First proposed guideline for the allocation of surgical patients in an intensive care unit
Roseny dos Reis Rodrigues, Luiz Marcelo Sá Malbouisson, Vinicius Caldeira Quintão, Tatiana Goldgraber, Claudia Marquez Simões, Filomena Regina Barbosa Gomes Galas, Juliano Pinheiro de Almeida, João Manoel da Silva Júnior, José Otávio Costa Auler Júnior, Maria José Carvalho Carmona
Abstract
The increasing number and complexity of surgeries worldwide necessitate effective preventive measures and appropriate postoperative care to avoid complications and organ dysfunctions. However, the scarcity of intensive care unit (ICU) bed space in most hospitals poses challenges in allocating surgical patients to the ICU. This article proposes a protocol and algorithm for indicating ICU hospitalization of surgical patients based on international guidelines and a national survey with anesthesiologists. The protocol aims to improve resource utilization, ensure appropriate patient allocation, and reduce surgery cancellations or postponements. The proposed algorithm considers factors such as surgical complexity, patient’s physical status, and risk of acute organ dysfunction to determine ICU indication. The protocol provides guidance for both elective and urgent/emergency surgeries, emphasizing the need for individualized clinical judgment in exceptional cases. Implementing this protocol and developing a national guideline can optimize postoperative care, mitigate the impact of limited ICU bed space, and enhance patient outcomes. The proposed algorithm aims to rationalize ICU bed requests, reduce patient waiting times, and minimize financial costs associated with postoperative care.
Keywords
References
1. Pelosi P, Ball L, Schultz MJ. How to optimize critical care resources in surgical patients: intensive care without physical borders. Curr Opin Crit Care. 2018;24(6):581- 7. http://dx.doi.org/10.1097/MCC.0000000000000557. PMid:30299312.
2. Rose J, Weiser TG, Hider P, Wilson L, Gruen RL, Bickler SW. The estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health. 2015;3(Suppl 2):S13-20. http://dx.doi.org/10.1016/S2214- 109X(15)70087-2. PMid:25926315.
3. Wong DJN, Popham S, Wilson AM, Barneto LM, Lindsay HA, Farmer L, et al. Postoperative critical care and high-acuity care provision in the United Kingdom, Australia, and New Zealand. Br J Anaesth. 2019;122(4):460-9. http://dx.doi. org/10.1016/j.bja.2018.12.026. PMid:30857602.
4. Hashim S, Wong DJN, Farmer L, Harris SK, Moonesinghe SR. Perceptions of UK clinicians towards postoperative critical care. Anaesthesia. 2021;76(3):336-45. http://dx.doi. org/10.1111/anae.15302. PMid:33338259.
5. Ghaffar S, Pearse RM, Gillies MA. ICU admission after surgery: who benefits? Curr Opin Crit Care. 2017;23(5):424- 9. http://dx.doi.org/10.1097/MCC.0000000000000448. PMid:28777159.
6. ASA: American Society of Anesthesiologists [Internet]. Schaumburg: American Society of Anesthesiologists; c2023 [cited 2021 Apr 13]. Available from: https://www. asahq.org/standards-and-guidelines/asa-physical-statusclassification-system
7. Findlay GP. Knowing the risk: a review of the perioperative care of surgical patients. A report by The National Confidential Enquiry into Patient Outcome and Death. London: National Confidential Enquiry into Patient Outcome and Death; 2011 [cited 2021 Apr 13]. Available from: https://www.ncepod.org.uk/2011poc. html
8. Janiques M, Rodrigues RR. Evaluation of the criteria used by anesthesiologists to indicate postoperative Intensive Care Unit beds: a national survey. (unpublish).
9. Prause G, Ratzenhofer-Comenda B, Pierer G, Smolle-Jüttner F, Glanzer H, Smolle J. Can ASA grade or Goldman’s cardiac risk index predict peri-operative mortality? Anaesthesia. 1997;52(3):203-6. http://dx.doi.org/10.1111/j.1365- 2044.1997.074-az0074.x. PMid:9124658.
10. Cashmore RMJ, Fowler AJ, Pearse RM. Post-operative intensive care: is it really necessary? Intensive Care Med. 2019;45(12):1799-801. http://dx.doi.org/10.1007/s00134- 019-05775-y. PMid:31549226.
11. Orsini J, Blaak C, Yeh A, Fonseca X, Helm T, Butala A, et al. Triage of patients consulted ICU admission during times of ICU-bed shortage. J Clin Med Res. 2014;6(6):463-8. http:// dx.doi.org/10.14740/jocmr1939w. PMid:25247021.
12. Covre ER, Melo WA, Tostes MFP, Fernandes CAM. Tendência de internações e mortalidade por causas cirúrgicas no Brasil, 2008 a 2016. Rev Col Bras Cir. 2019;46(1):e1979. http://dx.doi.org/10.1590/0100- 6991e-20191979. PMid:30785570.
13. Sprung CL, Joynt GM, Christian MD, Truog RD, Rello J, Nates JL. Adult ICU triage during the coronavirus disease 2019 pandemic: who will live and who will die? Recommendations to improve survival. Crit Care Med. 2020;48(8):1196-202. http://dx.doi.org/10.1097/ CCM.0000000000004410. PMid:32697491.
14. Lobo SM, Rezende E, Knibel MF, Silva NB, Páramo JA, Nácul F, et al. Epidemiologia e desfecho de pacientes cirúrgicos não cardíacos em unidades de terapia intensiva no Brasil. Rev Bras Ter Intensiva. 2008;20(4):376-84. http://dx.doi. org/10.1590/S0103-507X2008000400010. PMid:25307243.
15. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;64(22):e77-137. http://dx.doi.org/10.1016/j. jacc.2014.07.944. PMid:25091544.
16. Gualandro DM, Yu PC, Caramelli B, Marques AC, Calderaro D, Fornari LS, et al. 3ª diretriz de avaliação cardiovascular perioperatória da Sociedade Brasileira de Cardiologia. Arq Bras Cardiol. 2017;109(3, Suppl 1):1-104. PMid:29044300.
17. Mermiri M, Mavrovounis G, Chatzis D, Mpoutsikos I, Tsaroucha A, Dova M, et al. Critical emergency medicine and the resuscitative care unit. Acute Crit Care. 2021;36(1):22-8. http://dx.doi.org/10.4266/acc.2020.00521. PMid:33508185.
18. Lee A, Lum ME, O’Regan WJ, Hillman KM. Early postoperative emergencies requiring an intensive care team intervention: the role of ASA physical status and after-hours surgery. Anaesthesia. 1998;53(6):529-35. http://dx.doi.org/10.1046/ j.1365-2044.1998.00395.x. PMid:9709136.
19. Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77(2):217-22. http://dx.doi. org/10.1093/bja/77.2.217. PMid:8881629.
Submitted date:
03/13/2023
Accepted date:
05/08/2023
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