We'll skip the introduction part, and I have no disclosures. So I am here to convince you that the ICU should be the preferred location for operative procedures. We'll talk about why, which procedures, and how we should do it effectively. There are a lot of reasons to operate in the ICU, including things like urgent timing, difficult transportation, risky transportation, and then also limited OR availability and decreased cost. And we'll talk about those in a minute. But there are some other driving forces that were published by the Vanderbilt team in Thoracic Key and talk about the fact that there has been increasing severity of illness, and that's driving some of this for us to be operating in the ICU. Acceptance of staged procedures. We do damage control laparotomy followed by damage control resuscitation. We operate again, do another laparotomy, and resuscitation on and on. And those things make it more comfortable for the ICU to handle operative cases. Endoscopic and percutaneous advances have done it, as well as the cost of repetitive procedures. When we talk about the urgency of procedures, probably the one that is kind of the sine qua non of urgency of procedures is the abdominal compartment syndrome. I remember being a second-year resident, having a patient in bed two who had a very tight abdomen. She wasn't ventilating well. I kept giving her fluid to try to fix her urine output. And it would improve for a little bit, and then it would go back down again. And so I hoofed it down to the operating room where my attending was operating with the chief resident at 3 in the morning and said, this woman in bed two isn't doing well. And I explained the scenario that I had. And she laughed and said, well, it sounds like you think we need to operate on her. And I said, yes. And she said, well, then get it going. And I said, okay, upstairs? And she said, well, I don't think she's going to make it down here. So I got it going. And she arrived at the bedside. And we opened the patient's abdomen. She was ventilating better. She started urinating a few hours later. And it solved the problem. But it really impressed upon me the value of, we need to get the procedure done. It kind of doesn't matter where we do it. These difficult transportation images certainly make me think of, in the left, that's a military transport likely. And the complexity of what they're doing in small spaces in difficult places. And then the top right, how many times do you try to get in and out of a room that the door doesn't open or the door is supposed to open and doesn't open? And how frustrating that is to try to get the patient in and out. And it adds a challenge. And certainly the bottom right is the group that has been transporting patients and transporting patients and transporting patients and is clearly showing fatigue of what's been happening. We also have risks because it's not uncommon to get a patient in the room and then you're starting CPR because you figure out that they're pulseless. And how long have they really been pulseless during the transport? It's really not necessarily clear. But we do know that severe acute events happen in 30 to 45% of patients who are critically ill and having transport. So that matters. And then so does this. And we wait and we wait and we wait and we schedule the patients and we wait again. And Dr. Jabili finally tells us we're allowed to operate after three days of waiting to do this tracheostomy or whatever it might be. And it's expensive when we take patients to the operating room. We know this. We've heard about this before. The cost of the operating room has been described all the way from not very expensive to $100 a minute. This study was sort of helpful, and I'm sorry that this is blurry, that they looked at all the hospitals in California, essentially, so 302 different facilities that were academic, that were nonprofit and for-profit organizations, as well as some outpatient facilities. And it turned out that it's about $37 a minute, give or take. And about half of that is direct costs, which are salaries, wages, and benefits and that sort of thing. So it is expensive, maybe not as expensive as some of the single-center trials have—or some of the single-center reviews have suggested. There are a couple of other costs that we need to think about, and that is if your nurse at the bedside is not taking care of the patient because the patient's not there, then your nurse kind of has idle time. And shouldn't that nurse be able to care for the patient? Now my heart tells me that our nurses deserve idle time after managing three patients at once or something like that. But from an efficiency and effective standpoint, we do need to consider that in how we're using our time. And then there are a couple of other costs that we need to think about in the patient care realm, the costs to the patient. We're holding their nutrition, perhaps day after day, or just because they're going to go to the operating room. And for some reason, any time somebody's supposed to go to the operating room that day, the physical therapists and nurses decide they should not get out of bed, even if they're not going to go to the operating room until four in the afternoon. Now normally, if I tell them it's not until four in the afternoon, the mobilization will happen. But it's a lot of extra things for them to do, and so trying to coordinate all those things is difficult. And then there's also anticoagulation and holding that on recurrent episodes. So what things do we do in the ICU? You've seen the tracheostomies and the PEGs, maybe exploratory laparotomies, maybe not as much diagnostic laparotomies, and then there's some of these other things as well. So tracheostomies have been studied a lot, whether or not they can be safely done in the ICU. And this initial study on the left from India was looking at bedside open tracheostomies, OR open tracheostomies, and percutaneous tracheostomies. And what you can see is that the complication risks are pretty low. Similarly published in Vanderbilt, if you're doing procedures at the bedside, the complication rate is quite low. The group from India also tried to look at cost, and they didn't use it by dollars, but they looked at essentially supply costs, and we used three of these and two of those and that sort of thing, and said that it was pretty equal from a cost standpoint. They actually said that the percutaneous procedures were more expensive, were more costly because of the kit. This didn't account for the cleaning of supplies, but it was at least an attempt. If we're thinking about getting a patient to the OR or not, and the difficulty of getting them to OR with a busy OR, then timing becomes important because then it's not uncommon that you can do a procedure earlier at the bedside than you can do in the OR. And so we've known from a number of different studies, and this one from UPenn and University of Texas at San Antonio that says lower VAP rates, lower vent free days, lower ICU days, and that should have been higher vent free days, and no mortality difference. And so that really is a better outcome. And then I like this one because it was looking at the same questions, but then it also answered during COVID, we actually reduced our facility contamination because we're not driving these patients all over the hospital. PEGs have also been done very frequently, and this group from Brown looked at 156 of their patients and they had about 10% of their complications. Five of the tubes were in adjacent structures, mostly colon. Interestingly, one of them wasn't identified for four months when it fell out in the skilled nursing facility, and when it got put back is when they figured out that it was in the colon. So clearly the patient tolerated it for a while. But they had a success rate of about 94%. Most of them were done with the tracheostomies, and then their disposition was things that we are most familiar with. How about laparoscopy? Probably fewer of you are used to doing laparoscopy in the ICU, although I suspect some are. This was published from our center as well as the Rosen article from the Cleveland Clinic and demonstrates that you can do things in the ICU. There were not a lot of specifics, but not necessarily advanced laparoscopy, but using it as a diagnostic tool, and in which case we can show that it's feasible, it's safe, it's efficacious to do that and to do next steps. I actually thought this article was interesting because they had patients who essentially had sepsis of unknown etiology in mostly surgical ICUs, but some medical ICUs, and they consulted the minimally invasive department division to do the laparoscopy to look at the patients. Six of the 17 patients had positive findings, ischemic bowel and cholecystitis. And if they did, they were taken to the OR for their definitive therapy. Three of them died, but three of them recovered. And in a patient population where you have sepsis of unknown etiology and they're doing so poorly that you don't know what to do with them, that might be an effective outcome. Interestingly, all the patients who had CTs, the sensitivity, specificity, and accuracy were pretty marginal. And so they concluded that doing this diagnostic laparoscopy in the ICU expedited diagnosis. It limited transport not only to the OR, but perhaps to the CT scanner if you want to use it as your diagnostic tool. Instead, it decreased cost and then eliminated perhaps some of those inaccurate tests. Laparotomy has been published so much that it is in the textbooks as a thing to do in the ICU, and again, most notably when patients have abdominal compartment syndrome. And in this study, there were patients who were, again, critically ill, unstable, too go to the OR. And 41 patients had laparotomy in the ICU, and they had negative laparotomies, or five of them had negative laparotomies, and their 28-day mortality was 83% high, but this was a patient population that prior to the laparotomy was thought to be ready to die in the next few hours. So perhaps that 17% was valuable. There are other procedures that we can do. We can do vena cable filters, and we do these at Carolina's Medical Center. We've also done ECMO cannulation in the ICU, and then fasciotomies and amputations. So a number of other things that we can do. The important part, I would say, is how do we do them so that we're doing these efficaciously and safely. So most importantly, I would say, is that we have standard operating procedures, whether or not these are guidelines or algorithms. We include some safety protocols, perhaps have a bedside OR cart, and some simulation training. We look at the World Health Care Organization recommendations for operations. These apply to operations broadly. And so things like making sure you're operating on the right patient, making sure you have an airway management plan for safety, and that sort of thing. But also, the things that I would say are very specific that we should pay attention to if we're going to do them in the ICU are items 7 and 8. So preventing inadvertent retention of instruments and sponges, and secure and accurately identify all surgical specimens. These are not things that our ICU nurses are used to doing. And so if we're going to do procedures in the ICU, we have to make sure we're including those in our standard operating procedures where we give them an expectation of this is one thing we need to do, and we need to be communicating well with them about that. When you're doing standard operating procedures, there's actually kind of a process to this, and it's helpful to be very prescriptive about it. Make them all look the same. Your healthcare logo, your company name, the title, the number, the author, all those sorts of things, because what you really want people to focus on is the content. You want to make sure that people understand the scope, the purpose, their roles and responsibilities. Here's where you can put in the process of making sure that you're capturing specimens and that sort of thing, so that it's easier for them to do that. If so, then you can increase your productivity, and you can reduce your errors, and we know that. Other resources that you might need while you're up there. What do you need in the way of OR teams? Surgical techs, nurses, CRNAs, the anesthesiologist. What about the blood bank, and what kind of accessibility do you have that? Labs, the portable imaging, and that sort of thing, and then other supplies, so some sort of a supply cart. And then who is involved? Not just the OR staff, but how about your nurses? How many do you need? How many RTs should you have during this process? Runners. Do you need a runner or five? I always wish I had another runner, I feel like. And then do you have APPs, and do you have residents participating in the process? If you're going to manage this sedation, does it need to be conscious sedation, or do you need the anesthesiologist to do it, and how are you going to have that happen? There are a plethora of timeout options and how to do a timeout. I picked this one in particular because of the thing at the very bottom, and that is the concerns. In order for us to be doing things safely, we want our team, every member of our team, to be able to have a voice and say, I'm concerned about this, there's something wrong, whatever that might be, and so that we can then sort and say, yep, we do need to address this, because we're going to be pretty focused, and so having the team willing to do that is helpful. Our safety protocols, how are complications handled? We have to know how to do that, and we have to have an alert system for bringing more resources urgently when we need them, and we need to have a team that's going to communicate, communicate, communicate, communicate. This image looks like this team was in a stressful situation. I don't know if this is pre-event or post-event, but they are clearly having a team bonding thing. This is not the time where you want to teach your team to communicate with you and share with you. When you want your team to communicate and share with you is when you're creating the guidelines, when you're creating practices, when you're rounding on the patients and making decisions, and you're including everybody in that decision process so that everyone feels comfortable having a voice in a calm, normal setting, and then they're going to be willing in a stressed situation to speak up and say to you, hey, we've got a problem, and we need to say that. And then finally, I would say simulation training, these are the times where it gets people more comfortable with what they're doing. So can operative procedures be done in the ICU? Absolutely, yes, and they should. They should because there's urgent timing, they should because there's difficult and risky transport, they should because there's decreased OR availability, and they should because it decreases the cost. Thank you very much. Thank you.

operative procedures

ICU

urgent timing

difficult transportation

limited OR availability