Today’s PAAD is a pro/con debate1 (and accompanying editorial2) on providing general anesthesia and performing surgery at the ADULT patient’s ICU bedside (NORA) rather than transporting the critically ill patient to the OR. In pediatric anesthesia, we’ve been doing this with NICU and PICU patients for awhile, particularly with very sick neonates with necrotizing enterocolitis (NEC).3,4 Further, I’m sure this question of where to anesthetize and operate on critically ill children arises all of the time but for many pediatric NICU and PICU patients there isn’t really much data to help guide decision making. In adults, ICU bedside general anesthesia for procedures like tracheostomy are very well established and the practice is routine.5 And the number of procedures for which this is happening is increasing rapidly.2
In today’s PAAD we’ll review the pro/con arguments presented in the article by Karamchandani et al.1 and take a deeper dive into this issue. When reading it though, think about your own pediatric practice: “should we be doing this more often or not at all? What is known? Is there any data rather than anecdotes to guide decision making”? Hopefully, one or more of you, after reading this, will consider doing a multi-institutional (or survey) study to provide some answers. Myron Yaster MD
Editorial
Tung A. NORA in the ICU? Anesth Analg. 2023 Dec 1;137(6):1147-1148. doi: 10.1213/ANE.0000000000006556. Epub 2023 Nov 16. PMID: 37973128.
Original article
Karamchandani K, Evers M, Smith T, Bonavia A, Deshpande R, Klick JC, Abdelmalak BB. Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room? Anesth Analg. 2023 Dec 1;137(6):1149-1153. doi: 10.1213/ANE.0000000000006387. Epub 2023 Nov 16. PMID: 37973129.
The art of medicine is on display in decision-making surrounding bedside ICU or OR for critically ill children requiring procedural care. The considerations are many; most germane but some at the whim of “because that’s what I like to do”.
Karamchandani et al.1 provide the pros and cons. On the PRO side: timely (5.2 versus 1.3 days for tracheostomy placement!) and more cost-effective care, maintenance of patient isolation and containment procedures, avoidance of interruption of care, and perhaps most importantly, avoidance of the risks associated with patient transport. On the CON side: limited space for clinicians and equipment, poor lighting, lack of equipment, inability to use an anesthesia machine and vapor anesthetics, personnel and staffing challenges, ergonomic challenges (inadequate access to airway and IVs), and concerns about sterility.
A couple of years ago, Dr. Bishr Haydar6 published and presented an analysis of the Wake-Up Safe Database regarding complications in pediatric anesthesia transportation at the fall SPA meeting. This analysis is recent and likely the best source of evidence for this discussion. 5% of all pediatric anesthesia complications were associated with transport. Of these, 60% were deemed possibly preventable. Infants <6 months accounted for 40% of events and 60% of all transport complications were respiratory in nature. Drug errors, transitioning from PICU to anesthesia ventilators, dislodged tubes were all, not surprisingly, found in the database.6
So, if bedside ICU procedures are efficient, cost effective, and diminish the risks of transport why should we ever go to the OR with these kids? From a dialectic perspective, the antithesis to the cost and efficiency gains is the loss in OR resources (both equipment and personnel). If a specific piece of equipment is needed in the OR we know where it is, who can get it, and how to ask for it. In the ICU, we may be working with all new personnel (nurses, clinical assistants) who may not be familiar with equipment that you need, where to get it, or even if it exists in the PICU. Some items likely aren’t available, (i.e. volatile anesthetic and space). While the risks of transport are avoided, other risks may be introduced. For instance, the mechanisms in-place for massive transfusion and who to set up lines/drips may by performed differently in the PICU leading to delays.
Our (ELS and SJ) preference is to stay in the PICU for most procedures involving acutely ill children, the exception being the child with a difficult airway wherein rapid access to specialized equipment and personnel is critical. The patients also need not be intubated and sedated for us to consider delivering an anesthetic in the ICU. Last week, I (SJ) was approached about a 5-year-old with new onset leukemia (WBC of 350,000/uL) who had just been admitted to the PICU. The following day the oncology team requested a ‘sedated’ bone marrow, lumbar puncture, and PICC placement – something that is typically done in the OR at my institution. With a little bit of effort and coordination, we were able to perform a natural airway general anesthetic and complete all the procedures in the ICU that same day - all in an environment that felt comfortable and safe to the patient and their family. It was my hope that this positive initial experience will help set the tone for the many future anesthetics this patient will require on their path to remission.
Despite the benefits, in my (MY) experience, staffing challenges were particularly problematic in the NICU, where the patient’s bedside nurse would view me as a “know-nothing barbarian” invader who was going to harm his/her patient. Further, in many institutions, the ICU bedside nurses cannot take orders from non-ICU doctors and there are policy limitations on how and who could administer drugs in the ICU.
The solution to many problems for anesthesia in the ICU is improved communication and understanding of workflows. This is an arena ripe for simulation/educational efforts. Kids in the ICU should receive the best possible peri-procedural care. We believe this includes a pediatric anesthesiologist and we believe it would harm the profession to omit these populations/situations from our practice. Sadly, PICU/NICU and anesthesia has become increasingly siloed in a relatively short time. Building up these lagging relationships would benefit the kids we care for and about.
What are you doing in your practices? What challenges do you face? Are more patients undergoing surgery and procedures in the ICUs? Send your comments to Myron who will post in a Friday reader response.
References
1. Karamchandani K, Evers M, Smith T, Bonavia A, Deshpande R, Klick JC, Abdelmalak BB: Pro-Con Debate: Should Critically Ill Patients Undergo Procedures at Bedside or in the Operating Room? Anesth Analg 2023; 137: 1149-1153
2. Tung A: NORA in the ICU? Anesth Analg 2023; 137: 1147-1148
3. Anand S, Sandlas G, Nabar N, Joshi P, Terdal M, Suratkal S: Operating Within the Neonatal Intensive Care Unit: A Retrospective Analysis From a Tertiary Care Center. Cureus 2021; 13: e16077
4. Garge S, Kakani N, Khan J: Surgery in the Neonatal Intensive Care Unit in Indian Scenario: Should It be "The New State of the Art" or Just "The Need of the Hour"? J Indian Assoc Pediatr Surg 2020; 25: 368-371
5. Mirski MA, Pandian V, Bhatti N, Haut E, Feller-Kopman D, Morad A, Haider A, Schiavi A, Efron D, Ulatowski J, Yarmus L, Stevens KA, Miller CA, Papangelou A, Vaswani R, Kalmar C, Gupta S, Intihar P, Mack S, Rushing AP, Chi A, Roberts VJ, Jr.: Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program. Crit Care Med 2012; 40: 1827-34
6. Haydar B, Baetzel A, Stewart M, Voepel-Lewis T, Malviya S, Christensen R: Complications Associated With the Anesthesia Transport of Pediatric Patients: An Analysis of the Wake Up Safe Database. Anesth Analg 2020; 131: 245-254