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

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.