title: Elective bedside surgery in critically injured patients is safe and cost-effective.
abstract: OBJECTIVE
  The success of elective minimally invasive surgery suggested that this concept could be adapted to the intensive care unit. We hypothesized that minimally invasive surgery could be done safely and cost-effectively at the bedside in critically injured patients.
  
  
  BACKGROUND
  This case series, conducted between October 1991 and June 1997 at a Level I trauma center, examined bedside dilatational tracheostomy (BDT), percutaneous endoscopic gastrostomy (PEG), and inferior vena cava (IVC) filter placement. All procedures had been performed in the operating room (OR) before initiation of this study.
  
  
  METHODS
  All BDTs and PEGs were performed with intravenous general anesthesia (fentanyl, diazepam, and pancuronium) administered by the surgical team. IVC filters were placed using local anesthesia and conscious sedation. BDTs were done using a Ciaglia set, PEGs were done using a 20 Fr Flexiflow Inverta-PEG kit, and IVC filters were placed percutaneously under ultrasound guidance. Cost difference (delta cost) was defined as the difference in hospital cost and physician charges incurred in the OR as compared to the bedside.
  
  
  RESULTS
  Of 16,417 trauma admissions, 379 patients (2%) underwent 472 minimally invasive procedures (272 BDTs, 129 PEGs, 71 IVC filters). There were four major complications (0.8%). Two patients had loss of airway requiring reintubation. Two patients had an intraperitoneal leak from the gastrostomy requiring operative repair. No patient had a major complication after IVC filter placement. Total delta cost was $611,994. When examined independently, the cost was $324,224 for BDT, $164,088 for PEG, and $123,682 for IVC filter. OR use was reduced by 506 hours.
  
  
  CONCLUSIONS
  These bedside procedures have minimal complications, eliminate the risk associated with patient transport, reduce cost, improve OR utilization, and should be considered for routine use in the general surgery population.
authors.affiliation: Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
authors.forename: T L
authors.initials: TL
authors.lastname: Van Natta
authors.forename: J A
authors.initials: JA
authors.lastname: Morris
authors.forename: V A
authors.initials: VA
authors.lastname: Eddy
authors.forename: C R
authors.initials: CR
authors.lastname: Nunn
authors.forename: E J
authors.initials: EJ
authors.lastname: Rutherford
authors.forename: D
authors.initials: D
authors.lastname: Neuzil
authors.forename: J M
authors.initials: JM
authors.lastname: Jenkins
authors.forename: J G
authors.initials: JG
authors.lastname: Bass
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D016638:Critical Illness; D017558:Elective Surgical Procedures / Q000191:economics; D005774:Gastrostomy / Q000379:methods; D017722:Hospital Charges; D017721:Hospital Costs; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000191:economics; D019095:Point-of-Care Systems; D014139:Tracheostomy / Q000379:methods; D014481:United States; D016306:Vena Cava Filters; D014947:Wounds and Injuries / Q000601:surgery*