High-Risk Surgical Patients: Why We Should Pre-Optimize

  • B. Vallet
  • G. Lebuffe
  • E. Wiel
Conference paper


In the United Kingdom, a recent analysis of an intensive care unit (ICU) database reported that surgical patients represented 45% of total ICU admissions with an important mortality rate since 20.1% of them died [1]. A surgical patient is considered at high risk if their preoperative status is altered or if the surgical procedure is prolonged and/or associated with heavy blood loss. Many attempts have been made to identify such patients early and to evaluate the impact of perioperative therapeutic optimization on outcome. In 1979, Shoemaker et al. [2] defined criteria for high surgical risk. These included:
  • patient history: age more than 70 years with evidence of limited major physiologic function, previous severe cardiopulmonary or vascular illness, severe nutritional disorders

  • critical factors: severe multiple trauma, massive acute blood loss, shock, septicemia or septic shock, respiratory failure, acute abdominal catastrophe, acute intestinal or renal failure

  • surgical procedure factors: extensive surgery for cancer or prolonged surgery more than 8 hours.


Oxygen Delivery Major Abdominal Surgery Hemodynamic Optimization Severe Multiple Trauma Distant Organ Injury 
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.


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  1. 1.
    Grounds RM, Rhodes A, Bennett ED (2001) Reducing surgical mortality and complications. In: Vincent JL (ed) Yearbook of Intensive Care and Emergency Medicine: Springer, Heidelberg, pp 57–67Google Scholar
  2. 2.
    Shoemaker WC, Czer LS (1979) Evaluation of the biologic importance of various hemodynamic and oxygen transport variables: which variables should be monitored in postoperative shock? Crit Care Med 7: 424–431PubMedCrossRefGoogle Scholar
  3. 3.
    Boyd A, Tremblay R, Spencer F (1959) Estimation of cardiac output soon after intracardiac surgery with cardiopulmonary bypass. Ann Surg 150: 613–625PubMedCrossRefGoogle Scholar
  4. 4.
    Clowes GJ, Vucinic M, Weidner M (1966) Circulatory and metabolic alterations associated with survival or death in peritonitis: clinical analysis of 25 cases. Ann Surg 163: 866–885PubMedCrossRefGoogle Scholar
  5. 5.
    Lebuffe G, Decoene C, Pol A, Prat A, Vallet B (1999) Regional capnometry with air-automated tonometry detects circulatory failure earlier than conventional hemodynamics after cardiac surgery. Anesth Analg 89: 1084–1090PubMedCrossRefGoogle Scholar
  6. 6.
    Bennett-Guerrero E, Panah MH, Bodian CA, et al (2000) Automated detection of gastric luminal partial pressure of carbon dioxide during cardiovascular surgery using the Tonocap. Anesthesiology 92: 38–45PubMedCrossRefGoogle Scholar
  7. 7.
    Miller PR, Kincaid EH, Meredith JW, Chang MC (1998) Threshold values of intramucosal pH and mucosal-arterial CO2 gap during shock resuscitation. J Trauma 45: 868–872PubMedCrossRefGoogle Scholar
  8. 8.
    Pittet JF, Pastor CM, Morel DR (2000) Spontaneous high systemic oxygen delivery increases survival rate in awake sheep during sustained endotoxemia. Crit Care Med 28: 496–503PubMedCrossRefGoogle Scholar
  9. 9.
    Shoemaker WC, Appel PL, Kram HB, Waxman K, Lee TS (1988) Prospective trial of supra-normal values of survivors as therapeutic goals in high-risk surgical patients. Chest 94: 1176–1186PubMedCrossRefGoogle Scholar
  10. 10.
    Hayes MA, Timmins AC, Yau EH, Palazzo M, Hinds CJ, Watson D (1994) Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 330: 17171722Google Scholar
  11. 11.
    Vallet B, Chopin C, Curtis SE, et al (1993) Prognostic value of the dobutamine test in patients with sepsis syndrome and normal lactate values: a prospective, multicenter study. Crit Care Med 21: 1868–1875PubMedCrossRefGoogle Scholar
  12. 12.
    Rhodes A, Lamb FJ, Malagon I, Newman PJ, Grounds RM, Bennett ED (1999) A prospective study of the use of a dobutamine stress test to identify outcome in patients with sepsis, severe sepsis, or septic shock. Crit Care Med 27: 2361–2366PubMedCrossRefGoogle Scholar
  13. 13.
    Bhatt SB, Hutchinson RC, Tomlinson B, Oh TE, Mak M (1992) Effect of dobutamine on oxygen supply and uptake in healthy volunteers. Br J Anaesth 69: 298–303PubMedCrossRefGoogle Scholar
  14. 14.
    Vallet B, Chopin C (2000) The supranormal oxygen delivery trials controversy. Dobutamine in Sepsis Study Group. Crit Care Med 28: 1257–1258Google Scholar
  15. 15.
    Rivers E, Nguyen B, Haystad S, et al (2001) Early goal-irected therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345: 1368–1377PubMedCrossRefGoogle Scholar
  16. 16.
    Heyland DK, Cook DJ, King D, Kernerman P, Brun-Buisson C (1996) Maximizing oxygen delivery in critically ill patients: a methodologic appraisal of the evidence. Crit Care Med 24: 517–524PubMedCrossRefGoogle Scholar
  17. 17.
    Boyd 0, Grounds RM, Bennett ED (1993) A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 270: 2699–2707PubMedCrossRefGoogle Scholar
  18. 18.
    Wilson J, Woods I, Fawcett J, et al (1999) Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. Br Med J 318: 1099–1103CrossRefGoogle Scholar
  19. 19.
    Takala J, Meier-Hellmann A, Eddleston J, Hulstaert P, Sramek V (2000) Effect of dopexamine on outcome after major abdominal surgery: a prospective, randomized, controlled multicenter study. European Multicenter Study Group on Dopexamine in Major Abdominal Surgery. Crit Care Med 28: 3417–3423Google Scholar
  20. 20.
    Poeze M, Takala J, Greve JW, Ramsay G (2000) Pre-operative tonometry is predictive for mortality and morbidity in high-risk surgical patients. Intensive Care Med 26: 1272–1281PubMedCrossRefGoogle Scholar
  21. 21.
    Berlauk JF, Abrams JH, Gilmour IJ, O’Connor SR, Knighton DR, Cerra FB (1991) Preoperative optimization of cardiovascular hemodynamics improves outcome in peripheral vascular surgery. A prospective, randomized clinical trial. Ann Surg 214: 289–297Google Scholar
  22. 22.
    Bishop MH, Shoemaker WC, Appel PL, et al (1995) Prospective, randomized trial of survivor values of cardiac index, oxygen delivery, and oxygen consumption as resuscitation endpoints in severe trauma. J Trauma 38: 780–787PubMedCrossRefGoogle Scholar

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© Springer-Verlag Berlin Heidelberg 2003

Authors and Affiliations

  • B. Vallet
  • G. Lebuffe
  • E. Wiel

There are no affiliations available

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