Skip to main content
SpringerLink
Log in

Triage of Surgical Patients for Intensive Care

  • Chapter
Surgical Intensive Care Medicine

  • 2649 Accesses

Abstract

Patients undergoing surgery are at high risk for complications and mortality if they have comorbidities that might impact their outcome, are undergoing a high-risk procedure, or experience complications perioperatively that increase their risk. For some surgical procedures, the postoperative requirements dictate a need for intensive care. But for the majority, there is a specific triage decision that must be made which may be further complicated by a limited availability of ICU beds in some care settings. The use of intensive care services for high-risk patients may improve outcomes, but this remains speculative. Identifying high-risk surgical patients remains difficult, although patient factors, surgical characteristics, risk stratification tools, and biomarkers may help determine which patients may have poor postoperative outcomes and therefore are most likely to receive benefit from intensive care.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 219.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. Semel ME, Lipsitz SR, Funk LM, Bader AM, Weiser TG, Gawande AA. Rates and patterns of death after surgery in the United States, 1996 and 2006. Surgery. 2012;151:171–82.

    Article  PubMed  Google Scholar 

  2. Pearse RM, Moreno RP, Bauer P, Pelosi P, Metnitz P, Spies C, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet. 2012;380:1059–65.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Bainbridge D, Martin J, Arango M, Cheng D, Evidence-based Peri-operative Clinical Outcomes Research Group. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet. 2012;380:1075–81.

    Article  PubMed  Google Scholar 

  4. Simpson JC, Moonesinghe SR. Introduction to the postanaesthetic care unit. Perioper Med. 2013;2:5.

    Article  Google Scholar 

  5. Findlay GP, Goodwin A, Protopapa K, Smith NCE, Mason M. Knowing the risk: a review of the peri-operative care of surgical patients. National Confidential Enquiry into Patient Outcome and Death; 2011.

    Google Scholar 

  6. Weissman C. The enhanced postoperative care system. J Clin Anesth. 2005;17:314–22.

    Article  PubMed  Google Scholar 

  7. Aps C. Surgical critical care: the overnight intensive recovery (OIR) concept. Br J Anaesth. 2004;92:164–6.

    Article  CAS  PubMed  Google Scholar 

  8. Jones AG, Harper SJ. ‘Ventilating in recovery’—the way forward: intensive therapy or postoperative critical care? Br J Anaesth. 2002;88:473–4.

    Article  CAS  PubMed  Google Scholar 

  9. Cheng DC, Byrick RJ, Knobel E. Structural models for intermediate care areas. Crit Care Med. 1999;27:2266–71.

    Article  CAS  PubMed  Google Scholar 

  10. Simchen E, Sprung CL, Galai N, Zitser-Gurevich Y, Bar-Lavi Y, Levi L, et al. Survival of critically ill patients hospitalized in and out of intensive care. Crit Care Med. 2007;35:449–57.

    Article  PubMed  Google Scholar 

  11. Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EA, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36:2787–93.

    Article  PubMed  Google Scholar 

  12. Weissman C, Klein N. Who receives postoperative intensive and intermediate care? J Clin Anesth. 2008;20:263–70.

    Article  PubMed  Google Scholar 

  13. Khuri SF, Henderson WG, DePalma RG, Mosca C, Healey NA, Kumbhani DJ, et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications. Ann Surg. 2005;242:326–41; discussion 41–3.

    PubMed  PubMed Central  Google Scholar 

  14. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361:1368–75.

    Article  CAS  PubMed  Google Scholar 

  15. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care. 2011;49:1076–81.

    Article  PubMed  Google Scholar 

  16. Pearse RM, Harrison DA, James P, Watson D, Hinds C, Rhodes A, et al. Identification and characterisation of the high-risk surgical population in the United Kingdom. Crit Care. 2006;10:R81.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Moonesinghe SR, Mythen MG, Grocott MP. Patient-related risk factors for postoperative adverse events. Curr Opin Crit Care. 2009;15:320–7.

    Article  PubMed  Google Scholar 

  18. Finks JF, Osborne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med. 2011;364:2128–37.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Weissman C, Klein N. The importance of differentiating between elective and emergency postoperative critical care patients. J Crit Care. 2008;23:308–16.

    Article  PubMed  Google Scholar 

  20. Kertai MD, White WD, Gan TJ. Cumulative duration of “triple low” state of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia is not associated with increased mortality. Anesthesiology. 2014;121:18–28.

    Article  CAS  PubMed  Google Scholar 

  21. McNicol L, Story DA, Leslie K, Myles PS, Fink M, Shelton AC, et al. Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals. Med J Aust. 2007;186:447–52.

    PubMed  Google Scholar 

  22. Wolters U, Wolf T, Stutzer H, Schroder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77:217–22.

    Article  CAS  PubMed  Google Scholar 

  23. Owens WD, Felts JA, Spitznagel Jr EL. ASA physical status classifications: a study of consistency of ratings. Anesthesiology. 1978;49:239–43.

    Article  CAS  PubMed  Google Scholar 

  24. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.

    Article  CAS  PubMed  Google Scholar 

  25. Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery. Anesth Analg. 2005;100:4–10.

    Article  PubMed  Google Scholar 

  26. Struthers R, Erasmus P, Holmes K, Warman P, Collingwood A, Sneyd JR. Assessing fitness for surgery: a comparison of questionnaire, incremental shuttle walk, and cardiopulmonary exercise testing in general surgical patients. Br J Anaesth. 2008;101:774–80.

    Article  CAS  PubMed  Google Scholar 

  27. Biccard BM, Lurati Buse GA, Burkhart C, Cuthbertson BH, Filipovic M, Gibson SC, et al. The influence of clinical risk factors on pre-operative B-type natriuretic peptide risk stratification of vascular surgical patients. Anaesthesia. 2012;67:55–9.

    Article  CAS  PubMed  Google Scholar 

  28. Nagele P, Brown F, Gage BF, Gibson DW, Miller JP, Jaffe AS, et al. High-sensitivity cardiac troponin T in prediction and diagnosis of myocardial infarction and long-term mortality after noncardiac surgery. Am Heart J. 2013;166:325–32.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100:1043–9.

    Article  CAS  PubMed  Google Scholar 

  30. Sutton R, Bann S, Brooks M, Sarin S. The surgical risk scale as an improved tool for risk-adjusted analysis in comparative surgical audit. Br J Surg. 2002;89:763–8.

    Article  CAS  PubMed  Google Scholar 

  31. Glance LG, Lustik SJ, Hannan EL, Osler TM, Mukamel DB, Qian F, et al. The surgical mortality probability model: derivation and validation of a simple risk prediction rule for noncardiac surgery. Ann Surg. 2012;255:696–702.

    Article  PubMed  Google Scholar 

  32. Shum S, Tanzola R, McMullen M, Hopman WM, Engen D. How well are prebooked surgical step-down units utilized? J Clin Anesth. 2013;25:202–8.

    Article  PubMed  Google Scholar 

  33. Reich DL, Bennett-Guerrero E, Bodian CA, Hossain S, Winfree W, Krol M. Intraoperative tachycardia and hypertension are independently associated with adverse outcome in noncardiac surgery of long duration. Anesth Analg. 2002;95:273–7.

    PubMed  Google Scholar 

  34. Bijker JB, van Klei WA, Vergouwe Y, Eleveld DJ, van Wolfswinkel L, Moons KG, et al. Intraoperative hypotension and 1-year mortality after noncardiac surgery. Anesthesiology. 2009;111:1217–26.

    Article  PubMed  Google Scholar 

  35. Walsh M, Devereaux PJ, Garg AX, Kurz A, Turan A, Rodseth RN, et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology. 2013;119:507–15.

    Article  PubMed  Google Scholar 

  36. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78:355–60.

    Article  CAS  PubMed  Google Scholar 

  37. Prytherch DR, Whiteley MS, Higgins B, Weaver PC, Prout WG, Powell SJ. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity. Br J Surg. 1998;85:1217–20.

    Article  CAS  PubMed  Google Scholar 

  38. Bennett-Guerrero E, Hyam JA, Shaefi S, Prytherch DR, Sutton GL, Weaver PC, et al. Comparison of P-POSSUM risk-adjusted mortality rates after surgery between patients in the USA and the UK. Br J Surg. 2003;90:1593–8.

    Article  CAS  PubMed  Google Scholar 

  39. Regenbogen SE, Ehrenfeld JM, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Utility of the surgical apgar score: validation in 4119 patients. Arch Surg. 2009;144:30–6.

    Google Scholar 

  40. Wanderer JP, Anderson-Dam J, Levine W, Bittner EA. Development and validation of an intraoperative predictive model for unplanned postoperative intensive care. Anesthesiology. 2013;119:516–24.

    Article  PubMed  Google Scholar 

  41. Haller G, Myles PS, Wolfe R, Weeks AM, Stoelwinder J, McNeil J. Validity of unplanned admission to an intensive care unit as a measure of patient safety in surgical patients. Anesthesiology. 2005;103:1121–9.

    Article  PubMed  Google Scholar 

  42. Rodseth RN, Biccard BM, Le Manach Y, Sessler DI, Lurati Buse GA, Thabane L, et al. The prognostic value of pre-operative and post-operative B-type natriuretic peptides in patients undergoing noncardiac surgery: B-type natriuretic peptide and N-terminal fragment of pro-B-type natriuretic peptide: a systematic review and individual patient data meta-analysis. J Am Coll Cardiol. 2014;63:170–80.

    Article  CAS  PubMed  Google Scholar 

  43. Botto F, Alonso-Coello P, Chan MT, Villar JC, Xavier D, Srinathan S, et al. Myocardial injury after noncardiac surgery: a large, international, prospective cohort study establishing diagnostic criteria, characteristics, predictors, and 30-day outcomes. Anesthesiology. 2014;120:564–78.

    Article  PubMed  Google Scholar 

  44. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.

    Article  CAS  PubMed  Google Scholar 

  45. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270:2957–63.

    Article  PubMed  Google Scholar 

  46. Sakr Y, Krauss C, Amaral AC, Rea-Neto A, Specht M, Reinhart K, et al. Comparison of the performance of SAPS II, SAPS 3, APACHE II, and their customized prognostic models in a surgical intensive care unit. Br J Anaesth. 2008;101:798–803.

    Article  CAS  PubMed  Google Scholar 

  47. Sinuff T, Adhikari NK, Cook DJ, Schunemann HJ, Griffith LE, Rocker G, et al. Mortality predictions in the intensive care unit: comparing physicians with scoring systems. Crit Care Med. 2006;34:878–85.

    Article  PubMed  Google Scholar 

  48. Moonesinghe SR, Mythen MG, Das P, Rowan KM, Grocott MP. Risk stratification tools for predicting morbidity and mortality in adult patients undergoing major surgery: qualitative systematic review. Anesthesiology. 2013;119:959–81.

    Article  PubMed  Google Scholar 

  49. Bui JQ, Mendis RL, van Gelder JM, Sheridan MM, Wright KM, Jaeger M. Is postoperative intensive care unit admission a prerequisite for elective craniotomy? J Neurosurg. 2011;115:1236–41.

    Article  PubMed  Google Scholar 

  50. Dahm P, Tuttle-Newhall JE, Nimjee SM, Byrne RR, Yowell CW, Price DT. Indications for admission to the surgical intensive care unit after radical cystectomy and urinary diversion. J Urol. 2001;166:189–93.

    Article  CAS  PubMed  Google Scholar 

  51. Angel D, Sieunarine K, Finn J, McKenzie E, Taylor B, Kidd H, et al. Comparison of short-term clinical postoperative outcomes in patients who underwent carotid endarterectomy: intensive care unit versus the ward high-dependency unit. J Vasc Nurs. 2004;22:85–90.

    Google Scholar 

  52. Thompson JS, Baxter BT, Allison JG, Johnson FE, Lee KK, Park WY. Temporal patterns of postoperative complications. Arch Surg. 2003;138:596–602.

    Google Scholar 

  53. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288:1987–93.

    Article  PubMed  Google Scholar 

  54. Gardner-Thorpe J, Love N, Wrightson J, Walsh S, Keeling N. The value of Modified Early Warning Score (MEWS) in surgical in-patients: a prospective observational study. Ann R Coll Surg Engl. 2006;88:571–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Taenzer AH, Pyke JB, McGrath SP, Blike GT. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfers: a before-and-after concurrence study. Anesthesiology. 2010;112:282–7.

    Article  PubMed  Google Scholar 

  56. Chan PS, Jain R, Nallmothu BK, Berg RA, Sasson C. Rapid response teams: A systematic review and meta-analysis. Arch Intern Med. 2010;170:18–26.

    Article  PubMed  Google Scholar 

  57. Litvak E, Pronovost PJ. Rethinking rapid response teams. JAMA. 2010;304:1375–6.

    Article  CAS  PubMed  Google Scholar 

  58. Metcalfe MA, Sloggett A, McPherson K. Mortality among appropriately referred patients refused admission to intensive-care units. Lancet. 1997;350:7–11.

    Article  CAS  PubMed  Google Scholar 

  59. Iapichino G, Corbella D, Minelli C, Mills GH, Artigas A, Edbooke DL, et al. Reasons for refusal of admission to intensive care and impact on mortality. Intensive Care Med. 2010;36:1772–9.

    Article  PubMed  Google Scholar 

  60. Sinuff T, Kahnamoui K, Cook DJ, Luce JM, Levy MM, Values E, et al. Rationing critical care beds: a systematic review. Crit Care Med. 2004;32:1588–97.

    Article  PubMed  Google Scholar 

  61. Joynt GM, Gomersall CD, Tan P, Lee A, Cheng CA, Wong EL. Prospective evaluation of patients refused admission to an intensive care unit: triage, futility and outcome. Intensive Care Med. 2001;27:1459–65.

    Article  CAS  PubMed  Google Scholar 

  62. Robert R, Reignier J, Tournoux-Facon C, Boulain T, Lesieur O, Gissot V, et al. Refusal of intensive care unit admission due to a full unit: impact on mortality. Am J Respir Crit Care Med. 2012;185:1081–7.

    Article  PubMed  Google Scholar 

  63. Young MP, Gooder VJ, McBride K, James B, Fisher ES. Inpatient transfers to the intensive care unit: delays are associated with increased mortality and morbidity. J Gen Intern Med. 2003;18:77–83.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Goldhill DR, McNarry AF, Hadjianastassiou VG, Tekkis PP. The longer patients are in hospital before intensive care admission the higher their mortality. Intensive Care Med. 2004;30:1908–13.

    Article  PubMed  Google Scholar 

  65. Flabouris A, Jeyadoss J, Field J, Soulsby T. Direct and delayed admission to an intensive care or high dependency unit following discharge from the emergency department: associated patient characteristics and hospital outcomes. Crit Care Resusc. 2012;14:191–7.

    PubMed  Google Scholar 

  66. Vester-Andersen M, Lundstrom LH, Moller MH, Waldau T, Rosenberg J, Moller AM, et al. Mortality and postoperative care pathways after emergency gastrointestinal surgery in 2904 patients: a population-based cohort study. Br J Anaesth. 2014;112:860–70.

    Article  CAS  PubMed  Google Scholar 

  67. Buth KJ, Gainer RA, Legare JF, Hirsch GM. The changing face of cardiac surgery: practice patterns and outcomes 2001-2010. Can J Cardiol. 2014;30:224–30.

    Article  PubMed  Google Scholar 

  68. Truog RD, Brock DW, Cook DJ, Danis M, Luce JM, Rubenfeld GD, et al. Rationing in the intensive care unit. Crit Care Med. 2006;34:958–63.

    Article  PubMed  Google Scholar 

  69. Repine TB, Lisagor P, Cohen DJ. The dynamics and ethics of triage: rationing care in hard times. Mil Med. 2005;170:505–9.

    Article  PubMed  Google Scholar 

  70. Fair allocation of intensive care unit resources. American Thoracic Society. Am J Respir Crit Care Med. 1997;156:1282–301.

    Google Scholar 

  71. Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine. Critical Care Med. 1999;27:633–8.

    Google Scholar 

  72. White DB, Katz MH, Luce JM, Lo B. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150:132–8.

    Article  PubMed  PubMed Central  Google Scholar 

  73. Osborne M, Patterson J. Ethical allocation of ICU resources: a view from the USA. Intensive Care Med. 1996;22:1010–4.

    CAS  PubMed  Google Scholar 

  74. Lemeshow S, Klar J, Teres D. Outcome prediction for individual intensive care patients: useful, misused, or abused? Intensive Care Med. 1995;21:770–6.

    Article  CAS  PubMed  Google Scholar 

  75. The Royal College of Surgeons of England, Department of Health. The higher risk general surgical patient: towards improved care for a Forgotten Group; 2011.

    Google Scholar 

  76. Wunsch H, Gershengorn HB, Guerra C, Rowe J, Li G. Association between age and use of intensive care among surgical Medicare beneficiaries. J Crit Care. 2013;28:597–605.

    Article  PubMed  PubMed Central  Google Scholar 

  77. Marshall MF, Schwenzer KJ, Orsina M, Fletcher JC, Durbin Jr CG. Influence of political power, medical provincialism, and economic incentives on the rationing of surgical intensive care unit beds. Crit Care Med. 1992;20:387–94.

    Article  CAS  PubMed  Google Scholar 

  78. Wunsch H. Is there a Starling curve for intensive care? Chest. 2012;141:1393–9.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Kraiss LW, Kilberg L, Critch S, Johansen KJ. Short-stay carotid endarterectomy is safe and cost-effective. Am J Surg. 1995;169:512–5.

    Article  CAS  PubMed  Google Scholar 

  80. Giraud T, Dhainaut JF, Vaxelaire JF, Joseph T, Journois D, Bleichner G, et al. Iatrogenic complications in adult intensive care units: a prospective two-center study. Crit Care Med. 1993;21:40–51.

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, Columbia University, 622 West 168th St, PH5-527D, New York, NY, 10032, USA

    Julia Sobol MD, MPH

  2. Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Department of Anesthesia, University of Toronto, Toronto, ON, Canada

    Hannah Wunsch MD, MSc

Authors
  1. Julia Sobol MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Hannah Wunsch MD, MSc
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hannah Wunsch MD, MSc .

Editor information

Editors and Affiliations

  1. Department of Surgical Critical Care; Lahey Hospital and Medical Center, Division of Surgery, Burlington, Massachusetts, USA

    John M. O'Donnell

  2. Surgical Critical Care Medicine, Pr�-Card�o Hospital, Critical Care Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil

    Flávio E. Nácul

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Sobol, J., Wunsch, H. (2016). Triage of Surgical Patients for Intensive Care. In: O'Donnell, J., Nácul, F. (eds) Surgical Intensive Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19668-8_61

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-19668-8_61

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-19667-1

  • Online ISBN: 978-3-319-19668-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation