Optimization of the High-Risk Surgical Patient

  • Nawaf Al-Subaie
  • Andrew Rhodes


The normal acute physiological response to critical illness is to increase the oxygen delivery and consumption. Normal values are considered abnormal in the context of acute critical illness, and patients who achieve specific supra-normal hemodynamic variables have a better outcome. This forms the basis of optimization as these hemodynamic variables attained by survivors become a therapeutic target that achieved artificially by the use of intravenous fluids and inotropes under the guidance of cardiac output monitoring. This approach has been shown to improve the tissue oxygenation and prevents organ dysfunction and death in the high-risk patients undergoing major surgery.1,2 This chapter focuses on the perioperative optimization and the reader should refer to relevant chapters for the specific management of trauma and sepsis.


Stroke Volume Oxygen Delivery Fluid Challenge Cardiac Output Monitoring Intravenous Fluid Administration 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest. 1988;94:1176–1186.PubMedCrossRefGoogle Scholar
  2. 2.
    Boyd O, Grounds RM, Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA. 1993;270:2699–2707.PubMedCrossRefGoogle Scholar
  3. 3.
    Grounds RM. Reducing mortality and complications in patients undergoing surgery at high risk for post operative complications and death. In: Adams AP, Cashman JN, Grounds RM, editors. Recent advances in anaesthesia and intensive care 2003;22:117–133.Google Scholar
  4. 4.
    Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297:845–850.PubMedCrossRefGoogle Scholar
  5. 5.
    Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78:355–360.PubMedCrossRefGoogle Scholar
  6. 6.
    Older P, Smith R, Courtney P, Hone R. Preoperative evaluation of cardiac failure and ischemia in elderly patients by cardiopulmonary exercise testing. Chest. 1993;104:701–704.PubMedCrossRefGoogle Scholar
  7. 7.
    Older P, Hall A. Clinical review: how to identify high-risk surgical patients. Crit Care. 2004;8:369–372.PubMedCrossRefGoogle Scholar
  8. 8.
    Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery: focused update on perioperative beta-blocker therapy: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) developed in collaboration with the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society for Vascular Medicine and Biology. J Am Coll Cardiol. 2006;47:2343–2355.PubMedCrossRefGoogle Scholar
  9. 9.
    Shoemaker WC. Cardiorespiratory patterns of surviving and nonsurviving postoperative patients. Surg Gynecol Obstet. 1972;134:810–814.PubMedGoogle Scholar
  10. 10.
    Wilson J, Woods I, Fawcett J, et al. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ. 1999;318:1099–1103.PubMedCrossRefGoogle Scholar
  11. 11.
    Starling EH, Visscher MB. The regulation of the energy output of the heart. J Physiol. 1927;62(3):243–261.PubMedGoogle Scholar
  12. 12.
    Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. 1999;27(1):200–210.PubMedCrossRefGoogle Scholar
  13. 13.
    Schierhout G, Roberts I. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ. 1998;316:961–964.PubMedCrossRefGoogle Scholar
  14. 14.
    Moon PF, Hollyfield-Gilbert MA, Myers TL, Kramer GC. Effects of isotonic crystalloid resuscitation on fluid compartments in hemorrhaged rats. Shock. 1994;2:355–361.PubMedCrossRefGoogle Scholar
  15. 15.
    Grocott MP, Mythen MG, Gan TJ. Perioperative fluid management and clinical outcomes in adults. Anesth Analg. 2005;100(4):1093–1106.PubMedCrossRefGoogle Scholar
  16. 16.
    Vincent JL, Weil MH. Fluid challenge revisited. Crit Care Med. 2006;34:1333–1337.PubMedCrossRefGoogle Scholar
  17. 17.
    Williams G, Grounds M, Rhodes A. Pulmonary artery catheter. Curr Opin Crit Care. 2002;8(3):251–256.PubMedCrossRefGoogle Scholar
  18. 18.
    Singer M, Bennett ED. Noninvasive optimization of left ventricular filling using esophageal Doppler. Crit Care Med. 1991;19:1132–1137.PubMedCrossRefGoogle Scholar
  19. 19.
    Linton RA, Band DM, Haire KM. A new method of measuring cardiac output in man using lithium dilution. Br J Anaesth. 1993;71:262–266.PubMedCrossRefGoogle Scholar
  20. 20.
    Stewart GN. Researches on the circulation time and on the influences which affect it. IV. The output of the heart. J Physiol. 1897;22:159–183.PubMedGoogle Scholar
  21. 21.
    Polonen P, Ruokonen E, Hippelainen M, Poyhonen M, Takala J. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg. 2000;90:1052–1059.PubMedCrossRefGoogle Scholar
  22. 22.
    Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345:1368–1377.PubMedCrossRefGoogle Scholar
  23. 23.
    Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Changes in central venous saturation after major surgery, and association with outcome. Crit Care. 2005;9:R694–R699.PubMedCrossRefGoogle Scholar
  24. 24.
    Brown RA, Dixon J, Farmer JB, et al. Dopexamine: a novel agonist at peripheral dopamine receptors and beta 2-adrenoceptors. Br J Pharmacol. 1985;85:599–608.PubMedCrossRefGoogle Scholar
  25. 25.
    Bennett ED. Dopexamine: much more than a vasoactive agent. Crit Care Med. 1998;26:1621–1622.PubMedCrossRefGoogle Scholar
  26. 26.
    Kern JW, Shoemaker WC. Meta-analysis of hemodynamic optimization in high-risk patients. Crit Care Med. 2002;30:1686–1692.PubMedCrossRefGoogle Scholar
  27. 27.
    Mythen MG, Webb AR. Perioperative plasma volume expansion reduces the incidence of gut mucosal hypoperfusion during cardiac surgery. Arch Surg. 1995;130:423–429.PubMedCrossRefGoogle Scholar
  28. 28.
    Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. BMJ. 1997;315:909–912.PubMedCrossRefGoogle Scholar
  29. 29.
    Gan TJ, Soppitt A, Maroof M, et al. Goal-directed intraoperative fluid administration reduces length of hospital stay after major surgery. Anesthesiology. 2002;97:820–826.PubMedCrossRefGoogle Scholar
  30. 30.
    Wakeling HG, McFall MR, Jenkins CS, et al. Intraoperative oesophageal Doppler guided fluid management shortens postoperative hospital stay after major bowel surgery. Br J Anaesth. 2005;95:634–642.PubMedCrossRefGoogle Scholar
  31. 31.
    Noblett SE, Snowden CP, Shenton BK, Horgan AF. Randomized clinical trial assessing the effect of Doppler-optimized fluid management on outcome after elective colorectal resection. Br J Surg. 2006;93:1069–1076.PubMedCrossRefGoogle Scholar
  32. 32.
    Pearse R, Dawson D, Fawcett J, Rhodes A, Grounds RM, Bennett ED. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial. Crit Care. 2005;9:R687–R693.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Nawaf Al-Subaie
    • 1
  • Andrew Rhodes
    • 2
  1. 1.Anaesthesia and Intensive Care MedicineSt. George’s HospitalLondonUK
  2. 2.Department of Intensive Care MedicineSt. George’s HospitalLondonUK

Personalised recommendations