Reducing the risk of major elective surgery
Authors: S Sudhindran, I. Mitchell, D. Bihari, R O Feneck, P E Hersch, A S Kong, R Howard-Griffi, J. Wilson, I. Woods
Journal: BMJ (1999)

# Paper should have given details on causes of death {#article-title-2} EDITOR—Does the result of Wilson et al's trial from a district general hospital justify routine preoperative administration of inotropes and fluids to all patients having major elective surgery?1 Detailed mortality data, in particular on the cause of death, are lacking in their results, surprisingly. The morbidity data show that there was a significantly increased rate of surgical complications in the control group compared with the study group (seven of the 46 patients in the control group developed surgical complications (four cases of anastomotic breakdown and three of deep haemorrhage) compared with four of the 92 in the study group (all cases of deep haemorrhage); P=0.04). If any of these surgical complications were the direct cause of death in the controls then the effectiveness of the preoperative regimen in the study group in reducing mortality becomes ambiguous. This would be particularly pertinent with regard to the two late deaths in the control group, since these deaths are unlikely to have been due to inadequate preoperative optimisation of oxygen delivery. The use of 4.5% albumin and of red cell transfusion below a blanket threshold haemoglobin concentration of 110 g/l is a controversial issue.2–4 1. 1.↵1. Wilson J, 2. Woods I, 3. Fawcett J, 4. Whall R, 5. Dibb W, 6. Morris C, 7. et al . Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen therapy. BMJ 1999; 7191: 1099–1103. [OpenUrl][1] 2. 2.↵1. Cochrane Injuries Group Albumin Reviewers . Human albumin administration in critically ill patients: systematic review of randomised controlled trials. BMJ 1998; 317: 235–240. [OpenUrl][2][Abstract/FREE Full Text][3] 3. 3.1. Hebert PC, 2. Wells G, 3. Blajchman MA, 4. Marshall J, 5. Martin C, 6. Pagliarello G, 7. et al . A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. N Engl J Med 1999; 340: 409–417. [OpenUrl][4][CrossRef][5][PubMed][6][Web of Science][7] 4. 4.↵1. Schierhout G, 2. Roberts I . Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials. BMJ 1998; 316: 961–964. [OpenUrl][8][Abstract/FREE Full Text][9] # Better management of intensive care unit beds is necessary {#article-title-7} EDITOR—Wilson et al's randomised controlled trial in high risk surgical patients goes some way to showing the benefits of intensive care1—a service hopelessly underfunded and therefore underused in the United Kingdom. This low priority in the United Kingdom is highlighted yet again in the study, by the 16 patients in the control group who did not receive intensive or high dependency care immediately after their high risk surgery despite beds being available. It is hard to know if the small heterogeneous groups in the study were matched for severity of illness, skill of the surgeon and anaesthetist, and volume of blood transfused. 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