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Death following surgery remains a major cause of death worldwide, and ICU admission following major surgery is considered a standard of care in many healthcare systems. However, ICU resources are finite and expensive, thus identifying those most likely to benefit is of great importance.Advances in surgical and perioperative management have moved the focus of postoperative care to preventing complications and reducing duration of hospitalisation. Recent health services research has failed to find association between ICU admission and improved outcome in many types of elective major noncardiac surgery. Use of alternatives to ICU such as post anaesthesia care units (PACUs), high dependency units (HDUs) or specialist wards with enhanced nursing care are able to perform some elements of ICU monitoring in a less intensive environment, and may provide a better alternative to the traditional model of ICU admission for many patients having major surgery. ICU admission should still be considered for very high-risk patients and those having complex or emergency surgery. Improved triage tools are required to identify those at the highest risk of death or complications.Identifying those most at risk of death and complications following surgery and preventing them is the major challenge of perioperative care in the coming decades. Future research should focus on how postoperative care can best be structured to provide optimum care to patients within available resources. Incidence of complications or failure to rescue (FtR) may provide useful metrics in future research.