克氏外科学19版Chapter 24.pdfVIP

CHAPTER 24 BEDSIDE SURGICAL PROCEDURES Oliver L. Gunter, Jose J. Diaz, and Addison K. May rationale for bedside surgical procedures taking the operating room to the intensive care unit safety practices selection of patients bedside procedures A number of factors have combined to increase the frequency and appropriateness of operative procedures performed at the bedside in the intensive care unit (ICU) for critically ill surgical patients. These include the following: increasing severity of illness in critically ill surgical patients; acceptance of staged and damage control management strategies for severe abdominal, soft tissue, and orthopedic pathology; advances in endoscopic and percutaneous techniques; increasing competition for operating room (OR) space; difficulty of transporting severely critically ill patients; and resource cost of repetitive operative procedures. For abdominal procedures, in particular, the introduction of the open abdominal approach for the management of abdominal catastrophes and abdominal compartment syndrome has created the need for frequent and repetitive abdominal procedures that can safely and efficiently be done at the bedside. Also, acceptance by many surgeons of the usefulness of early tracheostomy with the introduction of percutaneous tracheostomy and endoscopically guided feeding access has resulted in a number of procedures being performed at the ICU bedside that formerly had been performed in the OR. As an example, over the 9-year period between July 2001 and December 2009, our Division of Trauma and Surgical Critical Care performed more than 13,000 bedside surgical procedures, including more than 2800 tracheostomies, 1240 gastrostomy or gastrojejunostomy tubes, 4000 bronchoscopies, and 900 laparotomies. Our monthly bedside laparotomy rate has increased from 1.9/month during 1996 to 2000 to 8.7/month during 2001 to 2009. During these two time periods, the indications for laparotomy shifted significantly from emergency indicatio