accidental dislodgment, and sinusitis from prolonged use of nasoenteric tubes, percutaneous cannulation of the gastrointestinal tract is preferred for long-term feeding access. Percutaneous endoscopic gastrostomy (PEG) can be performed by the surgeon at the bedside in the SICU. PEG was introduced in 1980 as an alternative to laparotomy for placement of gastrostomy.⁷^–⁹ The surgeon intensivist operator has the advantage of being familiar with the patient’s condition and possible recent abdominal surgery.