Dopexamine and survival: areas of consistency

We read with interest Gopal et al.’s meta-analysis of the effects of dopexamine on survival and its accompanying editorial [1, 2]. The meta-analysis did not find a significant improvement in survival associated with dopexamine infusion, in contrast with the findings of our own work [3]. However, the results of both this meta-analysis and our meta-regression analysis are consistent with the hypothesis that a survival benefit exists. Whilst we could continue to debate issues of study design, trial selection and the approach to handling important potential confounders, these have already been explored in considerable depth in the article and editorial. Instead we would like to draw attention to the areas of consistency between these analyses and the wider implications for this field of research. Gopal and colleagues acknowledge the continued uncertainty surrounding the survival benefit of peri-operative dopexamine infusion and the need for large clinical trials to resolve this question. We drew the same conclusion following our own work and Pandit [2] acknowledges the need for further investigation in his editorial. Successive reports produced by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) have emphasised the healthcare implications of poor outcomes following major surgery [4]. Our own work with the Intensive Care National Audit and Research Centre (ICNARC) has confirmed the existence of a large UK population of patients undergoing major non-cardiac surgery who have a very high incidence of complications, prolonged inpatient stays and a hospital mortality rate of 12% [5]. Clearly, there is an urgent need to develop new approaches to peri-operative care that might reduce complication rates and improve survival. The benefits of the most promising of these should then be confirmed in large clinical trials. Together with colleagues from across the UK, we are shortly to commence recruitment into a large pragmatic randomised trial of a peri-operative haemodynamic intervention that incorporates low dose dopexamine infusion and stroke volume guided fluid therapy (OPTIMISE trial). The findings of clinical trials and meta-analyses performed to date illustrate the equipoise that now exists on this issue. Funded by the National Institute for Health Research (UK) and supported by ICNARC, on completion this trial will shed considerable light on this important area of clinical practice. RP and CH are named inventors on a patent application relating to dopexamine.