Perioperative predictors of critical care admission following emergency surgical procedures: a comprehensive evaluation of anesthesia management

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Identifying perioperative factors associated with postoperative ICU requirement is essential for improving outcomes and optimizing resource allocation. This study evaluated anesthesia management practices in a large emergency surgery cohort and investigated independent predictors of postoperative ICU admission. Methods: This retrospective cohort study included 1,984 patients who underwent emergency surgical procedures at a tertiary center between 2022 and 2023. Demographics, trauma status, ASA classification, airway management, anesthetic technique, hemodynamic support, transfusion, and postoperative analgesia were recorded. The primary endpoint was postoperative ICU admission. Results: The ICU admission rate was 12.1%. ICU-admitted patients were older (57.5 ± 19.1 vs. 36.9 ± 15.2 years, p < 0.001) and more frequently presented with trauma (30.8% vs. 16.0%, p < 0.001). Higher ASA scores, vasopressor or inotrope use (19.9% vs. 0.3%, p < 0.001), and transfusion (32.1% vs. 3.6%, p < 0.001) were strongly associated with ICU need. Multivariate analysis identified age (OR 1.027), trauma (OR 1.606), ASA score (OR 4.376), vasopressor or inotrope use (OR 24.408), and transfusion (OR 4.952) as independent predictors (all p < 0.05). Specialties showed notable variation in anesthetic technique and postoperative practices. Conclusions: Postoperative ICU requirement in emergency surgery is influenced by advanced age, trauma, elevated ASA status, hemodynamic instability, and transfusion. Recognizing these predictors may improve risk stratification, perioperative planning, and ICU resource utilization. Standardizing anesthesia protocols and strengthening hemodynamic optimization strategies may enhance patient safety in emergency surgical settings. Anesthesia Emergency Surgical Procedures Hemodynamic Phenomena Intensive Care Units Perioperative Care Risk Factors Figures Figure 1 Introduction Emergency surgery is recognized worldwide as one of the most demanding and high-risk components of modern healthcare systems. According to data from the United Kingdom, emergency procedures account for more than half of the overall surgical workload, and morbidity and mortality rates among these patients remain significantly higher compared with elective operations [1–3]. Many emergency surgery patients undergo operative intervention under substantial time pressure, leaving limited opportunity for comprehensive preoperative assessment. Factors such as a full stomach, hemodynamic instability, trauma-related organ injury, multiple comorbidities, advanced age, and electrolyte disturbances further complicate anesthetic management in this population [4–6]. Among the major contributors to anesthetic risk in emergency settings, airway management challenges are of primary importance [7]. Endotracheal intubation may become difficult due to trauma, bleeding, facial anatomical disruption, or loss of spinal stability [8]. Previous literature consistently demonstrates that the incidence of difficult airway is markedly higher in emergency patients than in scheduled elective cases [9]. Consequently, the increasing adoption of advanced visualization tools such as videolaryngoscopy in emergency scenarios is considered an important step toward enhancing patient safety [10,11]. In addition, a substantial proportion of emergency surgery patients exhibit a fragile hemodynamic profile due to hemorrhage, inflammatory response, sepsis, or polytrauma [12,13]. As a result, fluid resuscitation, transfusion therapy, and inotropic support are frequently required throughout the perioperative period [14,15]. Prior studies have also emphasized that patients requiring blood transfusion experience higher complication rates and an increased need for postoperative intensive care [16]. Although regional anesthesia may provide notable advantages in selected emergency conditions, its use is often limited by prolonged procedure duration and restricted patient cooperation; thus, general anesthesia remains the predominant technique in most centers [17]. Nevertheless, regional techniques continue to be widely used in certain disciplines, particularly obstetrics [18]. The impact of anesthetic modality on clinical outcomes in emergency surgery has not been fully elucidated, and a significant gap persists in current literature regarding this topic [19]. Therefore, the present study aimed to comprehensively evaluate anesthetic techniques, airway management strategies, hemodynamic interventions, transfusion requirements, and postoperative outcomes in a broad cohort of emergency surgery patients, and to identify independent risk factors associated with postoperative intensive care unit admission. Materials and Methods Ethical Approval This study was approved by the Health Sciences University Gülhane Scientific Research Ethics Committee (decision no. 2024/559; December 12, 2024). All procedures were conducted in accordance with the principles of the World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects. Patient Selection This retrospective cohort study included all adult patients who underwent emergency surgical procedures at our institution between 2022 and 2023. Following ethical approval, anesthesia records, surgical operation notes, electronic hospital information system data, and intensive care unit (ICU) follow-up records were reviewed consecutively and transferred into a standardized data collection form for analysis. A total of 1,984 patients who met the inclusion criteria constituted the study sample. For each patient, age, sex, type of admission (trauma/emergency), American Society of Anesthesiologists (ASA) physical status classification, duration of surgery, and the surgical department were recorded. Intraoperative data included patient positioning (supine, prone, lithotomy, lateral, and others), anesthesia technique (general, spinal, combined, nerve block, sedation), and the general–regional anesthesia distinction. Airway management (spontaneous ventilation, laryngeal mask airway, endotracheal intubation, mask-cannula) and the use of videolaryngoscopy were documented as separate variables. Peripheral intravenous access site (hand, arm, foot, multiple attempts), arterial catheter presence and type (radial, femoral, brachial), and central venous catheter presence and insertion site (internal jugular, subclavian, femoral) were systematically recorded for all patients. Postoperative data included analgesia modalities (spinal, intravenous, patient-controlled analgesia [PCA], nerve block, and combinations thereof) and opioid administration. Additionally, allergic/anaphylactic reactions, vasopressor or inotropic requirements, blood transfusion, tranexamic acid administration, perioperative arrest/CPR, and mortality were noted. The presence of a nasogastric (NG) tube was evaluated in 697 patients with available documentation. Admission to the postoperative ICU served as the primary outcome variable. Patients who were and were not admitted to the ICU were compared in terms of demographic characteristics, perioperative findings, and intraoperative management. Patients from general surgery, obstetrics and gynecology, orthopedics and traumatology, thoracic surgery, neurosurgery, plastic and reconstructive surgery, urology, ophthalmology, otorhinolaryngology, and interventional departments were additionally analyzed as subgroups to compare postoperative ICU requirement, arrest/CPR, blood transfusion, allergic reactions, invasive vascular access, videolaryngoscope use, and NG tube status. For each specialty, postoperative analgesia techniques and preferred anesthesia modalities were evaluated in a separate subgroup analysis. The use of tranexamic acid was compared between patients who did and did not receive blood transfusion, and its utilization rate among transfused patients was specifically documented. Statistical Analysis Descriptive statistics for continuous variables were expressed as mean ± standard deviation and median (minimum–maximum, interquartile range [IQR]). Normality was assessed using the Shapiro–Wilk test. For non-normally distributed continuous variables, group comparisons were performed using the Mann–Whitney U test. Categorical variables were summarized as numbers and percentages; comparisons between groups were made using the Chi-square Exact test. Independent risk factors for postoperative ICU admission were evaluated using multivariate logistic regression analysis. Statistical analyses were performed using IBM SPSS Statistics v20 (Chicago, IL, USA), and p<0.05 was considered statistically significant. Results A total of 1,984 patients were included in the study. The mean age of the patients was 39.46±17.29 years, with a median age of 34 (8–83) years. The mean duration of surgery was 107.63±61.87 minutes, and the median duration was 90 (0–520) minutes. Of all cases, 57.3% were female and 42.7% were male. Regarding the mode of admission, 82.2% of the patients underwent emergency surgery, while 17.8% required surgery due to trauma. According to the ASA classification, the largest group was ASA II with 62.9%, followed by ASA III (19.3%) and ASA I (11.5%). The clinics with the highest operation frequency were General Surgery at 37.4% and Obstetrics and Gynecology at 33.2%. An indwelling urinary catheter was present in 59.7% of the patients, and similarly, urine output was recorded intraoperatively in 59.1% of cases (Figure 1) (Table 1). The vast majority of patients (95.6%) were operated in the supine position, while other positions were used at markedly lower frequencies (prone 2.0%, lithotomy 1.3%, lateral 0.8%). Evaluation of anesthesia techniques showed that general anesthesia was administered in 65.7% of all cases, followed by spinal anesthesia at 29.1%. Overall, regional techniques accounted for approximately one-third of the cohort (29.8%), whereas nerve blocks and combined techniques were used at low rates. In airway management, the most frequently applied method was endotracheal intubation (59.1%), while 29.2% of the patients maintained spontaneous ventilation, 6.7% were managed with an LMA, and 5.0% with mask-cannula ventilation. Videolaryngoscopy was used in only 9.0% of cases, indicating that 91.0% of airway management was performed using conventional methods. Examination of peripheral intravenous access sites revealed that the hand (38.1%) and arm (34.7%) were the most commonly preferred locations, and multiple access attempts were required in 22.7% of the patients. Arterial catheterization was performed in 14.8% of patients, most commonly via the radial artery (14.2%). Central venous catheter placement was performed in 9.9% of cases, with the internal jugular vein being the most frequently used access route (8.9%) (Table 2). Postoperative analgesia methods were evaluated, and more than half of the patients (52.6%) received intravenous analgesia, while spinal analgesia was administered in 28% of cases. In 10.4% of the patients, no postoperative analgesia method was used. Combined approaches such as intravenous analgesia with nerve block were applied in 4.7% of the patients, whereas patient-controlled analgesia (PCA), nerve blocks, or other combination techniques were utilized at considerably lower rates. Regarding postoperative opioid use, 54.5% of the patients did not receive any opioids, 42.6% were treated with Aldolan, and only 2.3% received morphine. Vasopressor or inotrope support was not required in 97.4% of the patients. Blood transfusion was performed in 7% of cases, and tranexamic acid was used in 2.3%. The postoperative arrest/CPR rate was low at 0.5%, and the overall mortality rate was 0.2%. Admission to the postoperative intensive care unit (ICU) occurred in 240 patients (12.1%). Among the 697 patients with available documentation, nasogastric tube placement was identified in 28.1%. These findings highlight the variability in postoperative interventions and clinical outcomes across a large and diverse patient cohort (Table 3). Postoperative intensive care admission rates showed marked variability across clinical specialties. The need for ICU admission was relatively low in General Surgery, Obstetrics and Gynecology, and Orthopedics, with rates of 11.7%, 1.7%, and 6.6%, respectively. In contrast, Neurosurgery (63.7%) and Otorhinolaryngology (69.2%) exhibited substantially higher ICU admission rates. The requirement for ICU care in Thoracic Surgery was 22.7%, which was higher than that observed in other smaller surgical branches. Arrest/CPR rates remained extremely low across all departments, with only a small number of cases recorded in Thoracic Surgery (4.5%) and Otorhinolaryngology (7.7%). Blood transfusion needs also varied significantly by specialty. Thoracic Surgery (31.8%) and Neurosurgery (25.8%) demonstrated the highest transfusion rates. In contrast, Plastic Surgery (2.9%), Ophthalmology, and Interventional units (5.0%) had very low transfusion requirements. Similarly, the incidence of allergy/anaphylaxis was low across all specialties, with only minimal cases reported. Central venous catheter placement was markedly more common in Thoracic Surgery (45.5%) and Neurosurgery (29.8%), while remaining limited in other departments. Arterial line insertion showed a similar pattern, being most frequent in Neurosurgery (69.4%) and Thoracic Surgery (68.2%). Videolaryngoscope usage varied among specialties, with overall low rates; however, a notable increase was observed in Otorhinolaryngology, where it reached 53.8%. Vasopressor or inotrope requirements were most frequent in Thoracic Surgery (22.7%) and Neurosurgery (11.3%), while other specialties demonstrated very low rates. Mortality rates were exceedingly low in all departments, with only isolated cases reported. Among patients with available data, NG tube placement was most commonly documented in General Surgery and Obstetrics and Gynecology. These findings highlight substantial inter-specialty differences likely attributable to variations in patient populations and the nature of surgical procedures performed (Table 4). Postoperative analgesia methods showed significant variation across clinical departments. In General Surgery patients, the most frequently preferred method was intravenous analgesia at 82.5%, followed by nerve block (1.6%), PCA (0.3%), and other combinations at lower rates. In the Obstetrics and Gynecology department, spinal analgesia was clearly predominant, being preferred in 71.5% of patients, while intravenous analgesia was used in 20.9%, and no analgesia was administered in 5.2% of cases. Among Orthopedics patients, intravenous analgesia (48.3%) and spinal analgesia (19.9%) were the most common methods, with nerve block applications reaching 12.2%, which was notably higher compared with other departments. In Thoracic Surgery, the most frequent method was intravenous analgesia at 50.0%, whereas in Neurosurgery, intravenous analgesia was used in 61.3% of patients, and the proportion of patients receiving no analgesia (37.1%) was remarkably high in this group. In Plastic Surgery, Urology, and Ophthalmology, intravenous methods were also predominantly preferred (71.4%, 30.6%, and 85.4%, respectively). In the ENT department, the proportion of patients receiving no analgesia was substantially high at 69.2%, and intravenous analgesia was administered in only 30.8% of cases. Across departments, the use of advanced analgesia techniques such as PCA and spinal+PCA remained at very low levels. Combined analgesia techniques (e.g., intravenous + nerve block) were applied to a limited extent in some departments, with the highest rate observed in Thoracic Surgery at 27.3%. These findings indicate that postoperative analgesia preferences vary considerably between surgical specialties (Table 5). Anesthesia techniques varied distinctly across surgical specialties. In General Surgery, Thoracic Surgery, Neurosurgery, Ophthalmology, ENT, and Interventional branches, nearly all patients underwent general anesthesia (98.0%, 100%, 99.2%, 100%, 100%, and 100%, respectively). In contrast, regional anesthesia was predominantly preferred in the Obstetrics and Gynecology clinic, where 74.1% of cases received regional anesthesia and 25.8% received general anesthesia. Among Orthopedics and Traumatology patients, the rate of general anesthesia was 66.3%, while regional anesthesia was used in 25.6% of cases; notably, nerve block application was higher in this group than in other specialties (8.1%). In Urology, the distribution between general (52.8%) and regional (47.2%) anesthesia was relatively balanced. In Plastic Surgery, 88.6% of patients underwent general anesthesia, with only a small proportion receiving regional or nerve block techniques. Overall, these findings demonstrate that anesthesia preferences differ substantially according to the surgical specialty (Table 6). Tranexamic acid usage by transfusion status showed a marked difference between groups. Among patients who did not receive a blood transfusion, 99.8% did not receive tranexamic acid, and only 0.2% received it. In contrast, the rate of tranexamic acid administration was substantially higher among patients who underwent transfusion, with 30.4% receiving the medication. These findings indicate that tranexamic acid use increased significantly in patients who required blood transfusion (Table 7). When comparing patients who required postoperative intensive care unit (ICU) admission with those who did not, the mean age of ICU-admitted patients was significantly higher (57.52 ± 19.12 vs. 36.93 ± 15.24, p<0.001). The proportion of trauma-related admissions was also markedly elevated in the ICU group (30.8%) compared with the non-ICU group (16.0%) (p<0.001). Regarding sex distribution, the ICU cohort exhibited a significantly higher proportion of males (64.4%), whereas the proportion of females was comparatively lower (p<0.001). A pronounced difference in ASA classification was observed between the groups. Most patients admitted to the ICU had higher ASA scores, predominantly ASA III (45.4%), ASA IV (29.2%), and ASA V (8.8%). Conversely, ASA II (69.7%) and ASA I (12.7%) were more frequent among patients who did not require ICU care (p<0.001). A similar pattern was noted for hemodynamic support: vasopressor/inotrope use was significantly more common in the ICU group (19.9%) compared with the non-ICU group (0.3%) (p<0.001). The need for blood transfusion was likewise substantially higher among ICU-admitted patients (32.1% vs. 3.6%, p<0.001). Collectively, these findings indicate that advanced age, trauma-related presentation, male sex, higher ASA classification, vasopressor requirement, and transfusion need are strongly associated with postoperative ICU admission (Table 8). In the multivariate logistic regression analysis, the independent variables associated with postoperative intensive care unit (ICU) admission were evaluated, and age was identified as a significant risk factor (OR: 1.027, 95% CI: 1.016–1.038, p<0.001). Each one-year increase in age was associated with a higher likelihood of requiring ICU care. Presentation due to trauma also emerged as an independent predictor; trauma patients demonstrated a 1.606-fold higher probability of ICU admission (p=0.027). An increase in ASA classification had a markedly strong effect, with each one-level rise in ASA score increasing the risk of ICU admission by approximately 4.4-fold (OR: 4.376, p<0.001). Hemodynamic support requirement was one of the strongest predictors in the model; the use of vasopressors or inotropes increased the odds of ICU admission by more than 24-fold (OR: 24.408, 95% CI: 6.935–85.909, p<0.001). Blood transfusion was likewise identified as an independent risk factor, with patients receiving transfusion exhibiting nearly a five-fold increase in the likelihood of ICU admission (OR: 4.952, p<0.001). These findings indicate that advanced age, trauma-related presentation, higher ASA classification, hemodynamic instability (vasopressor/inotrope requirement), and blood transfusion independently predict the need for postoperative ICU admission (Table 9). Discussion In this retrospective cohort study, anesthesia management, hemodynamic support, blood transfusion, airway interventions, and postoperative intensive care unit (ICU) requirement were comprehensively evaluated in a large adult population undergoing emergency surgical procedures between 2022 and 2023. The findings reaffirm that emergency surgery constitutes one of the highest-risk components of modern healthcare systems in terms of workload and complication burden. Data from the National Emergency Laparotomy Audit (NELA) and other multicenter studies consistently demonstrate that mortality and ICU utilization in emergency laparotomy and general emergency surgery are significantly higher than in elective procedures [20–22]. Our results support these observations, showing strong associations between ICU admission and advanced age, trauma-related presentation, higher ASA score, hemodynamic instability, and the need for blood transfusion. Although the mean age of our overall cohort was relatively young, the significantly higher age in the ICU-admitted group underscores age as an important risk determinant in emergency surgical populations. Studies in geriatric surgery and emergency laparotomy have noted that while advanced age does not always independently predict mortality, it remains closely associated with increased complication burden and ICU requirement [23–25]. Recent evidence further suggests that age should be interpreted alongside comorbidity burden, nutritional status, and functional capacity—an interpretation consistent with our findings highlighting the strong predictive value of ASA classification [21, 25]. In our study, each incremental increase in ASA class raised the likelihood of ICU admission by approximately 4.4-fold, reinforcing ASA classification as one of the most practical and widely applicable tools in emergency surgical risk assessment. In recent years, scoring models incorporating ASA—such as the Surgical Apgar Score plus ASA (“SASA”) and the Emergency Surgery Score—have been developed, and these models similarly identify ASA score, operative duration, intraoperative blood loss, and hemodynamic instability as independent predictors of ICU utilization [26–28]. Comparable findings from orthopedic surgery and elderly surgical populations also demonstrate that higher ASA scores and emergency surgical indication significantly increase ICU need and postoperative complication rates [29]. The markedly higher proportion of trauma patients in the ICU group suggests that the physiological burden of trauma and the presence of associated organ injuries likely contribute to greater hemodynamic fragility. Numerous studies have shown that hemorrhagic shock, inflammatory response, coagulopathy, and multiorgan involvement increase mortality and ICU requirement in trauma populations, with preoperative hypotension, sepsis, underlying malignancy, and frailty serving as important determinants [21, 30]. Consistent with these data, trauma emerged as an independent predictor of ICU admission in our multivariate analysis. The observation that vasopressor/inotrope requirement—signifying hemodynamic instability—increased ICU admission risk by nearly 24-fold emphasizes the pivotal importance of perioperative circulatory management in emergency surgery. Previous reports in both general surgical and mixed-ICU cohorts have demonstrated that postoperative inotropic support, low mean arterial pressure, and high physiological derangement scores are strongly associated with adverse outcomes and mortality [23, 31, 32]. Similarly, studies in emergency laparotomy and emergency abdominal surgery highlight that intraoperative hypotension, prolonged operative duration, and substantial blood loss significantly increase ICU utilization and postoperative complication indices [20, 21]. Blood transfusion also emerged as an important factor associated with ICU admission and adverse postoperative outcomes; transfused patients exhibited nearly a five-fold increase in ICU requirement. Current evidence indicates that intraoperative transfusion may reflect not only the severity of hemorrhage but also a heightened risk of infection, organ dysfunction, and prolonged hospital or ICU stay [21, 23, 32, 33]. Large-scale data analyses have resulted in the development of predictive models for perioperative transfusion requirement, in which age, ASA score, surgical category, preoperative anemia, and coagulopathy frequently appear as key variables [30, 33]. In our cohort, the significantly higher rate of tranexamic acid (TXA) use among transfused patients suggests selective administration in cases with anticipated high blood loss or trauma-related bleeding. Evidence from the CRASH-2 trial and subsequent analyses indicates that TXA, particularly when administered within the first three hours, reduces mortality in trauma patients without increasing thromboembolic complications and may decrease transfusion requirements [34–36]. Similar findings have been reported for traumatic brain injury and major trauma populations, although optimal patient selection and dosing strategies remain under debate [35]. While our data show that TXA use was concentrated among high-risk patients requiring transfusion, prospective studies are needed to determine its effects on mortality and postoperative complications. Regarding airway management, although the rate of endotracheal intubation in our cohort was high, the relatively low use of videolaryngoscopy is noteworthy. This finding is particularly interesting given that the incidence of difficult airway is higher in emergency and critically ill populations, and strong evidence from recent randomized trials and meta-analyses demonstrates that videolaryngoscopy improves first-attempt success, provides superior glottic visualization, and reduces complications such as esophageal intubation [37–39]. However, some meta-analyses emphasize that outcomes may be comparable between videolaryngoscopy and direct laryngoscopy in teams with extensive expertise, suggesting that videolaryngoscopy may not always be universally superior [40, 41]. These conflicting findings highlight the importance of institution-specific training, device availability, and clinical scenario-based airway algorithms. In our cohort, the higher use of videolaryngoscopy in specialties with a higher likelihood of difficult airway—such as otolaryngology and neurosurgery—illustrates how this awareness is reflected in clinical practice. Anesthetic techniques and postoperative analgesia strategies varied considerably across surgical specialties. The predominant use of regional anesthesia, particularly spinal techniques, in obstetric surgery aligns with current guidelines and large-scale obstetric series [42, 43]. In orthopedic surgery, the higher rate of peripheral nerve blocks and regional techniques corresponds with literature demonstrating that regional analgesia is associated with superior pain control, reduced opioid consumption, and—in some studies—shorter ICU or hospital stay [19, 44]. However, in emergency settings, regional anesthesia may not always be feasible due to limitations related to time, patient cooperation, and the need for hemodynamic stability; moreover, general anesthesia is often unavoidable in neurosurgical, thoracic, and high airway-risk cases [19, 43]. Our findings similarly show that general anesthesia rates in these specialties approached nearly 100%. Risk prediction models for identifying patients requiring postoperative ICU care have gained increasing prominence in emergency surgical practice. In this study, age, trauma, ASA classification, vasopressor/inotrope requirement, and transfusion emerged as independent predictors, consistent with established emergency surgery scores and ICU prediction models [23, 26, 27]. Previous studies on both elective and emergency surgical populations have demonstrated that age, higher ASA class, general anesthesia, obesity, hypotension, and preoperative sepsis increase the risk of unexpected ICU admission as well as mortality [24, 31, 45]. Our results confirm this emergency-specific risk profile and highlight the need to integrate intraoperative hemodynamic variables and transfusion requirements into ICU planning. From a clinical practice standpoint, these findings underscore the importance of enhancing preoperative risk stratification using ASA classification and emergency surgery-specific scoring systems, early ICU planning for high-risk patients, expanded and targeted use of advanced airway tools such as videolaryngoscopy and regional anesthesia techniques in appropriate scenarios, and the standardization of transfusion/TXA protocols based on evidence-based guidelines [19, 23, 27, 36]. Additionally, institution-level training programs and the implementation of standardized “difficult airway” and “massive transfusion” protocols may meaningfully improve patient safety and resource optimization. This study has several strengths, including its large sample size of 1,984 emergency surgical patients across diverse surgical specialties, the comprehensive dataset covering the entire perioperative course, and the identification of independent predictors of ICU requirement using multivariate analysis. However, the study also carries limitations: its retrospective design, the possibility of missing data, the single-center nature of the cohort, and the lack of long-term morbidity and mortality outcomes. As in similar reports in the literature, this study may not fully capture the complex nature of emergency surgery; thus, multicenter, prospective studies based on standardized databases are needed to validate our findings and to develop more refined risk-prediction models. Conclusion This large-scale retrospective analysis demonstrates that the need for postoperative ICU admission among emergency surgical patients is multifactorial and complex. Advanced age, trauma-related presentation, higher ASA score, intraoperative hemodynamic instability, and the requirement for blood transfusion emerged as the strongest independent determinants of ICU admission. Furthermore, notable interdepartmental variations in anesthetic techniques, airway management, and postoperative analgesia practices were observed, which may influence patient outcomes. Our findings highlight the importance of early identification of high-risk patients, enhanced hemodynamic optimization, broader implementation of safety-enhancing techniques such as videolaryngoscopy and regional anesthesia when appropriate, and standardized transfusion/TXA strategies. Overall, this study emphasizes the need for revisiting and strengthening clinical protocols in emergency surgery to improve patient safety and optimize ICU resource utilization. Multicenter prospective studies will be essential to validate these results and develop risk-based clinical decision support models. Declarations Previous Presentation in Conferences Not applicable. IRB Number Approved by the Health Sciences University Gülhane Scientific Research Ethics Committee (decision no. 2024/559; December 12, 2024) Research Registration Number Not applicable. Ethics approval and consent to participate This study was approved by the Health Sciences University Gülhane Scientific Research Ethics Committee (decision no. 2024/559 , dated December 12, 2024 ). All procedures were performed in accordance with the ethical standards of the World Medical Association Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent to participate was waived by the ethics committee. Consent for publication Not applicable. Availability of data and materials No additional research data are available outside the data presented in the submitted manuscript file. Competing interests The authors declare that they have no competing interests as defined by BMC, or any other interests that could be perceived to influence the results and/or discussion reported in this manuscript. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions Ş.Ç. conceived the study and wrote the main manuscript. B.E. and A.B.K.B. collected the data and contributed to data organization. E.E. developed the study concept and contributed to the methodological framework. B.U. and E.E. supervised the study and critically revised the manuscript. 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Outcomes and associated factors among patients undergone emergency laparotomy: A retrospective study. International Journal of Surgery Open. 2021;36:100413. Ylimartimo AT, Koskela M, Lahtinen S, Kaakinen T, Vakkala M, Liisanantti J. Outcomes in patients requiring intensive care unit (ICU) admission after emergency laparotomy: A retrospective study. Acta Anaesthesiol Scand. 2022;66(8):954-60. Ahmed M, Garry E, Moynihan A, Rehman W, Griffin J, Buggy DJ. Perioperative factors associated with postoperative morbidity after emergency laparotomy: a retrospective analysis in a university teaching hospital. Scientific Reports. 2020;10(1):16999. Hacım NA, Akbaş A, Ulgen Y, Aktokmakyan TV, Meric S, Tokocin M, et al. Association of Preoperative Risk Factors and Mortality in Older Patients following Emergency Abdominal Surgery: A Retrospective Cohort Study. Ann Geriatr Med Res. 2021;25(4):252-9. Tırnova I. Retrospective Analysis of Emergency Laparotomy and Laparoscopy Outcomes: A Single-center Experience Comparing Etiologies and Early Postoperative Results in Geriatric and Adult Patients. Comprehensive Medicine. 2025:317-22. Bumrungchatudom K, Chavez R, Tawanwongsri W, Puangrab S. Analysis of surgical apgar score combined with ASA classification (SASA) score in ICU and non-ICU patients following intra-abdominal surgery. Electronic Journal of General Medicine. 2025;22(5). Ghali MS, Hasan SA, Al-Qudimat AR, Alabidi M, Moustafa OS, Al-Zoubi RM. Validation of the emergency surgery score's predictive accuracy for postoperative outcomes and ICU admissions in MENA vs. non-MENA emergency surgery patients. Eur J Trauma Emerg Surg. 2025;51(1):216. Javanmard-Emamghissi H, Doleman B, Lund JN, Frisby J, Lockwood S, Hare S, et al. Quantitative futility in emergency laparotomy: an exploration of early-postoperative death in the National Emergency Laparotomy Audit. Tech Coloproctol. 2023;27(9):729-38. Tang Y, Li H, Guo Z. Prediction of ICU admission after orthopedic surgery in elderly patients. Pak J Med Sci. 2021;37(4):1179-84. Barazanchi AWH, Xia W, MacFater W, Bhat S, MacFater H, Taneja A, et al. Risk factors for mortality after emergency laparotomy: scoping systematic review. ANZ J Surg. 2020;90(10):1895-902. Girgin T, Sayur V, Guler E, Uc C, Goktepe B, Ersin S, et al. Predictors of Mortality in Surgical Patients Admitted to a Tertiary Intensive Care Unit. J Clin Med. 2025;14(18). Sim YS, Lee JH, Chang JH, Ryu YJ. Clinical Outcome and Prognosis of Patients Admitted to the Surgical ICU after Abdomen Surgery. The Korean Journal of Critical Care Medicine. 2015;30(1):1-7. Eyth A, Borngaesser F, Rudolph MI, Paschold B-S, Ramishvili T, Kaiser L, et al. Development and Validation of a Risk Model to Predict Intraoperative Blood Transfusion. JAMA Network Open. 2025;8(4):e255522-e. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. The Lancet. 2010;376(9734):23-32. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. The Lancet. 2019;394(10210):1713-23. Roberts I, Shakur H, Coats T, Hunt B, Balogun E, Barnetson L, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1-79. Alsabri M, Abdelwahab OA, Elsnhory AB, Diab RA, Sabesan V, Ayyan M, et al. Video laryngoscopy versus direct laryngoscopy in achieving successful emergency endotracheal intubations: a systematic review and meta-analysis of randomized controlled trials. Systematic Reviews. 2024;13(1):85. Prekker ME, Driver BE, Trent SA, Resnick-Ault D, Seitz KP, Russell DW, et al. Video versus Direct Laryngoscopy for Tracheal Intubation of Critically Ill Adults. N Engl J Med. 2023;389(5):418-29. Zhang K, Zhong C, Lou Y, Fan Y, Zhen N, Huang T, et al. Video laryngoscopy may improve the intubation outcomes in critically ill patients: a systematic review and meta-analysis of randomised controlled trials. Emerg Med J. 2025;42(5):334-42. Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. Crit Care. 2017;21(1):288. Li T, Jafari D, Meyer C, Voroba A, Haddad G, Abecassis S, et al. Video laryngoscopy is associated with improved first‐pass intubation success compared with direct laryngoscopy in emergency department trauma patients. JACEP Open. 2021;2(1):e12373. Li P, Li X, Peng G, Deng J, Li Q. Comparative analysis of general and regional anesthesia applications in geriatric hip fracture surgery. Medicine. 2025;104(2). O'Donnell CM, McLoughlin L, Patterson CC, Clarke M, McCourt KC, McBrien ME, et al. Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis. British Journal of Anaesthesia. 2018;120(1):37-50. Akbas S, Ozkan A, Korkmaz M. A comparison of general versus regional anesthesia in patients over 100 years old: A retrospective cohort study. Annals of Medical Research. 2021;28(11). Hailu S, Ayinie A, Amsalu H, Hailu S, Tadesse M, Mamo T, et al. Perioperative mortality and its predictors among patients undergoing emergency laparotomy at selected southern Ethiopian governmental hospitals, 2022: a multicenter prospective cohort study. Ann Med Surg (Lond). 2023;85(4):746-52. Tables Tables 1 to 9 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files table1.docx table2.docx table3.docx table4.docx table5.docx table6.docx table7.docx table8.docx table9.docx Cite Share Download PDF Status: Published Journal Publication published 06 Apr, 2026 Read the published version in Perioperative Medicine → Version 1 posted Editorial decision: Revision requested 22 Mar, 2026 Reviews received at journal 21 Mar, 2026 Reviewers agreed at journal 21 Mar, 2026 Reviewers invited by journal 20 Mar, 2026 Editor assigned by journal 19 Jan, 2026 Submission checks completed at journal 19 Jan, 2026 First submitted to journal 13 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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06:04:54","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":12881,"visible":true,"origin":"","legend":"","description":"","filename":"table9.docx","url":"https://assets-eu.researchsquare.com/files/rs-8591155/v1/88b6f85453346eca5ec48fd8.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative predictors of critical care admission following emergency surgical procedures: a comprehensive evaluation of anesthesia management","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEmergency surgery is recognized worldwide as one of the most demanding and high-risk components of modern healthcare systems. According to data from the United Kingdom, emergency procedures account for more than half of the overall surgical workload, and morbidity and mortality rates among these patients remain significantly higher compared with elective operations [1–3]. Many emergency surgery patients undergo operative intervention under substantial time pressure, leaving limited opportunity for comprehensive preoperative assessment. Factors such as a full stomach, hemodynamic instability, trauma-related organ injury, multiple comorbidities, advanced age, and electrolyte disturbances further complicate anesthetic management in this population [4–6].\u003c/p\u003e\n\u003cp\u003eAmong the major contributors to anesthetic risk in emergency settings, airway management challenges are of primary importance [7]. Endotracheal intubation may become difficult due to trauma, bleeding, facial anatomical disruption, or loss of spinal stability [8]. Previous literature consistently demonstrates that the incidence of difficult airway is markedly higher in emergency patients than in scheduled elective cases [9]. Consequently, the increasing adoption of advanced visualization tools such as videolaryngoscopy in emergency scenarios is considered an important step toward enhancing patient safety [10,11].\u003c/p\u003e\n\u003cp\u003eIn addition, a substantial proportion of emergency surgery patients exhibit a fragile hemodynamic profile due to hemorrhage, inflammatory response, sepsis, or polytrauma [12,13]. As a result, fluid resuscitation, transfusion therapy, and inotropic support are frequently required throughout the perioperative period [14,15]. Prior studies have also emphasized that patients requiring blood transfusion experience higher complication rates and an increased need for postoperative intensive care [16].\u003c/p\u003e\n\u003cp\u003eAlthough regional anesthesia may provide notable advantages in selected emergency conditions, its use is often limited by prolonged procedure duration and restricted patient cooperation; thus, general anesthesia remains the predominant technique in most centers [17]. Nevertheless, regional techniques continue to be widely used in certain disciplines, particularly obstetrics [18]. The impact of anesthetic modality on clinical outcomes in emergency surgery has not been fully elucidated, and a significant gap persists in current literature regarding this topic [19].\u003c/p\u003e\n\u003cp\u003eTherefore, the present study aimed to comprehensively evaluate anesthetic techniques, airway management strategies, hemodynamic interventions, transfusion requirements, and postoperative outcomes in a broad cohort of emergency surgery patients, and to identify independent risk factors associated with postoperative intensive care unit admission.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Health Sciences University Gülhane Scientific Research Ethics Committee (decision no. 2024/559; December 12, 2024). All procedures were conducted in accordance with the principles of the World Medical Association Declaration of Helsinki—Ethical Principles for Medical Research Involving Human Subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Selection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study included all adult patients who underwent emergency surgical procedures at our institution between 2022 and 2023. Following ethical approval, anesthesia records, surgical operation notes, electronic hospital information system data, and intensive care unit (ICU) follow-up records were reviewed consecutively and transferred into a standardized data collection form for analysis. A total of 1,984 patients who met the inclusion criteria constituted the study sample.\u003c/p\u003e\n\u003cp\u003eFor each patient, age, sex, type of admission (trauma/emergency), American Society of Anesthesiologists (ASA) physical status classification, duration of surgery, and the surgical department were recorded.\u003c/p\u003e\n\u003cp\u003eIntraoperative data included patient positioning (supine, prone, lithotomy, lateral, and others), anesthesia technique (general, spinal, combined, nerve block, sedation), and the general–regional anesthesia distinction. Airway management (spontaneous ventilation, laryngeal mask airway, endotracheal intubation, mask-cannula) and the use of videolaryngoscopy were documented as separate variables.\u003c/p\u003e\n\u003cp\u003ePeripheral intravenous access site (hand, arm, foot, multiple attempts), arterial catheter presence and type (radial, femoral, brachial), and central venous catheter presence and insertion site (internal jugular, subclavian, femoral) were systematically recorded for all patients.\u003c/p\u003e\n\u003cp\u003ePostoperative data included analgesia modalities (spinal, intravenous, patient-controlled analgesia [PCA], nerve block, and combinations thereof) and opioid administration. Additionally, allergic/anaphylactic reactions, vasopressor or inotropic requirements, blood transfusion, tranexamic acid administration, perioperative arrest/CPR, and mortality were noted. The presence of a nasogastric (NG) tube was evaluated in 697 patients with available documentation.\u003c/p\u003e\n\u003cp\u003eAdmission to the postoperative ICU served as the primary outcome variable. Patients who were and were not admitted to the ICU were compared in terms of demographic characteristics, perioperative findings, and intraoperative management.\u003c/p\u003e\n\u003cp\u003ePatients from general surgery, obstetrics and gynecology, orthopedics and traumatology, thoracic surgery, neurosurgery, plastic and reconstructive surgery, urology, ophthalmology, otorhinolaryngology, and interventional departments were additionally analyzed as subgroups to compare postoperative ICU requirement, arrest/CPR, blood transfusion, allergic reactions, invasive vascular access, videolaryngoscope use, and NG tube status.\u003c/p\u003e\n\u003cp\u003eFor each specialty, postoperative analgesia techniques and preferred anesthesia modalities were evaluated in a separate subgroup analysis. The use of tranexamic acid was compared between patients who did and did not receive blood transfusion, and its utilization rate among transfused patients was specifically documented.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDescriptive statistics for continuous variables were expressed as mean ± standard deviation and median (minimum–maximum, interquartile range [IQR]). Normality was assessed using the Shapiro–Wilk test. For non-normally distributed continuous variables, group comparisons were performed using the Mann–Whitney U test.\u003c/p\u003e\n\u003cp\u003eCategorical variables were summarized as numbers and percentages; comparisons between groups were made using the Chi-square Exact test. Independent risk factors for postoperative ICU admission were evaluated using multivariate logistic regression analysis. Statistical analyses were performed using IBM SPSS Statistics v20 (Chicago, IL, USA), and p\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1,984 patients were included in the study. The mean age of the patients was 39.46±17.29 years, with a median age of 34 (8–83) years. The mean duration of surgery was 107.63±61.87 minutes, and the median duration was 90 (0–520) minutes. Of all cases, 57.3% were female and 42.7% were male. Regarding the mode of admission, 82.2% of the patients underwent emergency surgery, while 17.8% required surgery due to trauma. According to the ASA classification, the largest group was ASA II with 62.9%, followed by ASA III (19.3%) and ASA I (11.5%). The clinics with the highest operation frequency were General Surgery at 37.4% and Obstetrics and Gynecology at 33.2%. An indwelling urinary catheter was present in 59.7% of the patients, and similarly, urine output was recorded intraoperatively in 59.1% of cases (Figure 1) (Table 1).\u003c/p\u003e\n\u003cp\u003eThe vast majority of patients (95.6%) were operated in the supine position, while other positions were used at markedly lower frequencies (prone 2.0%, lithotomy 1.3%, lateral 0.8%). Evaluation of anesthesia techniques showed that general anesthesia was administered in 65.7% of all cases, followed by spinal anesthesia at 29.1%. Overall, regional techniques accounted for approximately one-third of the cohort (29.8%), whereas nerve blocks and combined techniques were used at low rates. In airway management, the most frequently applied method was endotracheal intubation (59.1%), while 29.2% of the patients maintained spontaneous ventilation, 6.7% were managed with an LMA, and 5.0% with mask-cannula ventilation. Videolaryngoscopy was used in only 9.0% of cases, indicating that 91.0% of airway management was performed using conventional methods. Examination of peripheral intravenous access sites revealed that the hand (38.1%) and arm (34.7%) were the most commonly preferred locations, and multiple access attempts were required in 22.7% of the patients. Arterial catheterization was performed in 14.8% of patients, most commonly via the radial artery (14.2%). Central venous catheter placement was performed in 9.9% of cases, with the internal jugular vein being the most frequently used access route (8.9%) (Table 2).\u003c/p\u003e\n\u003cp\u003ePostoperative analgesia methods were evaluated, and more than half of the patients (52.6%) received intravenous analgesia, while spinal analgesia was administered in 28% of cases. In 10.4% of the patients, no postoperative analgesia method was used. Combined approaches such as intravenous analgesia with nerve block were applied in 4.7% of the patients, whereas patient-controlled analgesia (PCA), nerve blocks, or other combination techniques were utilized at considerably lower rates. Regarding postoperative opioid use, 54.5% of the patients did not receive any opioids, 42.6% were treated with Aldolan, and only 2.3% received morphine. Vasopressor or inotrope support was not required in 97.4% of the patients. Blood transfusion was performed in 7% of cases, and tranexamic acid was used in 2.3%. The postoperative arrest/CPR rate was low at 0.5%, and the overall mortality rate was 0.2%. Admission to the postoperative intensive care unit (ICU) occurred in 240 patients (12.1%). Among the 697 patients with available documentation, nasogastric tube placement was identified in 28.1%. These findings highlight the variability in postoperative interventions and clinical outcomes across a large and diverse patient cohort (Table 3).\u003c/p\u003e\n\u003cp\u003ePostoperative intensive care admission rates showed marked variability across clinical specialties. The need for ICU admission was relatively low in General Surgery, Obstetrics and Gynecology, and Orthopedics, with rates of 11.7%, 1.7%, and 6.6%, respectively. In contrast, Neurosurgery (63.7%) and Otorhinolaryngology (69.2%) exhibited substantially higher ICU admission rates. The requirement for ICU care in Thoracic Surgery was 22.7%, which was higher than that observed in other smaller surgical branches. Arrest/CPR rates remained extremely low across all departments, with only a small number of cases recorded in Thoracic Surgery (4.5%) and Otorhinolaryngology (7.7%).\u003c/p\u003e\n\u003cp\u003eBlood transfusion needs also varied significantly by specialty. Thoracic Surgery (31.8%) and Neurosurgery (25.8%) demonstrated the highest transfusion rates. In contrast, Plastic Surgery (2.9%), Ophthalmology, and Interventional units (5.0%) had very low transfusion requirements. Similarly, the incidence of allergy/anaphylaxis was low across all specialties, with only minimal cases reported. Central venous catheter placement was markedly more common in Thoracic Surgery (45.5%) and Neurosurgery (29.8%), while remaining limited in other departments. Arterial line insertion showed a similar pattern, being most frequent in Neurosurgery (69.4%) and Thoracic Surgery (68.2%).\u003c/p\u003e\n\u003cp\u003eVideolaryngoscope usage varied among specialties, with overall low rates; however, a notable increase was observed in Otorhinolaryngology, where it reached 53.8%. Vasopressor or inotrope requirements were most frequent in Thoracic Surgery (22.7%) and Neurosurgery (11.3%), while other specialties demonstrated very low rates. Mortality rates were exceedingly low in all departments, with only isolated cases reported. Among patients with available data, NG tube placement was most commonly documented in General Surgery and Obstetrics and Gynecology. These findings highlight substantial inter-specialty differences likely attributable to variations in patient populations and the nature of surgical procedures performed (Table 4).\u003c/p\u003e\n\u003cp\u003ePostoperative analgesia methods showed significant variation across clinical departments. In General Surgery patients, the most frequently preferred method was intravenous analgesia at 82.5%, followed by nerve block (1.6%), PCA (0.3%), and other combinations at lower rates. In the Obstetrics and Gynecology department, spinal analgesia was clearly predominant, being preferred in 71.5% of patients, while intravenous analgesia was used in 20.9%, and no analgesia was administered in 5.2% of cases. Among Orthopedics patients, intravenous analgesia (48.3%) and spinal analgesia (19.9%) were the most common methods, with nerve block applications reaching 12.2%, which was notably higher compared with other departments. In Thoracic Surgery, the most frequent method was intravenous analgesia at 50.0%, whereas in Neurosurgery, intravenous analgesia was used in 61.3% of patients, and the proportion of patients receiving no analgesia (37.1%) was remarkably high in this group.\u003c/p\u003e\n\u003cp\u003eIn Plastic Surgery, Urology, and Ophthalmology, intravenous methods were also predominantly preferred (71.4%, 30.6%, and 85.4%, respectively). In the ENT department, the proportion of patients receiving no analgesia was substantially high at 69.2%, and intravenous analgesia was administered in only 30.8% of cases. Across departments, the use of advanced analgesia techniques such as PCA and spinal+PCA remained at very low levels. Combined analgesia techniques (e.g., intravenous + nerve block) were applied to a limited extent in some departments, with the highest rate observed in Thoracic Surgery at 27.3%. These findings indicate that postoperative analgesia preferences vary considerably between surgical specialties (Table 5).\u003c/p\u003e\n\u003cp\u003eAnesthesia techniques varied distinctly across surgical specialties. In General Surgery, Thoracic Surgery, Neurosurgery, Ophthalmology, ENT, and Interventional branches, nearly all patients underwent general anesthesia (98.0%, 100%, 99.2%, 100%, 100%, and 100%, respectively). In contrast, regional anesthesia was predominantly preferred in the Obstetrics and Gynecology clinic, where 74.1% of cases received regional anesthesia and 25.8% received general anesthesia. Among Orthopedics and Traumatology patients, the rate of general anesthesia was 66.3%, while regional anesthesia was used in 25.6% of cases; notably, nerve block application was higher in this group than in other specialties (8.1%). In Urology, the distribution between general (52.8%) and regional (47.2%) anesthesia was relatively balanced. In Plastic Surgery, 88.6% of patients underwent general anesthesia, with only a small proportion receiving regional or nerve block techniques. Overall, these findings demonstrate that anesthesia preferences differ substantially according to the surgical specialty (Table 6).\u003c/p\u003e\n\u003cp\u003eTranexamic acid usage by transfusion status showed a marked difference between groups. Among patients who did not receive a blood transfusion, 99.8% did not receive tranexamic acid, and only 0.2% received it. In contrast, the rate of tranexamic acid administration was substantially higher among patients who underwent transfusion, with 30.4% receiving the medication. These findings indicate that tranexamic acid use increased significantly in patients who required blood transfusion (Table 7).\u003c/p\u003e\n\u003cp\u003eWhen comparing patients who required postoperative intensive care unit (ICU) admission with those who did not, the mean age of ICU-admitted patients was significantly higher (57.52 ± 19.12 vs. 36.93 ± 15.24, p\u0026lt;0.001). The proportion of trauma-related admissions was also markedly elevated in the ICU group (30.8%) compared with the non-ICU group (16.0%) (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eRegarding sex distribution, the ICU cohort exhibited a significantly higher proportion of males (64.4%), whereas the proportion of females was comparatively lower (p\u0026lt;0.001). A pronounced difference in ASA classification was observed between the groups. Most patients admitted to the ICU had higher ASA scores, predominantly ASA III (45.4%), ASA IV (29.2%), and ASA V (8.8%). Conversely, ASA II (69.7%) and ASA I (12.7%) were more frequent among patients who did not require ICU care (p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eA similar pattern was noted for hemodynamic support: vasopressor/inotrope use was significantly more common in the ICU group (19.9%) compared with the non-ICU group (0.3%) (p\u0026lt;0.001). The need for blood transfusion was likewise substantially higher among ICU-admitted patients (32.1% vs. 3.6%, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eCollectively, these findings indicate that advanced age, trauma-related presentation, male sex, higher ASA classification, vasopressor requirement, and transfusion need are strongly associated with postoperative ICU admission (Table 8).\u003c/p\u003e\n\u003cp\u003eIn the multivariate logistic regression analysis, the independent variables associated with postoperative intensive care unit (ICU) admission were evaluated, and age was identified as a significant risk factor (OR: 1.027, 95% CI: 1.016–1.038, p\u0026lt;0.001). Each one-year increase in age was associated with a higher likelihood of requiring ICU care. Presentation due to trauma also emerged as an independent predictor; trauma patients demonstrated a 1.606-fold higher probability of ICU admission (p=0.027).\u003c/p\u003e\n\u003cp\u003eAn increase in ASA classification had a markedly strong effect, with each one-level rise in ASA score increasing the risk of ICU admission by approximately 4.4-fold (OR: 4.376, p\u0026lt;0.001). Hemodynamic support requirement was one of the strongest predictors in the model; the use of vasopressors or inotropes increased the odds of ICU admission by more than 24-fold (OR: 24.408, 95% CI: 6.935–85.909, p\u0026lt;0.001). Blood transfusion was likewise identified as an independent risk factor, with patients receiving transfusion exhibiting nearly a five-fold increase in the likelihood of ICU admission (OR: 4.952, p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eThese findings indicate that advanced age, trauma-related presentation, higher ASA classification, hemodynamic instability (vasopressor/inotrope requirement), and blood transfusion independently predict the need for postoperative ICU admission (Table 9).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective cohort study, anesthesia management, hemodynamic support, blood transfusion, airway interventions, and postoperative intensive care unit (ICU) requirement were comprehensively evaluated in a large adult population undergoing emergency surgical procedures between 2022 and 2023. The findings reaffirm that emergency surgery constitutes one of the highest-risk components of modern healthcare systems in terms of workload and complication burden. Data from the National Emergency Laparotomy Audit (NELA) and other multicenter studies consistently demonstrate that mortality and ICU utilization in emergency laparotomy and general emergency surgery are significantly higher than in elective procedures [20–22]. Our results support these observations, showing strong associations between ICU admission and advanced age, trauma-related presentation, higher ASA score, hemodynamic instability, and the need for blood transfusion.\u003c/p\u003e\n\u003cp\u003eAlthough the mean age of our overall cohort was relatively young, the significantly higher age in the ICU-admitted group underscores age as an important risk determinant in emergency surgical populations. Studies in geriatric surgery and emergency laparotomy have noted that while advanced age does not always independently predict mortality, it remains closely associated with increased complication burden and ICU requirement [23–25]. Recent evidence further suggests that age should be interpreted alongside comorbidity burden, nutritional status, and functional capacity—an interpretation consistent with our findings highlighting the strong predictive value of ASA classification [21, 25].\u003c/p\u003e\n\u003cp\u003eIn our study, each incremental increase in ASA class raised the likelihood of ICU admission by approximately 4.4-fold, reinforcing ASA classification as one of the most practical and widely applicable tools in emergency surgical risk assessment. In recent years, scoring models incorporating ASA—such as the Surgical Apgar Score plus ASA (“SASA”) and the Emergency Surgery Score—have been developed, and these models similarly identify ASA score, operative duration, intraoperative blood loss, and hemodynamic instability as independent predictors of ICU utilization [26–28]. Comparable findings from orthopedic surgery and elderly surgical populations also demonstrate that higher ASA scores and emergency surgical indication significantly increase ICU need and postoperative complication rates [29].\u003c/p\u003e\n\u003cp\u003eThe markedly higher proportion of trauma patients in the ICU group suggests that the physiological burden of trauma and the presence of associated organ injuries likely contribute to greater hemodynamic fragility. Numerous studies have shown that hemorrhagic shock, inflammatory response, coagulopathy, and multiorgan involvement increase mortality and ICU requirement in trauma populations, with preoperative hypotension, sepsis, underlying malignancy, and frailty serving as important determinants [21, 30]. Consistent with these data, trauma emerged as an independent predictor of ICU admission in our multivariate analysis.\u003c/p\u003e\n\u003cp\u003eThe observation that vasopressor/inotrope requirement—signifying hemodynamic instability—increased ICU admission risk by nearly 24-fold emphasizes the pivotal importance of perioperative circulatory management in emergency surgery. Previous reports in both general surgical and mixed-ICU cohorts have demonstrated that postoperative inotropic support, low mean arterial pressure, and high physiological derangement scores are strongly associated with adverse outcomes and mortality [23, 31, 32]. Similarly, studies in emergency laparotomy and emergency abdominal surgery highlight that intraoperative hypotension, prolonged operative duration, and substantial blood loss significantly increase ICU utilization and postoperative complication indices [20, 21].\u003c/p\u003e\n\u003cp\u003eBlood transfusion also emerged as an important factor associated with ICU admission and adverse postoperative outcomes; transfused patients exhibited nearly a five-fold increase in ICU requirement. Current evidence indicates that intraoperative transfusion may reflect not only the severity of hemorrhage but also a heightened risk of infection, organ dysfunction, and prolonged hospital or ICU stay [21, 23, 32, 33]. Large-scale data analyses have resulted in the development of predictive models for perioperative transfusion requirement, in which age, ASA score, surgical category, preoperative anemia, and coagulopathy frequently appear as key variables [30, 33].\u003c/p\u003e\n\u003cp\u003eIn our cohort, the significantly higher rate of tranexamic acid (TXA) use among transfused patients suggests selective administration in cases with anticipated high blood loss or trauma-related bleeding. Evidence from the CRASH-2 trial and subsequent analyses indicates that TXA, particularly when administered within the first three hours, reduces mortality in trauma patients without increasing thromboembolic complications and may decrease transfusion requirements [34–36]. Similar findings have been reported for traumatic brain injury and major trauma populations, although optimal patient selection and dosing strategies remain under debate [35]. While our data show that TXA use was concentrated among high-risk patients requiring transfusion, prospective studies are needed to determine its effects on mortality and postoperative complications.\u003c/p\u003e\n\u003cp\u003eRegarding airway management, although the rate of endotracheal intubation in our cohort was high, the relatively low use of videolaryngoscopy is noteworthy. This finding is particularly interesting given that the incidence of difficult airway is higher in emergency and critically ill populations, and strong evidence from recent randomized trials and meta-analyses demonstrates that videolaryngoscopy improves first-attempt success, provides superior glottic visualization, and reduces complications such as esophageal intubation [37–39]. However, some meta-analyses emphasize that outcomes may be comparable between videolaryngoscopy and direct laryngoscopy in teams with extensive expertise, suggesting that videolaryngoscopy may not always be universally superior [40, 41]. These conflicting findings highlight the importance of institution-specific training, device availability, and clinical scenario-based airway algorithms. In our cohort, the higher use of videolaryngoscopy in specialties with a higher likelihood of difficult airway—such as otolaryngology and neurosurgery—illustrates how this awareness is reflected in clinical practice.\u003c/p\u003e\n\u003cp\u003eAnesthetic techniques and postoperative analgesia strategies varied considerably across surgical specialties. The predominant use of regional anesthesia, particularly spinal techniques, in obstetric surgery aligns with current guidelines and large-scale obstetric series [42, 43]. In orthopedic surgery, the higher rate of peripheral nerve blocks and regional techniques corresponds with literature demonstrating that regional analgesia is associated with superior pain control, reduced opioid consumption, and—in some studies—shorter ICU or hospital stay [19, 44]. However, in emergency settings, regional anesthesia may not always be feasible due to limitations related to time, patient cooperation, and the need for hemodynamic stability; moreover, general anesthesia is often unavoidable in neurosurgical, thoracic, and high airway-risk cases [19, 43]. Our findings similarly show that general anesthesia rates in these specialties approached nearly 100%.\u003c/p\u003e\n\u003cp\u003eRisk prediction models for identifying patients requiring postoperative ICU care have gained increasing prominence in emergency surgical practice. In this study, age, trauma, ASA classification, vasopressor/inotrope requirement, and transfusion emerged as independent predictors, consistent with established emergency surgery scores and ICU prediction models [23, 26, 27]. Previous studies on both elective and emergency surgical populations have demonstrated that age, higher ASA class, general anesthesia, obesity, hypotension, and preoperative sepsis increase the risk of unexpected ICU admission as well as mortality [24, 31, 45]. Our results confirm this emergency-specific risk profile and highlight the need to integrate intraoperative hemodynamic variables and transfusion requirements into ICU planning.\u003c/p\u003e\n\u003cp\u003eFrom a clinical practice standpoint, these findings underscore the importance of enhancing preoperative risk stratification using ASA classification and emergency surgery-specific scoring systems, early ICU planning for high-risk patients, expanded and targeted use of advanced airway tools such as videolaryngoscopy and regional anesthesia techniques in appropriate scenarios, and the standardization of transfusion/TXA protocols based on evidence-based guidelines [19, 23, 27, 36]. Additionally, institution-level training programs and the implementation of standardized “difficult airway” and “massive transfusion” protocols may meaningfully improve patient safety and resource optimization.\u003c/p\u003e\n\u003cp\u003eThis study has several strengths, including its large sample size of 1,984 emergency surgical patients across diverse surgical specialties, the comprehensive dataset covering the entire perioperative course, and the identification of independent predictors of ICU requirement using multivariate analysis. However, the study also carries limitations: its retrospective design, the possibility of missing data, the single-center nature of the cohort, and the lack of long-term morbidity and mortality outcomes. As in similar reports in the literature, this study may not fully capture the complex nature of emergency surgery; thus, multicenter, prospective studies based on standardized databases are needed to validate our findings and to develop more refined risk-prediction models.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis large-scale retrospective analysis demonstrates that the need for postoperative ICU admission among emergency surgical patients is multifactorial and complex. Advanced age, trauma-related presentation, higher ASA score, intraoperative hemodynamic instability, and the requirement for blood transfusion emerged as the strongest independent determinants of ICU admission. Furthermore, notable interdepartmental variations in anesthetic techniques, airway management, and postoperative analgesia practices were observed, which may influence patient outcomes. Our findings highlight the importance of early identification of high-risk patients, enhanced hemodynamic optimization, broader implementation of safety-enhancing techniques such as videolaryngoscopy and regional anesthesia when appropriate, and standardized transfusion/TXA strategies. Overall, this study emphasizes the need for revisiting and strengthening clinical protocols in emergency surgery to improve patient safety and optimize ICU resource utilization. Multicenter prospective studies will be essential to validate these results and develop risk-based clinical decision support models.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003ePrevious Presentation in Conferences\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIRB Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproved by the Health Sciences University G\u0026uuml;lhane Scientific Research Ethics Committee (decision no. 2024/559; December 12, 2024)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearch Registration Number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Health Sciences University G\u0026uuml;lhane Scientific Research Ethics Committee (decision no.\u003cstrong\u003e\u0026nbsp;2024/559\u003c/strong\u003e, dated \u003cstrong\u003eDecember 12, 2024\u003c/strong\u003e). All procedures were performed in accordance with the ethical standards of the World Medical Association Declaration of Helsinki. Due to the retrospective nature of the study, the requirement for informed consent to participate was waived by the ethics committee.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo additional research data are available outside the data presented in the submitted manuscript file.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests as defined by BMC, or any other interests that could be perceived to influence the results and/or discussion reported in this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eŞ.\u0026Ccedil;. conceived the study and wrote the main manuscript. B.E. and A.B.K.B. collected the data and contributed to data organization. E.E. developed the study concept and contributed to the methodological framework. B.U. and E.E. supervised the study and critically revised the manuscript. All authors reviewed and approved the final manuscript and take responsibility for the integrity of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank the operating room and anesthesia teams for their contributions to perioperative data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMai-Phan TA, Patel B, Walsh M, Abraham AT, Kocher HM. Emergency room surgical workload in an inner city UK teaching hospital. World Journal of Emergency Surgery. 2008;3(1):19.\u003c/li\u003e\n\u003cli\u003eRamsay G, Wohlgemut JM, Jansen JO. Emergency general surgery in the United Kingdom: A lot of general, not many emergencies, and not much surgery. 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Comparative analysis of general and regional anesthesia applications in geriatric hip fracture surgery. Medicine. 2025;104(2).\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Donnell CM, McLoughlin L, Patterson CC, Clarke M, McCourt KC, McBrien ME, et al. Perioperative outcomes in the context of mode of anaesthesia for patients undergoing hip fracture surgery: systematic review and meta-analysis. British Journal of Anaesthesia. 2018;120(1):37-50.\u003c/li\u003e\n\u003cli\u003eAkbas S, Ozkan A, Korkmaz M. A comparison of general versus regional anesthesia in patients over 100 years old: A retrospective cohort study. Annals of Medical Research. 2021;28(11).\u003c/li\u003e\n\u003cli\u003eHailu S, Ayinie A, Amsalu H, Hailu S, Tadesse M, Mamo T, et al. Perioperative mortality and its predictors among patients undergoing emergency laparotomy at selected southern Ethiopian governmental hospitals, 2022: a multicenter prospective cohort study. Ann Med Surg (Lond). 2023;85(4):746-52.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 9 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"perioperative-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"peri","sideBox":"Learn more about [Perioperative Medicine](http://perioperativemedicinejournal.biomedcentral.com)","snPcode":"13741","submissionUrl":"https://submission.nature.com/new-submission/13741/3","title":"Perioperative Medicine","twitterHandle":"@EMSurgeryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Anesthesia, Emergency Surgical Procedures, Hemodynamic Phenomena, Intensive Care Units, Perioperative Care, Risk Factors","lastPublishedDoi":"10.21203/rs.3.rs-8591155/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8591155/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eEmergency surgical procedures carry substantial risk, with increased morbidity, mortality, and unplanned intensive care unit (ICU) admissions. Identifying perioperative factors associated with postoperative ICU requirement is essential for improving outcomes and optimizing resource allocation. This study evaluated anesthesia management practices in a large emergency surgery cohort and investigated independent predictors of postoperative ICU admission.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study included 1,984 patients who underwent emergency surgical procedures at a tertiary center between 2022 and 2023. Demographics, trauma status, ASA classification, airway management, anesthetic technique, hemodynamic support, transfusion, and postoperative analgesia were recorded. The primary endpoint was postoperative ICU admission.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe ICU admission rate was 12.1%. ICU-admitted patients were older (57.5\u0026thinsp;\u0026plusmn;\u0026thinsp;19.1 vs. 36.9\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 years, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and more frequently presented with trauma (30.8% vs. 16.0%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Higher ASA scores, vasopressor or inotrope use (19.9% vs. 0.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and transfusion (32.1% vs. 3.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were strongly associated with ICU need. Multivariate analysis identified age (OR 1.027), trauma (OR 1.606), ASA score (OR 4.376), vasopressor or inotrope use (OR 24.408), and transfusion (OR 4.952) as independent predictors (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Specialties showed notable variation in anesthetic technique and postoperative practices.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003ePostoperative ICU requirement in emergency surgery is influenced by advanced age, trauma, elevated ASA status, hemodynamic instability, and transfusion. Recognizing these predictors may improve risk stratification, perioperative planning, and ICU resource utilization. Standardizing anesthesia protocols and strengthening hemodynamic optimization strategies may enhance patient safety in emergency surgical settings.\u003c/p\u003e","manuscriptTitle":"Perioperative predictors of critical care admission following emergency surgical procedures: a comprehensive evaluation of anesthesia management","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-25 06:04:49","doi":"10.21203/rs.3.rs-8591155/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-23T03:48:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T17:27:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126132413419957926379518346925067388120","date":"2026-03-21T08:06:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-20T05:49:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T10:29:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T10:27:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"Perioperative Medicine","date":"2026-01-13T10:58:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"perioperative-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"peri","sideBox":"Learn more about [Perioperative Medicine](http://perioperativemedicinejournal.biomedcentral.com)","snPcode":"13741","submissionUrl":"https://submission.nature.com/new-submission/13741/3","title":"Perioperative Medicine","twitterHandle":"@EMSurgeryBMC","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cb88e073-614d-42a4-aeac-f007ff18618d","owner":[],"postedDate":"March 25th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:03:52+00:00","versionOfRecord":{"articleIdentity":"rs-8591155","link":"https://doi.org/10.1186/s13741-026-00677-2","journal":{"identity":"perioperative-medicine","isVorOnly":false,"title":"Perioperative Medicine"},"publishedOn":"2026-04-06 15:59:06","publishedOnDateReadable":"April 6th, 2026"},"versionCreatedAt":"2026-03-25 06:04:49","video":"","vorDoi":"10.1186/s13741-026-00677-2","vorDoiUrl":"https://doi.org/10.1186/s13741-026-00677-2","workflowStages":[]},"version":"v1","identity":"rs-8591155","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8591155","identity":"rs-8591155","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}