This review addresses the currently available information that describes the identification of high risk patients undergoing surgery and how they may be treated to improve their outcome. It is clear from this data that high risk patients have a mortality rate of around 30% and that the major cause of death is due to multiple organ failure (MOF) which occurs days or in some cases weeks after the operation. The hypothesis for the onset of MOF is presented and it relates to the breakdown in gut patency which can allow the translocation of initiating inflammatory mediators which sets the MOF cascade in action. Current treatment strategies based on preclinical and clinical data to prevent MOF are discussed which includes the use of catecholamines such as dobutamine and dopexamine (Dopacard). It is concluded that the high risk surgical patient is not well defined and that the most rigorously tested criteria are those developed by Shoemaker. These criteria relate far more to the patients physiological status than the surgery that they are undergoing. The treatment of these patients is far more successful if intervention starts prior to surgery with fluids and vasoactive drugs such as Dopacard where the mortality rate has been shown to be reduced by 75%.