Planning intensive care unit admission after elective major abdominal surgery: good clinical practice document by SIAARTI-SIC-ANIARTI

Abstract

Postoperative complications (PCs) are a major cause of mortality following elective major abdominal surgery (EMAS). The increasing complexity of abdominal procedures, particularly in oncology, may significantly affect patient outcomes. However, this has also introduced a higher variability in postoperative management, and the use of tailored approaches to address critical issues such as hemodynamic stabilization, infection management, and respiratory failure. While elective admission to intensive care units (ICU) is a standard practice to manage high-risk surgical patients, ICU resource allocation is often influenced by local practices and bed availability.This document presents a framework for preoperative ICU admission planning after EMAS. It focuses on the identification of patient and surgical risk factors-using established scoring systems-and provides statements to determine ICU admission. The aim is to optimize resource allocation, reduce PCs, and prevent unplanned ICU admissions. This good clinical practice statement was developed through a multidisciplinary panel formed by selected members coming from SIAARTI (Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care), SIC (Italian Society of Surgery) and ANIARTI (National Association of Critical Area Nurses).The designed scientific board developed, through a systematic literature review and a consensus methodology, a roadmap for defining the priorities of perioperative care based on the complexity of the patient and the surgical procedure. Eventually, the panel worked out statements about six voted queries that could have supported the preoperative indication to postoperative ICU admission.Evaluation of patients' characteristics, comorbidities, and surgical factors are all essential to plan ICU admission for immediate postoperative patient care after EMAS.The presence and severity of comorbidities, assessed through various severity scores, play a crucial role in predicting PCs and guiding ICU admission decisions. Tools such as the American Society of Anesthesiologists physical status, Charlson Comorbidity Index, and Rockwood Frailty Index, along with surgical risk scores and intraoperative events, help define the need for intensive care. Preoperative frailty assessment-achieved using the Clinical Frailty Scale-is essential to anticipate postoperative care needs. Finally, during the postoperative phase, continuous monitoring and reassessment in the post-anesthesia care unit are key to determine whether ICU admission is required. Establishing high-dependency units and tailored care pathways based on individual patient needs and available resources will enhance patient outcomes and optimize postoperative care.

Keywords: Abdominal surgery; Frailty; Intensive care unit; Planning admission; Risk stratification.