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

Abstract

Objectives To determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery, and to determine whether the inotropes, adrenaline and dopexamine, used to enhance oxygen delivery influence outcome. Design Randomised controlled trial with double blinding between inotrope groups. Setting York District Hospital, England. Subjects 138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions. Interventions Patients were randomised into three groups. Two groups received invasive haemodynamic monitoring, fluid, and either adrenaline or dopexamine to increase oxygen delivery. Inotropic support was continued during surgery and for at least 12 hours afterwards. The third group (control) received routine perioperative care. Main outcome measures Hospital mortality and morbidity. Results Overall, 3/92 (3%) preoptimised patients died compared with 8/46 controls (17%) (P = 0.007). There were no differences in mortality between the treatment groups, but 14/46 (30%) patients in the dopexamine group developed complications compared with 24/46 (52%) patients in the adrenaline group (difference 22%, 95% confidence interval 2% to 41%) and 28 patients (61%) in the control group (31%, 11% to 50%). The use of dopexamine was associated with a decreased length of stay in hospital. Conclusion Routine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care.

Pre-operative optimisation employing dopexamine or adrenaline for patients undergoing major elective surgery: a cost-effectiveness analysis

“…1). The results showed a significant reduction in hospital mortality associated with pre-op (3%) compared with standard patient management (17%) and a reduction in morbidity associated with pre-op employing dopexamine (30%) compared with that employing adrenaline (53%) and standard patient management (61%) [3].…”

“…The design, baseline characteristics and clinical results of the study have been published elsewhere [3]. In brief, the trial included patients undergoing major elective surgical procedures in general surgery, vascular surgery or urology who had been identified as being at high risk of developing peri-operative complications.…”

“…In particular, the use of dopexamine was associated with a significantly shorter hospital stay [3]. This paper presents the results of a retrospective economic analysis of that trial.…”

“…Clinical trials have shown pre-operative optimisation (pre-op) to reduce the risk of complications and death in high-risk patients undergoing major elective surgery [1,2,3]. There is also evidence that the use of pre-op results in reduced hospital costs [1,2] and that it constitutes a cost-effective method of managing high-risk surgery [4].…”

“…A recent trial of pre-op [3] compared standard peri-operative patient management with pre-op in high-risk patients undergoing major elective surgery. In addition, the trial assessed the relative performance of the inotropesadrenaline and dopexamine -given to enhance oxygen delivery.…”