Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery

BMJ 1999;318:1099-1103 ( 24 April )

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Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery

Editorial by Treasure and Bennett

Jonathan Wilson, consultant, ^a Ian Woods, consultant, ^a Jayne Fawcett, research nurse, ^b Rebecca Whall, research nurse, ^b Wendy Dibb, research nurse, ^b Chris Morris, research nurse, ^b Elizabeth McManus, senior pharmacist. ^c

^a Department of Anaesthetics, York District Hospital, York YO31 8HE, ^b Intensive Care Unit, York District Hospital, ^c Pharmacy, York District Hospital

Correspondence to: Dr Wilson jonathan{at}critbase.demon.co.uk

Objectives: To determine whether preoperative optimisationof oxygen delivery improves outcome after major elective surgery,and to determine whether the inotropes, adrenaline and dopexamine,used to enhance oxygen delivery influenceoutcome.
Design: Randomised controlled trial with double blindingbetween inotropegroups.
Setting: York District Hospital,England.
Subjects: 138 patients undergoing major elective surgerywho were at risk of developing postoperative complications eitherbecause of the surgery or the presence of coexistent medicalconditions.
Interventions: Patients were randomised into three groups.Two groups received invasive haemodynamic monitoring, fluid, andeither adrenaline or dopexamine to increase oxygen delivery. Inotropicsupport was continued during surgery and for at least 12 hoursafterwards. The third group (control) received routine perioperativecare.
Main outcome measures: Hospital mortality andmorbidity.
Results: Overall, 3/92 (3%) preoptimised patients diedcompared with 8/46 controls (17%) (P=0.007). There were no differencesin mortality between the treatment groups, but 14/46 (30%) patientsin the dopexamine group developed complications compared with24/46 (52%) patients in the adrenaline group (difference 22%,95% confidence interval 2% to 41%) and 28 patients (61%) in thecontrol group (31%, 11% to 50%). The use of dopexamine was associatedwith a decreased length of stay inhospital.
Conclusion: Routine preoperative optimisation of patientsundergoing major elective surgery would be a significant and costeffective improvement in perioperativecare.

Key messages

Major elective surgery in UK general hospitals still carries significant mortality and morbidity
Preoperative administration of fluid and inotropes, guided by invasive monitoring, can significantly reduce mortality, morbidity, and length of hospital stay
The choice of inotrope may influence the extent of improvements in outcome
Routine preoperative optimisation would require initial investment in high dependency care facilities but is likely to be cost effective by reducing complications and length of hospital stay

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Reducing the risk of major elective surgery: S Sudhindran, Imogen Mitchell, David Bihari, R O Feneck, P E Hersch, A S Kong, R Howard-Griffi, Jonathan Wilson, and Ian Woods
BMJ 1999 319: 1369. [Extract] [Full Text]

Managing chronic disease
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Managing chronic disease
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Fluids and inotropes reduce the risk of major elective surgery
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Reducing the risk of major elective surgery: Tom Treasure and David Bennett
BMJ 1999 318: 1087-1088. [Extract] [Full Text] [PDF]

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Rapid Responses:

Read all Rapid Responses

Concern re elective surgery mortality: Robert Nesbit
bmj.com, 27 Apr 1999 [Full text]
Reducing the risk of major elective surgery; cardiac reserves need more careful assessment: S R Haynes
bmj.com, 29 Apr 1999 [Full text]
Risk of major surgery: why not just give more fluid?: Neville W Goodman
bmj.com, 30 Apr 1999 [Full text]
Perioperative optimization of oxygen delivery: David Bihari
bmj.com, 30 Apr 1999 [Full text]
Preoperative optimisation of oxygen delivery- conclusions are misleading: Jonathan Thompson
bmj.com, 30 Apr 1999 [Full text]
Does this paper show a benefit from pre-operative optimisation of oxygen delivery?: George Harrison
bmj.com, 3 May 1999 [Full text]
Non-surgical alternatives to major elective surgery: Tom Oommen
bmj.com, 4 May 1999 [Full text]
Could Preoperative Optimisation be achieved by House Officers?: J H Winn
bmj.com, 5 May 1999 [Full text]
Choice of fluids for optimisation: Jon Henrik Laake
bmj.com, 7 May 1999 [Full text]
Reducing the risk of major elective surgery: R O Feneck
bmj.com, 7 May 1999 [Full text]
What exactly reduces the risk of major elective surgery?: A S Kong
bmj.com, 14 May 1999 [Full text]
Details of mortality: S Sudhindran
bmj.com, 17 May 1999 [Full text]
Re: Reducing the risk of major elective surgery; cardiac reserves need more careful assessment: J Kurian
bmj.com, 17 May 1999 [Full text]
Death rate in the control group too high: W J Fawcett
bmj.com, 24 May 1999 [Full text]
Untitled: Ian Pope
bmj.com, 24 Jun 1999 [Full text]