Reducing the risk of major elective surgery

Papers p 1099 In this week's BMJ Wilson and colleagues report a randomised controlled trial in high risk surgical patients admitted to an intensive care unit at least four hours before elective operation for optimisation of cardiac output and oxygen delivery to >600 ml/min/m2. This pre-emptive strategy was compared with usual practice, which is to monitor the cardiovascular system intraoperatively and to respond to changes in arterial and filling pressures. They showed a reduction in mortality from 17% (95% confidence interval 8% to 31%) to 3% (0.7% to 9%) and reduction of bed use by up to 40% (p 1099).1 By the usual criteria their patients were high risk: about a third had known ischaemic heart disease and half of them were aged over 70. This finding is not unexpected, and the question now is what we should do about it. Control of the circulation is one of the first tutorials in cardiovascular physiology. We teach how baroreceptors sense the resulting pressure between the force of the contracting heart and the resistance …