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Kuh JH, Jung WS, Lim L, Yoo HK, Ju JW, Lee HJ, Kim WH. The effect of high perioperative inspiratory oxygen fraction for abdominal surgery on surgical site infection: a systematic review and meta-analysis. Sci Rep 2023; 13:15599. [PMID: 37730856 PMCID: PMC10511429 DOI: 10.1038/s41598-023-41300-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023] Open
Abstract
Guidelines from the World Health Organization strongly recommend the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anesthesia to reduce surgical site infection (SSI). However, previous meta-analyses reported inconsistent results. We aimed to address this controversy by focusing specifically on abdominal surgery with relatively high risk of SSI. Medline, EMBASE, and Cochrane CENTRAL databases were searched. Randomized trials of abdominal surgery comparing high to low perioperative FiO2 were included, given that the incidence of SSI was reported as an outcome. Meta-analyses of risk ratios (RR) were performed using a fixed effects model. Subgroup analysis and meta-regression were employed to explore sources of heterogeneity. We included 27 trials involving 15977 patients. The use of high FiO2 significantly reduced the incidence of SSI (n = 27, risk ratio (RR): 0.87; 95% confidence interval (CI): 0.79, 0.95; I2 = 49%, Z = 3.05). Trial sequential analysis (TSA) revealed that z-curve crossed the trial sequential boundary and data are sufficient. This finding held true for the subgroup of emergency operations (n = 2, RR: 0.54; 95% CI: 0.35, 0.84; I2 = 0%, Z = 2.75), procedures using air as carrier gas (n = 9, RR: 0.79; 95% CI: 0.69, 0.91; I2 = 60%, Z = 3.26), and when a high level of FiO2 was maintained for a postoperative 6 h or more (n = 9, RR: 0.68; 95% CI: 0.56, 0.83; I2 = 46%, Z = 3.83). Meta-regression revealed no significant interaction between SSI with any covariates including age, sex, body-mass index, diabetes mellitus, duration of surgery, and smoking. Quality of evidence was assessed to be moderate to very low. Our pooled analysis revealed that the application of high FiO2 reduced the incidence of SSI after abdominal operations. Although TSA demonstrated sufficient data and cumulative analysis crossed the TSA boundary, our results should be interpreted cautiously given the low quality of evidence.Registration: https://www.crd.york.ac.uk/prospero (CRD42022369212) on October 2022.
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Affiliation(s)
- Jae Hee Kuh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Woo-Seok Jung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Leerang Lim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Hae Kyung Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Ho-Jin Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul, 03080, Republic of Korea.
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Klitgaard TL, Schjørring OL, Nielsen FM, Meyhoff CS, Perner A, Wetterslev J, Rasmussen BS, Barbateskovic M. Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2023; 9:CD012631. [PMID: 37700687 PMCID: PMC10498149 DOI: 10.1002/14651858.cd012631.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik M Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Private Office, Hellerup, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Nam K, Nam JS, Kim HB, Chung J, Hwang IE, Ju JW, Bae J, Lee S, Cho YJ, Shim JK, Kwak YL, Chin JH, Choi IC, Lee EH, Jeon Y. Effects of intraoperative inspired oxygen fraction (FiO 2 0.3 vs 0.8) on patients undergoing off-pump coronary artery bypass grafting: the CARROT multicenter, cluster-randomized trial. Crit Care 2023; 27:286. [PMID: 37443130 PMCID: PMC10339585 DOI: 10.1186/s13054-023-04558-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/29/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND To maintain adequate oxygenation is of utmost importance in intraoperative care. However, clinical evidence supporting specific oxygen levels in distinct surgical settings is lacking. This study aimed to compare the effects of 30% and 80% oxygen in off-pump coronary artery bypass grafting (OPCAB). METHODS This multicenter trial was conducted in three tertiary hospitals from August 2019 to August 2021. Patients undergoing OPCAB were cluster-randomized to receive either 30% or 80% oxygen intraoperatively, based on the month when the surgery was performed. The primary endpoint was the length of hospital stay. Intraoperative hemodynamic data were also compared. RESULTS A total of 414 patients were cluster-randomized. Length of hospital stay was not different in the 30% oxygen group compared to the 80% oxygen group (median, 7.0 days vs 7.0 days; the sub-distribution hazard ratio, 0.98; 95% confidence interval [CI] 0.83-1.16; P = 0.808). The incidence of postoperative acute kidney injury was significantly higher in the 30% oxygen group than in the 80% oxygen group (30.7% vs 19.4%; odds ratio, 1.94; 95% CI 1.18-3.17; P = 0.036). Intraoperative time-weighted average mixed venous oxygen saturation was significantly higher in the 80% oxygen group (74% vs 64%; P < 0.001). The 80% oxygen group also had a significantly greater intraoperative time-weighted average cerebral regional oxygen saturation than the 30% oxygen group (56% vs 52%; P = 0.002). CONCLUSIONS In patients undergoing OPCAB, intraoperative administration of 80% oxygen did not decrease the length of hospital stay, compared to 30% oxygen, but may reduce postoperative acute kidney injury. Moreover, compared to 30% oxygen, intraoperative use of 80% oxygen improved oxygen delivery in patients undergoing OPCAB. Trial registration ClinicalTrials.gov (NCT03945565; April 8, 2019).
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Affiliation(s)
- Karam Nam
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Hye-Bin Kim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jaeyeon Chung
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Medical Service Corps of the First Logistics Support Command, Wonju, Gangwon State, Republic of Korea
| | - In Eob Hwang
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Woo Ju
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jinyoung Bae
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Anesthesiology and Pain Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Gyeonggi Province, Republic of Korea
| | - Seohee Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Youn Joung Cho
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji-Hyun Chin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
- Hana Anesthesia Clinic, Seoul, Republic of Korea.
| | - Yunseok Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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Gottlieb J. [Oxygen therapy in intensive care]. Dtsch Med Wochenschr 2023; 148:759-766. [PMID: 37257478 DOI: 10.1055/a-1940-0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
PULSE OXIMETRY AND BLOOD GAS ANALYSES Pulse oximetry has high sensitivity but low specificity for detecting hypoxemia. Arterial blood gas analyses are the gold standard for monitoring O2 therapy. Venous blood gas analyses should not be used in this setting. TARGET VALUES OF O2 THERAPY: The target range of acute O2 therapy for ventilated patients and nonventilated patients not at risk of hypercapnia should be between 92% and 96% for oxygen saturation (SpO2) measured by pulse oximetry. Indications for high-dose O2 therapy without a target range in critical care include carbon monoxide poisoning and patients with severe respiratory distress when SpO2 cannot be derived. Hyperoxemia, i.e., SpO2 values above 96%, has not improved survival in randomized trials of predominantly ventilated ICU patients. Under hyperoxemia in nonventilated patients at risk of hypercapnia (e.g., patients with chronic obstructive pulmonary disease), one in three patients is at risk of increasing carbon dioxide. Therefore, a target SpO2 of 88-92% should be aimed for in these patients. O2 TARGET RANGES ON EXTRACORPOREAL PROCEDURES: There are no randomized studies recommending other SpO2 target ranges for patients on extracorporeal procedures. These patients should always be monitored with arterial blood gases-in the case of peripheral VA-ECMO on the right arm and downstream of the oxygenator. HIGH-FLOW OXYGEN THERAPY FOR ACUTE HYPERCAPNIC RESPIRATORY FAILURE: High-flow oxygen therapy (HFNC) was not associated with reduced in-hospital mortality compared with conventional O2 in a meta-analysis of predominantly patients with acute hypoxemia (type I respiratory failure), although intubation rates were reduced. Also, in acute hypercapnic respiratory failure (type II), HFNC with high flow rates is not inferior to noninvasive ventilation (NIV).
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover; Deutsches Zentrum für Lungenforschung (DZL), Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover
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Calderwood MS, Anderson DJ, Bratzler DW, Dellinger EP, Garcia-Houchins S, Maragakis LL, Nyquist AC, Perkins KM, Preas MA, Saiman L, Schaffzin JK, Schweizer M, Yokoe DS, Kaye KS. Strategies to prevent surgical site infections in acute-care hospitals: 2022 Update. Infect Control Hosp Epidemiol 2023; 44:695-720. [PMID: 37137483 PMCID: PMC10867741 DOI: 10.1017/ice.2023.67] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The intent of this document is to highlight practical recommendations in a concise format designed to assist acute-care hospitals in implementing and prioritizing their surgical-site infection (SSI) prevention efforts. This document updates the Strategies to Prevent Surgical Site Infections in Acute Care Hospitals published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the American Hospital Association (AHA), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.
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Affiliation(s)
| | - Deverick J. Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina, United States
| | - Dale W. Bratzler
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | | | | | - Lisa L. Maragakis
- Johns Hopkins School of Medicine, Baltimore, Maryland, United States
| | - Ann-Christine Nyquist
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Kiran M. Perkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Michael Anne Preas
- University of Maryland Medical System, Baltimore, Maryland, United States
| | - Lisa Saiman
- Columbia University Irving Medical Center and NewYork–Presbyterian Hospital, New York, New York, United States
| | - Joshua K. Schaffzin
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Marin Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City VA Health Care System, University of Iowa, Iowa City, Iowa
| | - Deborah S. Yokoe
- University of California-San Francisco, San Francisco, California, United States
| | - Keith S. Kaye
- Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, United States
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Figiel W, Niewiński G, Grąt M, Krawczyk M, Stypułkowski J, Lewandowski Z, Krasnodębski M, Patkowski W, Zieniewicz K. Postoperative Supplemental Oxygen in Liver Transplantation (PSOLT) does not reduce the rate of infections: results of a randomized controlled trial. BMC Med 2023; 21:51. [PMID: 36782227 PMCID: PMC9924861 DOI: 10.1186/s12916-023-02741-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/18/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Despite inconsistent evidence, international guidelines underline the importance of perioperative hyperoxygenation in prevention of postoperative infections. Further, data on safety and efficacy of this method in liver transplant setting are lacking. The aim was to evaluate efficacy and safety of postoperative hyperoxygenation in prophylaxis of infections after liver transplantation. METHODS In this randomized controlled trial, patients undergoing liver transplantation were randomly assigned to either 28% or 80% fraction of inspired oxygen (FiO2) for 6 postoperative hours. Infections occurring during 30-day post-transplant period were the primary outcome measure. Secondary outcome measures included 90-day mortality, 90-day severe morbidity, 30-day pulmonary complications, durations of hospital and intensive care unit stay, and 5-day postoperative bilirubin concentration, alanine and aspartate transaminase activity, and international normalized ratio (INR) (clinicatrials.gov NCT02857855). RESULTS A total of 193 patients were included and randomized to 28% (n = 99) and 80% (n = 94) FiO2. With similar patient, operative, and donor characteristics in both groups, infections occurred in 34.0% (32/94) of patients assigned to 80% FiO2 as compared to 23.2% (23/99) of patients assigned to 28% FiO2 (p = 0.112). Patients randomized to 80% FiO2 more frequently developed severe complications (p = 0.035), stayed longer in the intensive care unit (p = 0.033), and had higher bilirubin concentration over first 5 post-transplant days (p = 0.043). No significant differences were found regarding mortality, duration of hospital stay, pulmonary complications, and 5-day aspartate and alanine transaminase activity and INR. CONCLUSIONS Postoperative hyperoxygenation should not be used for prophylaxis of infections after liver transplantation due to the lack of efficacy. TRIAL REGISTRATION ClinicalTrials.gov NCT02857855. Registered 7 July 2016.
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Affiliation(s)
- Wojciech Figiel
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Grzegorz Niewiński
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Michał Grąt
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland.
| | - Marek Krawczyk
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Jan Stypułkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Zbigniew Lewandowski
- Department of Epidemiology and Biostatistics, Medical University of Warsaw, Oczki 3, 02-007, Warsaw, Poland
| | - Maciej Krasnodębski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Banacha 1A, 02-097, Warsaw, Poland
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Abstract
IMPORTANCE Approximately 0.5% to 3% of patients undergoing surgery will experience infection at or adjacent to the surgical incision site. Compared with patients undergoing surgery who do not have a surgical site infection, those with a surgical site infection are hospitalized approximately 7 to 11 days longer. OBSERVATIONS Most surgical site infections can be prevented if appropriate strategies are implemented. These infections are typically caused when bacteria from the patient's endogenous flora are inoculated into the surgical site at the time of surgery. Development of an infection depends on various factors such as the health of the patient's immune system, presence of foreign material, degree of bacterial wound contamination, and use of antibiotic prophylaxis. Although numerous strategies are recommended by international organizations to decrease surgical site infection, only 6 general strategies are supported by randomized trials. Interventions that are associated with lower rates of infection include avoiding razors for hair removal (4.4% with razors vs 2.5% with clippers); decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures (0.8% with decolonization vs 2% without); use of chlorhexidine gluconate and alcohol-based skin preparation (4.0% with chlorhexidine gluconate plus alcohol vs 6.5% with povidone iodine plus alcohol); maintaining normothermia with active warming such as warmed intravenous fluids, skin warming, and warm forced air to keep the body temperature warmer than 36 °C (4.7% with active warming vs 13% without); perioperative glycemic control (9.4% with glucose <150 mg/dL vs 16% with glucose >150 mg/dL); and use of negative pressure wound therapy (9.7% with vs 15% without). Guidelines recommend appropriate dosing, timing, and choice of preoperative parenteral antimicrobial prophylaxis. CONCLUSIONS AND RELEVANCE Surgical site infections affect approximately 0.5% to 3% of patients undergoing surgery and are associated with longer hospital stays than patients with no surgical site infections. Avoiding razors for hair removal, maintaining normothermia, use of chlorhexidine gluconate plus alcohol-based skin preparation agents, decolonization with intranasal antistaphylococcal agents and antistaphylococcal skin antiseptics for high-risk procedures, controlling for perioperative glucose concentrations, and using negative pressure wound therapy can reduce the rate of surgical site infections.
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Affiliation(s)
- Jessica L Seidelman
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
| | - Christopher R Mantyh
- Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Deverick J Anderson
- Duke Center for Antimicrobial Stewardship and Infection Prevention, Duke University School of Medicine, Durham, North Carolina
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Douin DJ, Dylla L, Anderson EL, Rice JD, Jackson CL, Bebarta VS, Neumann RT, Schauer SG, Ginde AA. Hyperoxia is associated with a greater risk for mortality in critically ill traumatic brain injury patients than in critically ill trauma patients without brain injury. Sci Prog 2023; 106:368504231160416. [PMID: 36879502 PMCID: PMC10450323 DOI: 10.1177/00368504231160416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
OBJECTIVE The role of hyperoxia in patients with traumatic brain injury (TBI) remains controversial. The objective of this study was to determine the association between hyperoxia and mortality in critically ill TBI patients compared to critically ill trauma patients without TBI. DESIGN Secondary analysis of a multicenter retrospective cohort study. SETTING Three regional trauma centers in Colorado, USA, between October 1, 2015, and June 30, 2018. PATIENTS We included 3464 critically injured adults who were admitted to an intensive care unit (ICU) within 24 h of arrival and qualified for inclusion into the state trauma registry. We analyzed all available SpO2 values during the first seven ICU days. The primary outcome was in-hospital mortality. Secondary outcomes included the proportion of time spent in hyperoxia (defined as SpO2 > 96%) and ventilator-free days. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS In-hospital mortality occurred in 163 patients (10.7%) in the TBI group and 101 patients (5.2%) in the non-TBI group. After adjusting for ICU length of stay, TBI patients spent a significantly greater amount of time in hyperoxia versus non-TBI patients (p = 0.024). TBI status significantly modified the effect of hyperoxia on mortality. At each specific SpO2 level, the risk of mortality increases with increasing FiO2 for both patients with and without TBI. This trend was more pronounced at lower FiO2 and higher SpO2 values, where a greater number of patient observations were obtained. Among patients who required invasive mechanical ventilation, TBI patients required significantly more days of ventilation to day 28 than non-TBI patients. CONCLUSIONS Critically ill trauma patients with a TBI spend a greater proportion of time in hyperoxia compared to those without a TBI. TBI status significantly modified the effect of hyperoxia on mortality. Prospective clinical trials are needed to better assess a possible causal relationship.
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Affiliation(s)
- David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Erin L Anderson
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Rice
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Conner L Jackson
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert T Neumann
- Department of Neurological Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven G Schauer
- US Air Force 59th Medical Wing, Office of the Chief Scientist, JBSA, Lackland, TX, USA
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
- Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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9
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Ahn JH, Shim JG, Park J, Lee SH, Ryu KH, Cho EA. Oxygen reserve index guided fraction of inspired oxygen titration to reduce hyperoxemia during laparoscopic gastrectomy: A randomized controlled trial. Medicine (Baltimore) 2022; 101:e31592. [PMID: 36401493 PMCID: PMC9678519 DOI: 10.1097/md.0000000000031592] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The usefulness of the oxygen reserve index (ORi) in reducing hyperoxemia remains unclear. We designed this study to investigate whether fraction of inspired oxygen (FiO2) adjustment under a combination of ORi and peripheral oxygen saturation (SpO2) guidance can reduce intraoperative hyperoxemia compared to SpO2 alone. METHODS In this prospective, double-blind, randomized controlled study, we allocated patients scheduled for laparoscopic gastrectomy to the SpO2 group (FiO2 adjusted to target SpO2 ≥ 98%) or the ORi-SpO2 group (FiO2 adjusted to target 0 < 0 ORi < .3 and SpO2 ≥ 98%). The ORi, SpO2, FiO2, arterial partial pressure of oxygen (PaO2), and incidence of severe hyperoxemia (PaO2 ≥ 200 mm Hg) were recorded before and 1, 2, and 3 hours after surgical incision. Data from 32 and 30 subjects in the SpO2 and ORi-SpO2 groups, respectively, were analyzed. RESULTS PaO2 was higher in the SpO2 group (250.31 ± 57.39 mm Hg) than in the ORi-SpO2 group (170.07 ± 49.39 mm Hg) 1 hour after incision (P < .001). PaO2 was consistently higher in the SpO2 group than in the ORi-SpO2 group, over time (P = .045). The incidence of severe hyperoxemia was higher in the SpO2 group (84.4%) than in the ORi-SpO2 group (16.7%, P < .001) 1 hour after incision. Higher FiO2 was administered to the SpO2 group [52.5 (50-60)] than the ORi-SpO2 group [40 (35-50), P < .001] 1 hour after incision. SpO2 was not different between the 2 groups. CONCLUSION The combination of ORi and SpO2 guided FiO2 adjustment reduced hyperoxemia compared to SpO2 alone during laparoscopic gastrectomy.
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Affiliation(s)
- Jin Hee Ahn
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jae-Geum Shim
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jiyeon Park
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyoung-Ho Ryu
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Ah Cho
- Department of Anaesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- * Correspondence: Eunah Cho, Department of Anesthesiology and Pain Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul 03181, Republic of Korea (e-mail: )
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10
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Gomes ET, Carbogim FDC, Lins RS, Lins-Filho RLDM, Poveda VDB, Püschel VADA. Effectiveness of supplemental oxygenation to prevent surgical site infections: A systematic review with meta-analysis. Rev Lat Am Enfermagem 2022; 30:e3648. [PMID: 36228236 PMCID: PMC9545934 DOI: 10.1590/1518-8345.6106.3648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/06/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE to assess the effectiveness of supplemental oxygenation with high FiO2 when compared to conventional FiO2 in the prevention of surgical site infection. METHOD an effectiveness systematic review with meta-analysis conducted in five international databases and portals. The research was guided by the following question: Which is the effectiveness of supplemental oxygenation with high FiO2 (greater than 80%) when compared to conventional FiO2 (from 30% to 35%) in the prevention of surgical site infections in adults? RESULTS fifteen randomized clinical trials were included. Although all the subgroups presented a general effect in favor of the intervention, colorectal surgeries had this relationship evidenced with statistical significance (I2=10%;X2=4.42; p=0.352). CONCLUSION inspired oxygen fractions greater than 80% during the perioperative period in colorectal surgeries have proved to be effective to prevent surgical site infections, reducing their incidence by up to 27% (p=0.006). It is suggested to conduct new studies in groups of patients subjected to surgeries from other specialties, such as cardiac and vascular. PROSPERO registration No.: 178,453.
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Affiliation(s)
- Eduardo Tavares Gomes
- Universidade de São Paulo, Escola de Enfermagem, São Paulo, SP,
Brazil., Universidade Federal de Pernambuco, Hospital das Clínicas, Recife,
PE, Brazil
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11
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Elfeky A, Chen YF, Grove A, Hooper A, Wilson A, Couper K, Thompson M, Uthman O, Court R, Tomassini S, Yeung J. Perioperative oxygen therapy: a protocol for an overview of systematic reviews and meta-analyses. Syst Rev 2022; 11:140. [PMID: 35831881 PMCID: PMC9277880 DOI: 10.1186/s13643-022-02005-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Oxygen is routinely given to patients during and after surgery. Perioperative oxygen administration has been proposed as a potential strategy to prevent and treat hypoxaemia and reduce complications, such as surgical site infections, pulmonary complications and mortality. However, uncertainty exists as to which strategies in terms of amount, delivery devices and timing are clinically effective. The aim of this overview of systematic reviews and meta-analyses is to answer the research question, 'For which types of surgery, at which stages of care, in which sub-groups of patients and delivered under what conditions are different types of perioperative oxygen therapy clinically effective?'. METHODS We will search key electronic databases (MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, CENTRAL, Epistemonikos, PROSPERO, the INAHTA International HTA Database and DARE archives) for systematic reviews and randomised controlled trials comparing perioperative oxygen strategies. Each review will be mapped according to type of surgery, surgical pathway timepoints and clinical comparison. The highest quality reviews with the most comprehensive and up-to-date coverage of relevant literature will be chosen as anchoring reviews. Standardised data will be extracted from each chosen review, including definition of oxygen therapy, summaries of interventions and comparators, patient population, surgical characteristics and assessment of overall certainty of evidence. For clinical outcomes and adverse events, the overall pooled findings and results of subgroup and sensitivity analyses (where available) will be extracted. Trial-level data will be extracted for surgical site infections, mortality, and potential trial-level effect modifiers such as risk of bias, outcome definition and type of surgery to facilitate quantitative data analysis. This analysis will adopt a multiple indication review approach with panoramic meta-analysis using review-level data and meta-regression using trial-level data. An evidence map will be produced to summarise our findings and highlight any research gaps. DISCUSSION There is a need to provide a panoramic overview of systematic reviews and meta-analyses describing peri-operative oxygen practice to both inform clinical practice and identify areas of ongoing uncertainty, where further research may be required. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021272361.
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Affiliation(s)
- Adel Elfeky
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Yen-Fu Chen
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
| | - Amy Grove
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Amy Hooper
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Anna Wilson
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Keith Couper
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Marion Thompson
- Independent patient and public involvement and engagement advisor, Birmingham, UK
| | - Olalekan Uthman
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Rachel Court
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Sara Tomassini
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Joyce Yeung
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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12
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Kucukosman G, Can M, Aydin BG, Bilgin E, Ayoglu H. The Effects of Intraoperative Oxygen used at Different Concentrations on Oxidative Stress Markers: A Randomized Prospective Study. HASEKI TIP BÜLTENI 2022. [DOI: 10.4274/haseki.galenos.2022.8130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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13
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Guerrero-Gutiérrez MA, Mancilla-Galindo J, Kammar-García A, Morgado-Villaseñor LA, Zamarrón-López EI, Pérez-Nieto OR. Commentary to: Hyperoxemia in postsurgical sepsis/septic shock patients is associated with reduced mortality. Crit Care 2022; 26:67. [PMID: 35321726 PMCID: PMC8941768 DOI: 10.1186/s13054-022-03932-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | - Ashuin Kammar-García
- Dirección de Investigación, Instituto Nacional de Geriatría, Ciudad de México, Mexico
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14
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, König M, Markewitz A, Nothacker M, Roiter S, Unverzagt S, Veit W, Volk T, Witt C, Wildenauer R, Worth H, Fühner T. [Oxygen in the acute care of adults : Short version of the German S3 guideline]. Med Klin Intensivmed Notfmed 2022; 117:4-15. [PMID: 34651197 PMCID: PMC8516090 DOI: 10.1007/s00063-021-00884-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Oxygen is a drug with specific properties, a defined dose-effect range and side effects. In 2015, in a sample of UK hospital patients, 14% were treated with oxygen, of which only 42% had a prescription. Health care workers are often uncertain about the relevance of hypoxemia, and there is limited awareness of the risks of hyperoxemia. Numerous randomized controlled trials on oxygen therapy have recently been published. METHODS As part of the guideline program of the Working Group of Scientific Medical Societies e. V. (AWMF), this S3 guideline was developed with the participation of 10 medical societies on the basis of a literature search up to 02/01/2021. The system of the Oxford Centre for Evidence-Based Medicine (CEBM) (The Oxford 2011 Levels of Evidence) was used to evaluate the literature. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE), and a formal consensus process of recommendations was performed. RESULTS The guideline contains 34 evidence-based recommendations on the indication, prescription, monitoring, and discontinuation of oxygen therapy in acute care. The indication for oxygen is mainly hypoxemia. Hypoxemia and hyperoxemia should be avoided, since both increase mortality. The guideline recommends target ranges of oxygen saturation for acute oxygen therapy without differentiating between different diagnoses. Target areas depend on the risk for hypercapnia and ventilation status. The guideline provides an overview of available oxygen delivery systems and contains recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first German guideline on the use of oxygen in acute care. It is aimed at medical professionals who use oxygen in and outside hospitals and is valid until June 30th, 2024.
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie OE 6870, Medizinische Hochschule Hannover, 30625, Hannover, Deutschland.
- Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland.
| | - Philipp Capetian
- Klinik für Neurologie, Neurologische Intensivstation, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Uwe Hamsen
- Fachbereich für Unfallchirurgie und Orthopädie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland
| | - Uwe Janssens
- Innere Medizin und internistische Intensivmedizin, Sankt Antonius Hospital GmbH, Eschweiler, Deutschland
| | - Christian Karagiannidis
- Abteilung für Pneumologie und Beatmungsmedizin, ARDS/ECMO Zentrum, Lungenklinik Köln-Merheim, Köln, Deutschland
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg, Deutschland
| | - Marco König
- Deutscher Berufsverband Rettungsdienst e. V., Lübeck, Deutschland
| | - Andreas Markewitz
- ehem. Klinik für Herz- und Gefäßchirurgie, Bundeswehrzentralkrankenhaus Koblenz, Koblenz, Deutschland
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg, Deutschland
| | - Sabrina Roiter
- Intensivstation, Israelitisches Krankenhaus Hamburg, Hamburg, Deutschland
| | - Susanne Unverzagt
- Abteilung für Allgemeinmedizin, Universität Leipzig, Leipzig, Deutschland
| | - Wolfgang Veit
- Bundesverband der Organtransplantierten e. V., Marne, Deutschland
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
| | - Christian Witt
- Seniorprofessor Innere Medizin und Pneumologie, Charité Berlin, Berlin, Deutschland
| | | | | | - Thomas Fühner
- Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH), Deutsches Zentrum für Lungenforschung (DZL), Hannover, Deutschland
- Krankenhaus Siloah, Klinik für Pneumologie und Beatmungsmedizin, Klinikum Region Hannover, Hannover, Deutschland
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15
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, Nothacker M, Roiter S, Volk T, Worth H, Fühner T. German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients. Respiration 2021; 101:214-252. [PMID: 34933311 DOI: 10.1159/000520294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Philipp Capetian
- Department of Neurology, University Hospital Würzburg, Wuerzburg, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management, Marburg, Germany
| | - Sabrina Roiter
- Intensive Care Unit, Israelite Hospital Hamburg, Hamburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, University Hospital of Saarland, Saarland University, Homburg, Germany
| | | | - Thomas Fühner
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Siloah Hospital, Hannover, Germany
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16
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Dylla L, Douin DJ, Anderson EL, Rice JD, Jackson CL, Bebarta VS, Lindsell CJ, Cheng AC, Schauer SG, Ginde AA. A multicenter cluster randomized, stepped wedge implementation trial for targeted normoxia in critically ill trauma patients: study protocol and statistical analysis plan for the Strategy to Avoid Excessive Oxygen (SAVE-O2) trial. Trials 2021; 22:784. [PMID: 34749762 PMCID: PMC8574946 DOI: 10.1186/s13063-021-05688-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 10/06/2021] [Indexed: 11/29/2022] Open
Abstract
Background Targeted normoxia (SpO2 90–96% or PaO2 60–100 mmHg) may help to conserve oxygen and improve outcomes in critically ill patients by avoiding potentially harmful hyperoxia. However, the role of normoxia for critically ill trauma patients remains uncertain. The objective of this study is to describe the study protocol and statistical analysis plan for the Strategy to Avoid Excessive Oxygen for Critically Ill Trauma Patients (SAVE-O2) clinical trial. Methods Design, setting, and participants: Protocol for a multicenter cluster randomized, stepped wedge implementation trial evaluating the effectiveness of a multimodal intervention to target normoxia in critically ill trauma patients at eight level 1 trauma centers in the USA. Each hospital will contribute pre-implementation (control) and post-implementation (intervention) data. All sites will begin in the control phase with usual care. When sites reach their randomly assigned time to transition, there will be a one-month training period, which does not contribute to data collection. Following the 1-month training period, the site will remain in the intervention phase for the duration of the trial. Main outcome measures: The primary outcome will be supplemental oxygen-free days, defined as the number of days alive and not on supplemental oxygen. Secondary outcomes include in-hospital mortality to day 90, hospital-free days to day 90, ventilator-free days (VFD) to day 28, time to room air, Glasgow Outcome Score (GOS), and duration of time receiving supplemental oxygen. Discussion SAVE-O2 will determine if a multimodal intervention to improve compliance with targeted normoxia will safely reduce the need for concentrated oxygen for critically injured trauma patients. These data will inform military stakeholders regarding oxygen requirements for critically injured warfighters, while reducing logistical burden in prolonged combat casualty care. Trial registration ClinicalTrials.govNCT04534959. Registered September 1, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05688-6.
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Affiliation(s)
- Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - David J Douin
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Erin L Anderson
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Rice
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Conner L Jackson
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Vikhyat S Bebarta
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.,US Air Force 59th Medical Wing, Office of the Chief Scientist, JBSA, Lackland, San Antonio, TX, USA.,Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Alex C Cheng
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven G Schauer
- US Air Force 59th Medical Wing, Office of the Chief Scientist, JBSA, Lackland, San Antonio, TX, USA.,US Army Institute of Surgical Research, JBSA Fort Sam, Houston, TX, USA.,Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA. .,Center for COMBAT Research, Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
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17
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Young PJ, Frei D. Oxygen therapy for critically Ill and post-operative patients. J Anesth 2021; 35:928-938. [PMID: 34490494 PMCID: PMC8420843 DOI: 10.1007/s00540-021-02996-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/28/2021] [Indexed: 11/02/2022]
Abstract
Nearly all patients receiving treatment in a peri-operative or intensive care setting receive supplemental oxygen therapy. It is biologically plausible that the dose of oxygen used might affect important patient outcomes. Most peri-operative research has focussed on oxygen regimens that target higher than normal blood oxygen levels. Whereas, intensive care research has mostly focussed on conservative oxygen regimens which assiduously avoid exposure to higher than normal blood oxygen levels. While such conservative oxygen therapy is preferred for spontaneously breathing patients with chronic obstructive pulmonary disease, the optimal oxygen regimen in other patient groups is not clear. Some data suggest that conservative oxygen therapy might be preferred for patients with hypoxic ischaemic encephalopathy. However, unless oxygen supplies are constrained, routinely aggressively down-titrating oxygen in either the peri-operative or intensive care setting is not necessary based on available data. Targeting higher than normal levels of oxygen might reduce surgical site infections in the perioperative setting and/or improve outcomes for intensive care patients with sepsis but further research is required and available data are not sufficiently strong to warrant routine implementation of such oxygen strategies.
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Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand. .,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand. .,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
| | - Daniel Frei
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.,Department of Anaesthesia, Wellington Regional Hospital, Wellington, New Zealand
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18
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Lassen ML, Risgaard B, Baekgaard JS, Rasmussen LS. Determining a safe upper limit of oxygen supplementation for adult patients: a systematic review. BMJ Open 2021; 11:e045057. [PMID: 34312194 PMCID: PMC8314741 DOI: 10.1136/bmjopen-2020-045057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This systematic review aimed to describe the connection between the inspired oxygen fraction and pulmonary complications in adult patients, with the objective of determining a safe upper limit of oxygen supplementation. METHODS MEDLINE and Embase were systematically searched in August 2019 (updated July 2020) for studies fulfilling the following criteria: intubated adult patients (Population); high fractions of oxygen (Intervention) versus low fractions of (Comparison); atelectasis, acute respiratory distress syndrome (ARDS), pneumonia and/or duration of mechanical ventilation (Outcome); original studies both observational and interventional (Studies). Screening, data extraction and risk of bias assessment was done by two independent reviewers. RESULTS Out of 6120 records assessed for eligibility, 12 were included. Seven studies were conducted in the emergency setting, and five studies included patients undergoing elective surgery. Eight studies reported data on atelectasis, two on ARDS, four on pneumonia and two on duration of mechanical ventilation. There was a non-significant increased risk of atelectasis if an oxygen fraction of 0.8 or above was used, relative risk (RR): 1.37 (95% CI 0.95 to 1.96). One study showed an almost threefold higher risk of pneumonia in the high oxygen fraction group (RR: 2.83 (95% CI 2.25 to 3.56)). The two studies reporting ARDS and the two studies with data on mechanical ventilation showed no association with oxygen fraction. Four studies had a high risk of bias in one domain. CONCLUSIONS In this systematic review, we found inadequate evidence to identify a safe upper dosage of oxygen, but the identified studies suggest a benefit of keeping inspiratory oxygen fraction below 0.8 with regard to formation of atelectases. PROSPERO REGISTRATION NUMBER CRD42020154242.
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Affiliation(s)
| | - Bjarke Risgaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Josefine S Baekgaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Association Between Hyperoxia, Supplemental Oxygen, and Mortality in Critically Injured Patients. Crit Care Explor 2021; 3:e0418. [PMID: 34036272 PMCID: PMC8133168 DOI: 10.1097/cce.0000000000000418] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Supplemental Digital Content is available in the text. OBJECTIVES: Hyperoxia is common among critically ill patients and may increase morbidity and mortality. However, limited evidence exists for critically injured patients. The objective of this study was to determine the association between hyperoxia and in-hospital mortality in adult trauma patients requiring ICU admission. DESIGN, SETTING, AND PARTICIPANTS: This multicenter, retrospective cohort study was conducted at two level I trauma centers and one level II trauma center in CO between October 2015 and June 2018. All adult trauma patients requiring ICU admission within 24 hours of emergency department arrival were eligible. The primary exposure was oxygenation during the first 7 days of hospitalization. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Primary outcome was in-hospital mortality. Secondary outcomes were hospital-free days and ventilator-free days. We included 3,464 critically injured patients with a mean age of 52.6 years. Sixty-five percent were male, and 66% had blunt trauma mechanism of injury. The primary outcome of in-hospital mortality occurred in 264 patients (7.6%). Of 226,057 patient-hours, 46% were spent in hyperoxia (oxygen saturation > 96%) and 52% in normoxia (oxygen saturation 90–96%). During periods of hyperoxia, the adjusted risk for mortality was higher with greater oxygen administration. At oxygen saturation of 100%, the adjusted risk scores for mortality (95% CI) at Fio2 of 100%, 80%, 60%, and 50% were 6.4 (3.5–11.8), 5.4 (3.4–8.6), 2.7 (1.7–4.1), and 1.5 (1.1–2.2), respectively. At oxygen saturation of 98%, the adjusted risk scores for mortality (95% CI) at Fio2 of 100%, 80%, 60%, and 50% were 7.7 (4.3–13.5), 6.3 (4.1–9.7), 3.2 (2.2–4.8), and 1.9 (1.4–2.7), respectively. CONCLUSIONS: During hyperoxia, higher oxygen administration was independently associated with a greater risk of mortality among critically injured patients. Level of evidence: Cohort study, level III.
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Röttgering JG, de Man AME, Schuurs TC, Wils EJ, Daniels JM, van den Aardweg JG, Girbes ARJ, Smulders YM. Determining a target SpO2 to maintain PaO2 within a physiological range. PLoS One 2021; 16:e0250740. [PMID: 33983967 PMCID: PMC8118260 DOI: 10.1371/journal.pone.0250740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/12/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE In the context of an ongoing debate on the potential risks of hypoxemia and hyperoxemia, it seems prudent to maintain the partial arterial oxygen pressure (PaO2) in a physiological range during administration of supplemental oxygen. The PaO2 and peripheral oxygen saturation (SpO2) are closely related and both are used to monitor oxygenation status. However, SpO2 values cannot be used as an exact substitute for PaO2. The aim of this study in acutely ill and stable patients was to determine at which SpO2 level PaO2 is more or less certain to be in the physiological range. METHODS This is an observational study prospectively collecting data pairs of PaO2 and SpO2 values in patients admitted to the emergency room or intensive care unit (Prospective Inpatient Acutely ill cohort; PIA cohort). A second cohort of retrospective data of patients who underwent pulmonary function testing was also included (Retrospective Outpatient Pulmonary cohort; ROP cohort). Arterial hypoxemia was defined as PaO2 < 60 mmHg and hyperoxemia as PaO2 > 125 mmHg. The SpO2 cut-off values with the lowest risk of hypoxemia and hyperoxemia were determined as the 95th percentile of the observed SpO2 values corresponding with the observed hypoxemic and hyperoxemic PaO2 values. RESULTS 220 data pairs were collected in the PIA cohort. 95% of hypoxemic PaO2 measurements occurred in patients with an SpO2 below 94%, and 95% of hyperoxemic PaO2 measurements occurred in patients with an SpO2 above 96%. Additionally in the 1379 data pairs of the ROP cohort, 95% of hypoxemic PaO2 measurements occurred in patients with an SpO2 below 93%. CONCLUSION The SpO2 level marking an increased risk of arterial hypoxemia is not substantially different in acutely ill versus stable patients. In acutely ill patients receiving supplemental oxygen an SpO2 target of 95% maximizes the likelihood of maintaining PaO2 in the physiological range.
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Affiliation(s)
- Jantine G. Röttgering
- Department of Intensive Care, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
- Institute for Cardiovascular Research (ICaR-VU), Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
| | - Angelique M. E. de Man
- Department of Intensive Care, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
- Institute for Cardiovascular Research (ICaR-VU), Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
| | - Thomas C. Schuurs
- Department of Emergency Medicine, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
| | - Evert-Jan Wils
- Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Johannes M. Daniels
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
| | | | - Armand R. J. Girbes
- Department of Intensive Care, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
- Institute for Cardiovascular Research (ICaR-VU), Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
| | - Yvo M. Smulders
- Institute for Cardiovascular Research (ICaR-VU), Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
- Department of Internal Medicine, Amsterdam UMC, Amsterdam, Noord-Holland, The Netherlands
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Intraoperative subcutaneous culture as a predictor of surgical site infection in open gynecological surgery. PLoS One 2021; 16:e0244551. [PMID: 33434238 PMCID: PMC7802959 DOI: 10.1371/journal.pone.0244551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 12/13/2020] [Indexed: 11/19/2022] Open
Abstract
Purpose To analyze the relationship between intraoperative cultures and the development of surgical site infection (SSI) in women undergoing laparotomy for gynecological surgery. Methods Prospective observational cohort study. Over a six-year period, women who underwent elective laparotomy at our hospital were included. Patients’ demographics, underlying co-morbidities, surgical variables, type and etiology of postoperative surgical site infections were collected. Skin and subcutaneous samples were taken just prior to skin closure and processed for microbiological analysis. Univariate and multivariate analyses (logistic regression model) were conducted to explore the association of the studied variables with SSIs. Results 284 patients were included in our study, of which 20 (7%) developed surgical site infection, including 11 (55%) superficial and nine (45%) organ-space. At univariate analysis, length of surgery, colon resection, transfusion and positive intraoperative culture were associated with surgical site infection occurrence. Skin and subcutaneous cultures were positive in 25 (8.8%) and 20 (7%) patients, respectively. SSI occurred in 35% of women with positive subcutaneous culture and in 20% of those with positive skin cultures. Using multivariate analysis, the only independent factor associated with surgical site infection was a positive subcutaneous culture (OR 10.4; 95% CI 3.5–30.4; P<0.001). Conclusion Intraoperative subcutaneous cultures before skin closure may help early prediction of surgical site infection in open gynecological procedures.
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Smith BK, Roberts RH, Frizelle FA. O 2 No Longer the Go 2: A Systematic Review and Meta-Analysis Comparing the Effects of Giving Perioperative Oxygen Therapy of 30% FiO 2 to 80% FiO 2 on Surgical Site Infection and Mortality. World J Surg 2020; 44:69-77. [PMID: 31605182 DOI: 10.1007/s00268-019-05224-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the effects of perioperative high (80%) versus low (30%) fraction of inspired oxygen (FiO2) on surgical site infection (SSI) and mortality in adult surgical patients. BACKGROUND The routine use of high fraction perioperative oxygen in patients is "standard of care" and recommended by the World Health Organisation; however, whether there is truly any benefit to this therapy has been challenged by some authors. Questions have also been raised about the possibility of harm from oxygen therapy. METHOD Randomised control trials comparing high-to-low FiO2 were located by searching MEDLINE, Embase, CENTRAL and Web of Science. The primary outcomes were SSI up to 15 days and up to any time point postoperatively and mortality up to 30 days. The data were analysed using random effects meta-analysis. RESULTS Twelve studies involving 10,212 participants were included. At 15 days postoperatively, and at the longest point of post-operative follow-up, there was no statistically significant reduction in the risk of SSI when comparing patients who received a perioperative FiO2 of 30% to those with an FiO2 of 80% (RR 1.41, 95% CI 1.00-2.01, p 0.05 and RR 1.23, 95% CI 1.00-1.51, p 0.05). There was no statistically significant difference in mortality between the 30% FiO2 and the 80% FiO2 groups (RR 1.12, 95% CI 0.56-2.22, p 0.76). CONCLUSION This meta-analysis showed no statistically significant difference in post-operative SSI or mortality when comparing patients receiving an FiO2 of 80% to those receiving an FiO2 of 30%.
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Affiliation(s)
- Brianna K Smith
- Christchurch Public Hospital, Canterbury District Health Board, 2 Riccarton Ave, Christchurch Central, Christchurch, 8011, New Zealand.
| | - Ross H Roberts
- Department of General Surgery at Christchurch Public Hospital, Canterbury District Health Board, Christchurch, New Zealand
- University of Otago Christchurch, Christchurch, New Zealand
| | - Frank A Frizelle
- Department of General Surgery at Christchurch Public Hospital, Canterbury District Health Board, Christchurch, New Zealand
- University of Otago Christchurch, Christchurch, New Zealand
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Cumpstey AF, Oldman AH, Smith AF, Martin D, Grocott MP. Oxygen targets in the intensive care unit during mechanical ventilation for acute respiratory distress syndrome: a rapid review. Cochrane Database Syst Rev 2020; 9:CD013708. [PMID: 32870512 PMCID: PMC8133396 DOI: 10.1002/14651858.cd013708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Supplemental oxygen is frequently administered to patients with acute respiratory distress syndrome (ARDS), including ARDS secondary to viral illness such as coronavirus disease 19 (COVID-19). An up-to-date understanding of how best to target this therapy (e.g. arterial partial pressure of oxygen (PaO2) or peripheral oxygen saturation (SpO2) aim) in these patients is urgently required. OBJECTIVES To address how oxygen therapy should be targeted in adults with ARDS (particularly ARDS secondary to COVID-19 or other respiratory viruses) and requiring mechanical ventilation in an intensive care unit, and the impact oxygen therapy has on mortality, days ventilated, days of catecholamine use, requirement for renal replacement therapy, and quality of life. SEARCH METHODS We searched the Cochrane COVID-19 Study Register, CENTRAL, MEDLINE, and Embase from inception to 15 May 2020 for ongoing or completed randomized controlled trials (RCTs). SELECTION CRITERIA Two review authors independently assessed all records in accordance with standard Cochrane methodology for study selection. We included RCTs comparing supplemental oxygen administration (i.e. different target PaO2 or SpO2 ranges) in adults with ARDS and receiving mechanical ventilation in an intensive care setting. We excluded studies exploring oxygen administration in patients with different underlying diagnoses or those receiving non-invasive ventilation, high-flow nasal oxygen, or oxygen via facemask. DATA COLLECTION AND ANALYSIS One review author performed data extraction, which a second review author checked. We assessed risk of bias in included studies using the Cochrane 'Risk of bias' tool. We used the GRADE approach to judge the certainty of the evidence for the following outcomes; mortality at longest follow-up, days ventilated, days of catecholamine use, and requirement for renal replacement therapy. MAIN RESULTS We identified one completed RCT evaluating oxygen targets in patients with ARDS receiving mechanical ventilation in an intensive care setting. The study randomized 205 mechanically ventilated patients with ARDS to either conservative (PaO2 55 to 70 mmHg, or SpO2 88% to 92%) or liberal (PaO2 90 to 105 mmHg, or SpO2 ≥ 96%) oxygen therapy for seven days. Overall risk of bias was high (due to lack of blinding, small numbers of participants, and the trial stopping prematurely), and we assessed the certainty of the evidence as very low. The available data suggested that mortality at 90 days may be higher in those participants receiving a lower oxygen target (odds ratio (OR) 1.83, 95% confidence interval (CI) 1.03 to 3.27). There was no evidence of a difference between the lower and higher target groups in mean number of days ventilated (14.0, 95% CI 10.0 to 18.0 versus 14.5, 95% CI 11.8 to 17.1); number of days of catecholamine use (8.0, 95% CI 5.5 to 10.5 versus 7.2, 95% CI 5.9 to 8.4); or participants receiving renal replacement therapy (13.7%, 95% CI 5.8% to 21.6% versus 12.0%, 95% CI 5.0% to 19.1%). Quality of life was not reported. AUTHORS' CONCLUSIONS We are very uncertain as to whether a higher or lower oxygen target is more beneficial in patients with ARDS and receiving mechanical ventilation in an intensive care setting. We identified only one RCT with a total of 205 participants exploring this question, and rated the risk of bias as high and the certainty of the findings as very low. Further well-conducted studies are urgently needed to increase the certainty of the findings reported here. This review should be updated when more evidence is available.
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Affiliation(s)
- Andrew F Cumpstey
- Critical Care Research Group, University Hospital of Southampton, Southampton, UK
| | - Alex H Oldman
- Anaesthetics and Intensive Care, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - Daniel Martin
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Michael Pw Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, University of Southampton, Southampton, UK
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Tretter V, Zach ML, Böhme S, Ullrich R, Markstaller K, Klein KU. Investigating Disturbances of Oxygen Homeostasis: From Cellular Mechanisms to the Clinical Practice. Front Physiol 2020; 11:947. [PMID: 32848874 PMCID: PMC7417655 DOI: 10.3389/fphys.2020.00947] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/14/2020] [Indexed: 12/22/2022] Open
Abstract
Soon after its discovery in the 18th century, oxygen was applied as a therapeutic agent to treat severely ill patients. Lack of oxygen, commonly termed as hypoxia, is frequently encountered in different disease states and is detrimental to human life. However, at the end of the 19th century, Paul Bert and James Lorrain Smith identified what is known as oxygen toxicity. The molecular basis of this phenomenon is oxygen's readiness to accept electrons and to form different variants of aggressive radicals that interfere with normal cell functions. The human body has evolved to maintain oxygen homeostasis by different molecular systems that are either activated in the case of oxygen under-supply, or to scavenge and to transform oxygen radicals when excess amounts are encountered. Research has provided insights into cellular mechanisms of oxygen homeostasis and is still called upon in order to better understand related diseases. Oxygen therapy is one of the prime clinical interventions, as it is life saving, readily available, easy to apply and economically affordable. However, the current state of research also implicates a reconsidering of the liberal application of oxygen causing hyperoxia. Increasing evidence from preclinical and clinical studies suggest detrimental outcomes as a consequence of liberal oxygen therapy. In this review, we summarize concepts of cellular mechanisms regarding different forms of disturbed cellular oxygen homeostasis that may help to better define safe clinical application of oxygen therapy.
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Affiliation(s)
- Verena Tretter
- Department of Anaesthesia, General Intensive Care and Pain Therapy, Medical University Vienna, Vienna, Austria
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Kirov MY, Kuzkov VV. Protective ventilation from ICU to operating room: state of art and new horizons. Korean J Anesthesiol 2020; 73:179-193. [PMID: 32008277 PMCID: PMC7280889 DOI: 10.4097/kja.19499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/16/2022] Open
Abstract
The prevention of ventilator-associated lung injury (VALI) and postoperative pulmonary complications (PPC) is of paramount importance for improving outcomes both in the operating room and in the intensive care unit (ICU). Protective respiratory support includes a wide spectrum of interventions to decrease pulmonary stress-strain injuries. The motto 'low tidal volume for all' should become routine, both during major surgery and in the ICU, while application of a high positive end-expiratory pressure (PEEP) strategy and of alveolar recruitment maneuvers requires a personalized approach and requires further investigation. Patient self-inflicted lung injury is an important type of VALI, which should be diagnosed and mitigated at the early stage, during restoration of spontaneous breathing. This narrative review highlights the strategies used for protective positive pressure ventilation. The emerging concepts of damaging energy and power, as well as pathways to personalization of the respiratory settings, are discussed in detail. In the future, individualized approaches to protective ventilation may involve multiple respiratory settings extending beyond low tidal volume and PEEP, implemented in parallel with quantifying the risk of VALI and PPC.
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Affiliation(s)
- Mikhail Y. Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
| | - Vsevolod V. Kuzkov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russian Federation
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Barbateskovic M, Schjørring OL, Russo Krauss S, Jakobsen JC, Meyhoff CS, Dahl RM, Rasmussen BS, Perner A, Wetterslev J. Higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2019; 2019:CD012631. [PMID: 31773728 PMCID: PMC6880382 DOI: 10.1002/14651858.cd012631.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The mainstay treatment for hypoxaemia is oxygen therapy, which is given to the vast majority of adults admitted to the intensive care unit (ICU). The practice of oxygen administration has been liberal, which may result in hyperoxaemia. Some studies have indicated an association between hyperoxaemia and mortality, whilst other studies have not. The ideal target for supplemental oxygen for adults admitted to the ICU is uncertain. Despite a lack of robust evidence of effectiveness, oxygen administration is widely recommended in international clinical practice guidelines. The potential benefit of supplemental oxygen must be weighed against the potentially harmful effects of hyperoxaemia. OBJECTIVES To assess the benefits and harms of higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We identified trials through electronic searches of CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, CINAHL, and LILACS. We searched for ongoing or unpublished trials in clinical trials registers. We also scanned the reference lists of included studies. We ran the searches in December 2018. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We included trials with a difference between the intervention and control groups of a minimum 1 kPa in partial pressure of arterial oxygen (PaO2), minimum 10% in fraction of inspired oxygen (FiO2), or minimum 2% in arterial oxygen saturation of haemoglobin/non-invasive peripheral oxygen saturation (SaO2/SpO2). We excluded trials randomizing participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, and PaO2 below 6 kPa) and to hyperbaric oxygen. DATA COLLECTION AND ANALYSIS Three review authors independently, and in pairs, screened the references retrieved in the literature searches and extracted data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events, and quality of life. None of the trials reported the proportion of participants with one or more serious adverse events according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. Nonetheless, most trials reported several serious adverse events. We therefore included an analysis of the effect of higher versus lower fraction of inspired oxygen, or targets using the highest reported proportion of participants with a serious adverse event in each trial. Our secondary outcomes were lung injury, acute myocardial infarction, stroke, and sepsis. None of the trials reported on lung injury as a composite outcome, however some trials reported on acute respiratory distress syndrome (ARDS) and pneumonia. We included an analysis of the effect of higher versus lower fraction of inspired oxygen or targets using the highest reported proportion of participants with ARDS or pneumonia in each trial. To assess the risk of systematic errors, we evaluated the risk of bias of the included trials. We used GRADE to assess the overall certainty of the evidence. MAIN RESULTS We included 10 RCTs (1458 participants), seven of which reported relevant outcomes for this review (1285 participants). All included trials had an overall high risk of bias, whilst two trials had a low risk of bias for all domains except blinding of participants and personnel. Meta-analysis indicated harm from higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation regarding mortality at the time point closest to three months (risk ratio (RR) 1.18, 95% confidence interval (CI) 1.01 to 1.37; I2 = 0%; 4 trials; 1135 participants; very low-certainty evidence). Meta-analysis indicated harm from higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation regarding serious adverse events at the time point closest to three months (estimated highest proportion of specific serious adverse events in each trial RR 1.13, 95% CI 1.04 to 1.23; I2 = 0%; 1234 participants; 6 trials; very low-certainty evidence). These findings should be interpreted with caution given that they are based on very low-certainty evidence. None of the included trials reported any data on quality of life at any time point. Meta-analysis indicated no evidence of a difference between higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation on lung injury at the time point closest to three months (estimated highest reported proportion of lung injury RR 1.03, 95% CI 0.78 to 1.36; I2 = 0%; 1167 participants; 5 trials; very low-certainty evidence). None of the included trials reported any data on acute myocardial infarction or stroke, and only one trial reported data on the effects on sepsis. AUTHORS' CONCLUSIONS We are very uncertain about the effects of higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU on all-cause mortality, serious adverse events, and lung injuries at the time point closest to three months due to very low-certainty evidence. Our results indicate that oxygen supplementation with higher versus lower fractions or oxygenation targets may increase mortality. None of the trials reported the proportion of participants with one or more serious adverse events according to the ICH-GCP criteria, however we found that the trials reported an increase in the number of serious adverse events with higher fractions or oxygenation targets. The effects on quality of life, acute myocardial infarction, stroke, and sepsis are unknown due to insufficient data.
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Affiliation(s)
- Marija Barbateskovic
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Olav L Schjørring
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Aalborg University HospitalDepartment of Anaesthesia and Intensive CareHobrovej 18‐22AalborgDenmark9000
| | - Sara Russo Krauss
- Copenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9Copenhagen2100DenmarkØ
| | - Janus C Jakobsen
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenSjællandDenmarkDK‐2100
- Holbaek HospitalDepartment of CardiologyHolbaekDenmark4300
- Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812CopenhagenDenmark
| | - Christian S Meyhoff
- Bispebjerg and Frederiksberg Hospital, University of CopenhagenDepartment of Anaesthesia and Intensive CareBispebjerg Bakke 23CopenhagenDenmarkDK‐2400
| | - Rikke M Dahl
- Herlev Hospital, University of CopenhagenDepartment of AnaesthesiologyHerlev Ringvej 75, Pavillon 10, I65F10HerlevDenmark2730
| | - Bodil S Rasmussen
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Aalborg University HospitalDepartment of Anaesthesia and Intensive CareHobrovej 18‐22AalborgDenmark9000
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Righospitalet, Copenhagen University HospitalDepartment of Intensive CareCopenhagenDenmark
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University HospitalCopenhagen Trial Unit, Centre for Clinical Intervention ResearchBlegdamsvej 9CopenhagenDenmarkDK‐2100
- Department 7831, Rigshospitalet, Copenhagen University HospitalCentre for Research in Intensive CareBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Ottolenghi S, Rubino FM, Sabbatini G, Coppola S, Veronese A, Chiumello D, Paroni R. Oxidative Stress Markers to Investigate the Effects of Hyperoxia in Anesthesia. Int J Mol Sci 2019; 20:ijms20215492. [PMID: 31690051 PMCID: PMC6862279 DOI: 10.3390/ijms20215492] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/24/2019] [Accepted: 10/29/2019] [Indexed: 12/15/2022] Open
Abstract
Oxygen (O2) is commonly used in clinical practice to prevent or treat hypoxia, but if used in excess (hyperoxia), it may act as toxic. O2 toxicity arises from the enhanced formation of Reactive Oxygen Species (ROS) that exceed the antioxidant defenses and generate oxidative stress. In this study, we aimed at assessing whether an elevated fraction of inspired oxygen (FiO2) during and after general anesthesia may contribute to the unbalancing of the pro-oxidant/antioxidant equilibrium. We measured five oxidative stress biomarkers in blood samples from patients undergoing elective abdominal surgery, randomly assigned to FiO2 = 0.40 vs. 0.80: hydroperoxides, antioxidants, nitrates and nitrites (NOx), malondialdehyde (MDA), and glutathionyl hemoglobin (HbSSG). The MDA concentration was significantly higher 24 h after surgery, and the body antioxidant defense lower, in the FiO2 = 0.80 group with respect to both the FiO2 = 0.40 group and the baseline values (p ≤ 0.05, Student’s t-test). HbSSG in red blood cells was also higher in the FiO2 = 0.80 group at the end of the surgery. NOx was higher in the FiO2 = 0.80 group than the FiO2 = 0.40 group at t = 2 h after surgery. MDA, the main end product of the peroxidation of polyunsaturated fatty acids directly influenced by FiO2, may represent the best marker to assess the pro-oxidant/antioxidant equilibrium after surgery.
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Affiliation(s)
- Sara Ottolenghi
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
| | - Federico Maria Rubino
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
| | - Giovanni Sabbatini
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
| | - Silvia Coppola
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
| | - Alice Veronese
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
| | - Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, 20142 Milan, Italy.
- Coordinated Research Center on Respiratory Failure, University of Milan, 20123 Milan, Italy.
| | - Rita Paroni
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, 20142 Milan, Italy.
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Li XF, Jiang D, Jiang YL, Yu H, Jiang JL, He LL, Yang XY, Yu H. PROtective Ventilation with a low versus high Inspiratory Oxygen fraction (PROVIO) and its effects on postoperative pulmonary complications: protocol for a randomized controlled trial. Trials 2019; 20:619. [PMID: 31675982 PMCID: PMC6823955 DOI: 10.1186/s13063-019-3668-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 08/19/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Postoperative pulmonary complications (PPCs) are the most common perioperative complications following surgical site infection (SSI). They prolong the hospital stay and increase health care costs. A lung-protective ventilation strategy is considered better practice in abdominal surgery to prevent PPCs. However, the role of the inspiratory oxygen fraction (FiO2) in the strategy remains disputed. Previous trials have focused on reducing SSI by increasing the inhaled oxygen concentration but higher FiO2 (80%) was found to be associated with a greater incidence of atelectasis and mortality in recent research. The trial aims at evaluating the effect of different FiO2 added to the lung-protective ventilation strategy on the incidence of PPCs during general anesthesia for abdominal surgery. METHODS AND DESIGN PROtective Ventilation with a low versus high Inspiratory Oxygen fraction trial (PROVIO) is a single-center, prospective, randomized controlled trial planning to recruit 252 patients undergoing abdominal surgery lasting for at least 2 h. The patients will be randomly assigned to (1) a low-FiO2 (30% FiO2) group and (2) a high-FiO2 (80% FiO2) group in the lung-protective ventilation strategy. The primary outcome of the study is the occurrence of PPCs within the postoperative 7 days. Secondary outcomes include the severity grade of PPCs, the occurrence of postoperative extrapulmonary complications and all-cause mortality within the postoperative 7 and 30 days. DISCUSSION The PROVIO trial assesses the effect of low versus high FiO2 added to a lung-protective ventilation strategy on PPCs for abdominal surgery patients and the results should provide practical approaches to intraoperative oxygen management. TRIAL REGISTRATION www.ChiCTR.org.cn , identifier: ChiCTR18 00014901 . Registered on 13 February 2018.
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Affiliation(s)
- Xue-Fei Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Dan Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Yu-Lian Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jia-Li Jiang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Lei-Lei He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Xiao-Yun Yang
- Department of Gynecology, West China Second University Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Battaglini D, Robba C, Rocco PRM, De Abreu MG, Pelosi P, Ball L. Perioperative anaesthetic management of patients with or at risk of acute distress respiratory syndrome undergoing emergency surgery. BMC Anesthesiol 2019; 19:153. [PMID: 31412784 PMCID: PMC6694484 DOI: 10.1186/s12871-019-0804-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/15/2019] [Indexed: 02/07/2023] Open
Abstract
Patients undergoing emergency surgery may present with the acute respiratory distress syndrome (ARDS) or develop this syndrome postoperatively. The incidence of ARDS in the postoperative period is relatively low, but the impact of ARDS on patient outcomes and healthcare costs is relevant Aakre et.al (Mayo Clin Proc 89:181-9, 2014).The development of ARDS as a postoperative pulmonary complication (PPC) is associated with prolonged hospitalisation, longer duration of mechanical ventilation, increased intensive care unit length of stay and high morbidity and mortality Ball et.al (Curr Opin Crit Care 22:379-85, 2016). In order to mitigate the risk of ARDS after surgery, the anaesthetic management and protective mechanical ventilation strategies play an important role. In particular, a careful integration of general anaesthesia with neuraxial or locoregional techniques might promote faster recovery and reduce opioid consumption. In addition, the use of low tidal volume, minimising plateau pressure and titrating a low-moderate PEEP level based on the patient's need can improve outcome and reduce intraoperative adverse events. Moreover, perioperative management of ARDS patients includes specific anaesthesia and ventilator settings, hemodynamic monitoring, moderately restrictive fluid administration and pain control.The aim of this review is to provide an overview and evidence- and opinion-based recommendations concerning the management of patients at risk of and with ARDS who undergo emergency surgical procedures.
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Affiliation(s)
- Denise Battaglini
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Patricia Rieken Macêdo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Gama De Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
| | - Lorenzo Ball
- Anaesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Oldman AH, Cumpstey AF, Martin DS, Grocott MPW. Data integrity issues: catalyst for a more robust approach to research on perioperative oxygen therapy? Perioper Med (Lond) 2019; 8:7. [PMID: 31312441 PMCID: PMC6610798 DOI: 10.1186/s13741-019-0118-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/26/2019] [Indexed: 01/18/2023] Open
Affiliation(s)
- Alex H. Oldman
- Critical Care Research Group, Southampton National Institute of Health Research, Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Andrew F. Cumpstey
- Critical Care Research Group, Southampton National Institute of Health Research, Biomedical Research Centre, University Hospital Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Daniel S. Martin
- Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
| | - Michael P. W. Grocott
- Critical Care Research Group, Southampton National Institute of Health Research, Biomedical Research Centre, University Hospital Southampton, Southampton, UK
- Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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Rasmussen BS, Frei D, Schjørring OL, Meyhoff CS, Young PJ. Perioperative Oxygenation Targets in Adults. CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00326-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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L’her E, Jaber S, Verzilli D, Jacob C, Huiban B, Futier E, Kerforne T, Pateau V, Bouchard PA, Gouillou M, Nowak E, Lellouche F. Automated oxygen administration versus conventional oxygen therapy after major abdominal or thoracic surgery: study protocol for an international multicentre randomised controlled study. BMJ Open 2019; 9:e023833. [PMID: 30782716 PMCID: PMC6340445 DOI: 10.1136/bmjopen-2018-023833] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION Hypoxemia and hyperoxia may occur after surgery with potential related complications. The FreeO2 PostOp trial is a prospective, multicentre, randomised controlled trial that evaluates the clinical impact of automated O2 administration versus conventional O2 therapy after major abdominal or thoracic surgeries. The study is powered to demonstrate benefits of automated oxygen titration and weaning in term of oxygenation, which is an important surrogate for complications after such interventions. METHODS AND ANALYSIS After extubation, patients are randomly assigned to the Standard (manual O2 administration) or FreeO2 group (automated closed-loop O2 administration). Stratification is performed for the study centre and a medical history of chronic obstructive pulmonary disease (COPD). Primary outcome is the percentage of time spent in the target zone of oxygen saturation, during a 3-day time frame. In both groups, patients will benefit from continuous oximetry recordings. The target zone of oxygen saturation is SpO2=88%-92% for patients with COPD and 92%-96% for patients without COPD. Secondary outcomes are the nursing workload assessed by the number of manual O2 flow adjustments, the time spent with severe desaturation (SpO2 <85%) and hyperoxia area (SpO2 >98%), the time spent in a hyperoxia area (SpO2 >98%), the VO2, the duration of oxygen administration during hospitalisation, the frequency of use of mechanical ventilation (invasive or non-invasive), the duration of the postrecovery room stay, the hospitalisation length of stay and the survival rate. ETHICS AND DISSEMINATION The FreeO2 PostOp study is conducted in accordance with the declaration of Helsinki and was registered on 11 September 2015 (http://www.clinicaltrials.gov). First patient inclusion was performed on 14 January 2016. The results of the study will be presented at academic conferences and submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02546830.
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Affiliation(s)
- Erwan L’her
- Medical Intensive Care, CHRU de Brest—La Cavale Blanche, Brest, France
- LATIM INSERM UMR 1101, FHU Techsan, Université de Bretagne Occidentale, Brest, France
| | - Samir Jaber
- Intensive Care Unit, Department of Anesthesiology B, DAR B CHU de Montpellier, Hôpital Saint Eloi, Université Montpellier 1, Montpellier, France
| | - Daniel Verzilli
- Intensive Care Unit, Department of Anesthesiology B, DAR B CHU de Montpellier, Hôpital Saint Eloi, Université Montpellier 1, Montpellier, France
| | - Christophe Jacob
- Anesthesiology Department, CHRU de Brest—La Cavale Blanche, Brest, France
| | - Brigitte Huiban
- Anesthesiology Department, CHRU de Brest—La Cavale Blanche, Brest, France
| | - Emmanuel Futier
- Anesthesiology Department, Hôpital Estaing, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas Kerforne
- Anesthesiology Department, CHU de Poitiers, Poitiers Cedex, France
| | - Victoire Pateau
- LATIM INSERM UMR 1101, FHU Techsan, Université de Bretagne Occidentale, Brest, France
- R&D, Oxynov Inc., Technopôle Brest Iroise, Plouzané, France
| | - Pierre-Alexandre Bouchard
- Research laboratory, Centre de recherche de l’Institut de Cardiologie et de Pneumologie de Québec, Québec, France
| | - Maellen Gouillou
- Centre d’Investigation Clinique CIC INSERM 1412, CHRU de Brest—La Cavale Blanche, Brest, France
| | - Emmanuel Nowak
- Centre d’Investigation Clinique CIC INSERM 1412, CHRU de Brest—La Cavale Blanche, Brest, France
| | - François Lellouche
- Research laboratory, Centre de recherche de l’Institut de Cardiologie et de Pneumologie de Québec, Québec, France
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Park J, Min JJ, Kim SJ, Ahn JH, Kim K, Lee JH, Park K, Chung IS. Effects of lowering inspiratory oxygen fraction during microvascular decompression on postoperative gas exchange: A pre-post study. PLoS One 2018; 13:e0206371. [PMID: 30427854 PMCID: PMC6235305 DOI: 10.1371/journal.pone.0206371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/11/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite many previous studies, the optimal oxygen fraction during general anesthesia remains controversial. This study aimed to evaluate the effects of lowering intraoperative fraction of inspired oxygen on postoperative gas exchange in patients undergoing microvascular decompression (MVD). METHODS We conducted a pre-post study to compare postoperative gas exchange with different intraoperative oxygen fractions. From April 2010 to June 2017, 1456 consecutive patients who underwent MVD were enrolled. Starting in January 2014, routine oxygen fraction was lowered from 1.0 to 0.3 during anesthetic induction/awakening and from 0.5 to 0.3 during anesthetic maintenance. Postoperative gas exchange, presented as the minimum value of PaO2/FIO2 ratio within 48 hours, were compared along with adverse events. RESULTS Among 1456 patients, 623 (42.8%) patients were stratified into group H (high FIO2) and 833 (57.2%) patients into group L (low FIO2). Intraoperative positive end-expiratory pressure was used in 126 (15.1%) patients in group H and 90 (14.4%) patients in group L (p = 0.77).The minimum value of PaO2/ FIO2 ratio within 48 hours after surgery was significantly greater in the group L (226.13 vs. 323.12; p < 0.001) without increasing any adverse events. CONCLUSION In patients undergoing MVD, lowering routine FIO2 and avoiding 100% O2 improved postoperative gas exchange.
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Affiliation(s)
- Jungchan Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong Jin Min
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Jin Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Hee Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keoungah Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong-Hwan Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- * E-mail:
| | - Kwan Park
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ik Soo Chung
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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The Effect of Anaesthetic and Analgesic Technique on Oncological Outcomes. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0299-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Mehmood S, Changeez M, Aziz M, Adnan N, Tariq M, Malik S, Khan JS. Effects of Supplemental Perioperative Oxygen in Preventing Transient Hypoparathyroidism After Total Thyroidectomy. Cureus 2018; 10:e3440. [PMID: 30915262 PMCID: PMC6433448 DOI: 10.7759/cureus.3440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Background Thyroidectomy is one of the most common endocrine procedures performed worldwide. Post-operative hypocalcemia is a troublesome complication of thyroid surgery. Few studies have considered the role of supplemental oxygen in preventing postoperative hypocalcemia in patients undergoing thyroidectomy. Materials and methods This was a randomized controlled study comparing the use of high flow supplemental oxygen (FiO2 80%) with low flow oxygen (FiO2 30%) in preventing transient postoperative hypocalcemia. Seventy-eight patients undergoing thyroidectomy during the year 2017 in Surgery Unit-1, Holy Family Hospital were included in the study. Results Transient hypoparathyroidism was present in 20.5% (n=8/39) in group 1 while it was present in 59.0% (n=23/39) in group 2 patients. Patients in group 1 (FiO2 80%) demonstrated a significantly lower percentage of transient hypoparathyroidism than group 2 (FiO2 30%) (P=0.001). Conclusion Our study concluded that high flow supplemental oxygen (FiO2 80%) significantly decreases the risk of developing postoperative transient hypocalcemia.
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Affiliation(s)
| | | | | | | | - Maham Tariq
- Surgery, Holy Family Hospital, Rawalpindi, PAK
| | - Sara Malik
- Surgery, Holy Family Hospital, Rawalpindi, PAK
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Morkane CM, McKenna H, Cumpstey AF, Oldman AH, Grocott MPW, Martin DS. Intraoperative oxygenation in adult patients undergoing surgery (iOPS): a retrospective observational study across 29 UK hospitals. Perioper Med (Lond) 2018; 7:17. [PMID: 30062007 PMCID: PMC6057104 DOI: 10.1186/s13741-018-0098-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 07/06/2018] [Indexed: 01/26/2023] Open
Abstract
Background Considerable controversy remains about how much oxygen patients should receive during surgery. The 2016 World Health Organization (WHO) guidelines recommend that intubated patients receive a fractional inspired oxygen concentration (FIO2) of 0.8 throughout abdominal surgery to reduce the risk of surgical site infection. However, this recommendation has been widely criticised by anaesthetists and evidence from other clinical contexts has suggested that giving a high concentration of oxygen might worsen patient outcomes. This retrospective multi-centre observational study aimed to ascertain intraoperative oxygen administration practice by anaesthetists across parts of the UK. Methods Patients undergoing general anaesthesia with an arterial catheter in situ across hospitals affiliated with two anaesthetic trainee audit networks (PLAN, SPARC) were eligible for inclusion unless undergoing cardiopulmonary bypass. Demographic and intraoperative oxygenation data, haemoglobin saturation and positive end-expiratory pressure were retrieved from anaesthetic charts and arterial blood gases (ABGs) over five consecutive weekdays in April and May 2017. Results Three hundred seventy-eight patients from 29 hospitals were included. Median age was 66 years, 205 (54.2%) were male and median ASA grade was 3. One hundred eight (28.6%) were emergency cases. An anticipated difficult airway or raised BMI was documented preoperatively in 31 (8.2%) and 45 (11.9%) respectively. Respiratory or cardiac comorbidity was documented in 103 (27%) and 83 (22%) respectively. SpO2 < 96% was documented in 83 (22%) patients, with 7 (1.9%) patients desaturating < 88% at any point intraoperatively. The intraoperative FIO2 ranged from 0.25 to 1.0, and median PaO2/FIO2 ratios for the first four arterial blood gases taken in each case were 24.6/0.5, 23.4/0.49, 25.7/0.46 and 25.4/0.47 respectively. Conclusions Intraoperative oxygenation currently varies widely. An intraoperative FIO2 of 0.5 currently represents standard intraoperative practice in the UK, with surgical patients often experiencing moderate levels of hyperoxaemia. This differs from both WHO’s recommendation of using an FIO2 of 0.8 intraoperatively, and also, the value most previous interventional oxygen therapy trials have used to represent standard care (typically FIO2 = 0.3). These findings should be used to aid the design of future intraoperative oxygen studies.
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Affiliation(s)
- Clare M Morkane
- 1Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
| | - Helen McKenna
- 1Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
| | - Andrew F Cumpstey
- University of Southampton/University Hospital Southampton and NIHR Biomedical Research Centre, Tremona Rd, Southampton, SO16 6YD UK
| | - Alex H Oldman
- 3University Hospital Southampton, Tremona Rd, Southampton, SO16 6YD UK
| | - Michael P W Grocott
- University of Southampton/University Hospital Southampton and NIHR Biomedical Research Centre, Tremona Rd, Southampton, SO16 6YD UK
| | - Daniel S Martin
- 1Division of Surgery and Interventional Science (University College London) and Royal Free Perioperative Research Group, Department of Anaesthesia, Royal Free Hospital, 3rd Floor, Pond Street, London, NW3 2QG UK
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Grensemann J, Fuhrmann V, Kluge S. Oxygen Treatment in Intensive Care and Emergency Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:455-462. [PMID: 30064624 PMCID: PMC6111205 DOI: 10.3238/arztebl.2018.0455] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 11/02/2017] [Accepted: 03/26/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Oxygen treatment is often life-saving, but multiple studies in recent years have yielded evidence that the indiscriminate administration of oxygen to patients in the intensive care unit and emergency room can cause hyperoxia and thereby elevate mortality. METHODS This review is based on prospective, randomized trials concerning the optimum use of oxygen in adult medicine, which were retrieved by a selective search in PubMed, as well as on pertinent retrospective studies and guideline recommendations. RESULTS 13 prospective, randomized trials involving a total of 17 213 patients were analyzed. In patients with acute exacerbations of chronic obstructive pulmonary disease (COPD) and in ventilated intensive-care patients, normoxia was associated with a lower mortality than hyperoxia (2% vs. 9%). In patients with myocardial infarction, restrictive oxygen administration was associated with a smaller infarct size on cardiac MRI at 6 months compared to oxygen administration at 8 L/min (13.1 g vs. 20.3 g). For patients with stroke, the currently available data do not reveal any benefit or harm from oxygen administration. None of the trials showed any benefit from the administration of oxygen to non-hypoxemic patients; in fact, this was generally associated with increased morbidity or mortality. CONCLUSION Hypoxemia should certainly be avoided, but the fact that the liberal administration of oxygen to patients in intensive care units and emergency rooms tends to increase morbidity and mortality implies the advisability of a conservative, normoxic oxygenation strategy.
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Affiliation(s)
- Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
OBJECTIVE This systematic review aimed to identify and describe the evidence for supplementary oxygen for spontaneously breathing trauma patients, and for high (0.60-0.90) versus low (0.30-0.50) inspiratory oxygen fraction (FiO2) for intubated trauma patients in the initial phase of treatment. METHODS Several databases were systematically searched in September 2017 for studies fulfilling the following criteria: trauma patients (Population); supplementary oxygen/high FiO2 (Intervention) versus no supplementary oxygen/low FiO2 (Control) for spontaneously breathing or intubated trauma patients, respectively, in the initial phase of treatment; mortality, complications, days on mechanical ventilation and/or length of stay (LOS) in hospital/intensive care unit (ICU) (Outcomes); prospective interventional trials (Study design). Two independent reviewers screened and identified studies and extracted data from included studies. RESULTS 6142 citations were screened with an inter-rater reliability (Cohen's kappa) of 0.88. One interventional trial of intubated trauma patients was included. 68 trauma patients were randomised to receive an FiO2 of 0.80 (intervention group) or 0.50 (control group) during mechanical ventilation (first 6 hours). There was no significant difference in hospital or ICU LOS between the groups. No patient died in either group. Another interventional trial, not strictly fulfilling the inclusion criteria, was presented for descriptive purposes. 21 trauma patients were alternately assigned to two types of mechanical ventilation (first 48 hours), both aiming at an FiO2 of 0.40, but resulted in estimated mean FiO2s of 0.45 (intervention group) and 0.60 (control group). No difference in days on mechanical ventilation was found. Two patients in the control group died, none in the intervention group. No prospective, interventional trials on spontaneously breathing trauma patients were identified. CONCLUSIONS Evidence for the use of supplementary oxygen for spontaneously breathing trauma patients is lacking, and the evidence for low versus high FiO2 for intubated trauma patients is limited. PROSPERO REGISTRATION NUMBER 42016050552.
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Affiliation(s)
| | | | - Jacob Steinmetz
- Department of Anesthesia, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anesthesia, University of Copenhagen, Copenhagen, Denmark
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Robson JP, Kokhanenko P, Marshall JK, Phillips AR, van der Linden J. Increased visceral tissue perfusion with heated, humidified carbon dioxide insufflation during open abdominal surgery in a rodent model. PLoS One 2018; 13:e0195465. [PMID: 29617447 PMCID: PMC5884566 DOI: 10.1371/journal.pone.0195465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 03/22/2018] [Indexed: 01/07/2023] Open
Abstract
Tissue perfusion during surgery is important in reducing surgical site infections and promoting healing. This study aimed to determine if insufflation of the open abdomen with heated, humidified (HH) carbon dioxide (CO2) increased visceral tissue perfusion and core body temperature during open abdominal surgery in a rodent model. Using two different rodent models of open abdominal surgery, visceral perfusion and core temperature were measured. Visceral perfusion was investigated using a repeated measures crossover experiment with rodents receiving the same sequence of two alternating treatments: exposure to ambient air (no insufflation) and insufflation with HH CO2. Core body temperature was measured using an independent experimental design with three treatment groups: ambient air, HH CO2 and cold, dry (CD) CO2. Visceral perfusion was measured by laser speckle contrast analysis (LASCA) and core body temperature was measured with a rectal thermometer. Insufflation with HH CO2 into a rodent open abdominal cavity significantly increased visceral tissue perfusion (2.4 perfusion units (PU)/min (95% CI 1.23-3.58); p<0.0001) compared with ambient air, which significantly reduced visceral blood flow (-5.20 PU/min (95% CI -6.83- -3.58); p<0.0001). Insufflation of HH CO2 into the open abdominal cavity significantly increased core body temperature (+1.15 ± 0.14°C) compared with open cavities exposed to ambient air (-0.65 ± 0.52°C; p = 0.037), or cavities insufflated with CD CO2 (-0.73 ± 0.33°C; p = 0.006). Abdominal visceral temperatures also increased with HH CO2 insufflation compared with ambient air or CD CO2, as shown by infrared thermography. This study reports for the first time the use of LASCA to measure visceral perfusion in open abdominal surgery and shows that insufflation of open abdominal cavities with HH CO2 significantly increases visceral tissue perfusion and core body temperature.
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Affiliation(s)
| | | | | | - Anthony R. Phillips
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Jan van der Linden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Crowley PD, Stuttgen V, O'Carroll E, Ash SA, Buggy DJ, Gallagher HC. Exposure to 60% oxygen promotes migration and upregulates angiogenesis factor secretion in breast cancer cells. Med Gas Res 2018; 7:226-235. [PMID: 29497482 PMCID: PMC5806442 DOI: 10.4103/2045-9912.222446] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Peri-operative factors, including anaesthetic drugs and techniques, may affect cancer cell biology and clinical recurrence. In breast cancer cells, we demonstrated that sevoflurane promotes migration and angiogenesis in high fractional oxygen but not in air. Follow-up analysis of the peri-operative oxygen fraction trial found an association between high inspired oxygen during cancer surgery and reduced tumor-free survival. Here we evaluated effects of acute, high oxygen exposure on breast cancer cell viability, migration and secretion of angiogenesis factors in vitro. MDA-MB-231 and MCF-7 breast cancer cells were exposed to 21%, 30%, 60%, or 80% v/v O2 for 3 hours. Cell viability at 24 hours was determined by MTT and migration at 24 hours with the Oris™ Cell Migration Assay. Secretion of angiogenesis factors at 24 hours was measured via membrane-based immunoarray. Exposure to 30%, 60% or 80% oxygen did not affect cell viability. Migration of MDA-MB-231 and MCF-7 cells was increased by 60% oxygen (P = 0.012 and P = 0.007, respectively) while 30% oxygen increased migration in MCF-7 cells (P = 0.011). These effects were reversed by dimethyloxaloylglycine. In MDA-MB-231 cells high fractional oxygen increased secretion of angiogenesis factors monocyte chemotactic protein 1, regulated on activation normal T-cell expressed and vascular endothelial growth factor. In MCF-7 cells, interleukin-8, angiogenin and vascular endothelial growth factor secretion was significantly increased by high fractional oxygen. High oxygen exposure stimulates migration and secretion of angiogenesis factors in breast cancer cells in vitro.
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Affiliation(s)
- Peter D Crowley
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Vivian Stuttgen
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland.,School of Veterinary Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Emma O'Carroll
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland
| | - Simon A Ash
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland.,Discipline of Anesthesia, Memorial University, Canada
| | - Donal J Buggy
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland.,Mater Misericordiae University Hospital, Dublin, Ireland.,Outcomes Research Consortium, Cleveland Clinic, Cleveland, OH, USA.,UCD-Mater Clinical Research Centre, Catherine McCauley Centre, Dublin, Ireland
| | - Helen C Gallagher
- School of Medicine, Conway Institute, University College Dublin, Dublin, Ireland.,UCD-Mater Clinical Research Centre, Catherine McCauley Centre, Dublin, Ireland
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Brugniaux JV, Coombs GB, Barak OF, Dujic Z, Sekhon MS, Ainslie PN. Highs and lows of hyperoxia: physiological, performance, and clinical aspects. Am J Physiol Regul Integr Comp Physiol 2018; 315:R1-R27. [PMID: 29488785 DOI: 10.1152/ajpregu.00165.2017] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Molecular oxygen (O2) is a vital element in human survival and plays a major role in a diverse range of biological and physiological processes. Although normobaric hyperoxia can increase arterial oxygen content ([Formula: see text]), it also causes vasoconstriction and hence reduces O2 delivery in various vascular beds, including the heart, skeletal muscle, and brain. Thus, a seemingly paradoxical situation exists in which the administration of oxygen may place tissues at increased risk of hypoxic stress. Nevertheless, with various degrees of effectiveness, and not without consequences, supplemental oxygen is used clinically in an attempt to correct tissue hypoxia (e.g., brain ischemia, traumatic brain injury, carbon monoxide poisoning, etc.) and chronic hypoxemia (e.g., severe COPD, etc.) and to help with wound healing, necrosis, or reperfusion injuries (e.g., compromised grafts). Hyperoxia has also been used liberally by athletes in a belief that it offers performance-enhancing benefits; such benefits also extend to hypoxemic patients both at rest and during rehabilitation. This review aims to provide a comprehensive overview of the effects of hyperoxia in humans from the "bench to bedside." The first section will focus on the basic physiological principles of partial pressure of arterial O2, [Formula: see text], and barometric pressure and how these changes lead to variation in regional O2 delivery. This review provides an overview of the evidence for and against the use of hyperoxia as an aid to enhance physical performance. The final section addresses pathophysiological concepts, clinical studies, and implications for therapy. The potential of O2 toxicity and future research directions are also considered.
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Affiliation(s)
| | - Geoff B Coombs
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada
| | - Otto F Barak
- Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia.,Faculty of Sport and Physical Education, University of Novi Sad, Novi Sad, Serbia
| | - Zeljko Dujic
- Department of Integrative Physiology, School of Medicine, University of Split , Split , Croatia
| | - Mypinder S Sekhon
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada.,Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia , Vancouver, British Columbia , Canada
| | - Philip N Ainslie
- Centre for Heart, Lung, and Vascular Health, University of British Columbia , Kelowna, British Columbia , Canada
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42
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Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O'Connor L, Cawthorne J, George RP, Crosbie EJ, Rithalia AD, Cheng H. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2018; 2:CD012653. [PMID: 29406579 PMCID: PMC6491077 DOI: 10.1002/14651858.cd012653.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient's own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. OBJECTIVES To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. METHODS Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and 'Risk of bias' and certainty assessment. We used the ROBIS (risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. MAIN RESULTS We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence.There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence - assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between short-term compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). AUTHORS' CONCLUSIONS This overview provides the most up-to-date evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews. There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood.
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Affiliation(s)
- Zhenmi Liu
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Gill Norman
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Maggie J Westby
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery and Social Work, School of Health Sciences, Faculty of Biology, Medicine and HealthJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Jane Blazeby
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Emma McFarlane
- National Institute for Health and Care ExcellenceCentre for GuidelinesLevel 1A, City TowerPiccadilly PlazaManchesterUKM1 4BD
| | - Nicky J Welton
- University of BristolNIHR Bristol Biomedical Research Centre, School of Social and Community Medicine, Bristol Medical SchoolBristolUK
| | - Louise O'Connor
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Julie Cawthorne
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Ryan P George
- Central Manchester University Hospitals NHS Foundation TrustInfection Prevention and Control / Tissue Viability TeamCobbett HouseOxford RoadManchesterUKM13 9WL
| | - Emma J Crosbie
- Faculty of Biology, Medicine and Health, University of ManchesterDivision of Cancer Sciences5th Floor ‐ ResearchSt Mary's HospitalManchesterUKM13 9WL
| | - Amber D Rithalia
- Independent Researcher7 Victoria Terrace, KirkstallLeedsUKLS5 3HX
| | - Hung‐Yuan Cheng
- University of BristolBristol Centre for Surgical Research, Bristol Medical SchoolOffice 2.01Canynge Hall, 39 Whatley RoadBristolUKBS8 2PS
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Akca O, Ball L, Belda FJ, Biro P, Cortegiani A, Eden A, Ferrando C, Gattinoni L, Goldik Z, Gregoretti C, Hachenberg T, Hedenstierna G, Hopf HW, Hunt TK, Pelosi P, Qadan M, Sessler DI, Soro M, Şentürk M. WHO Needs High FIO 2? Turk J Anaesthesiol Reanim 2017; 45:181-192. [PMID: 28868164 DOI: 10.5152/tjar.2017.250701] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
World Health Organization and the United States Center for Disease Control have recently recommended the use of 0.8 FIO2 in all adult surgical patients undergoing general anaesthesia, to prevent surgical site infections. This recommendation has arisen several discussions: As a matter of fact, there are numerous studies with different results about the effect of FIO2 on surgical site infection. Moreover, the clinical effects of FIO2 are not limited to infection control. We asked some prominent authors about their comments regarding the recent recommendations.
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Affiliation(s)
- Ozan Akca
- Department of Anesthesiology and Perioperative Medicine, Neuroscience ICU, University of Louisville, Kentucky, USA
| | - Lorenzo Ball
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - F Javier Belda
- Department of Anesthesiology and Critical Care, Hospital Clinico Universitario, University of Valencia, Valencia, Spain
| | - Peter Biro
- Institute of Anesthesiology, University Hospital Zurich, Switzerland
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone. University of Palermo, Italy
| | - Arieh Eden
- Department of Anesthesiology, Critical Care and Pain Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Carlos Ferrando
- Department of Anesthesiology and Critical Care, Hospital Clinico Universitario, University of Valencia, Valencia, Spain
| | - Luciano Gattinoni
- Department of Anesthesiology Emergency & Intensive Care Medicine, Gottingen University, Gottingen, Germany
| | - Zeev Goldik
- Department of Anesthesiology, Critical Care and Pain Medicine, Lady Davis Carmel Medical Center, Haifa, Israel
| | - Cesare Gregoretti
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone. University of Palermo, Italy
| | - Thomas Hachenberg
- Department of Anaesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | | | - Harriet W Hopf
- Department of Anesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Thomas K Hunt
- Division of General Surgery, University of California, San Francisco, USA
| | - Paolo Pelosi
- IRCCS AOU San Martino-IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Motaz Qadan
- Massachusetts General Hospital, Department of Surgery, Harvard University, Massachusetts, USA
| | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marina Soro
- Department of Anesthesiology and Critical Care, Hospital Clinico Universitario, University of Valencia, Valencia, Spain
| | - Mert Şentürk
- Department of Anaesthesiology and Reanimation, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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Ferrando C, Soro M, Unzueta C, Canet J, Tusman G, Suarez-Sipmann F, Librero J, Peiró S, Pozo N, Delgado C, Ibáñez M, Aldecoa C, Garutti I, Pestaña D, Rodríguez A, García del Valle S, Diaz-Cambronero O, Balust J, Redondo FJ, De La Matta M, Gallego L, Granell M, Martínez P, Pérez A, Leal S, Alday K, García P, Monedero P, Gonzalez R, Mazzinari G, Aguilar G, Villar J, Belda FJ. Rationale and study design for an individualised perioperative open-lung ventilatory strategy with a high versus conventional inspiratory oxygen fraction (iPROVE-O2) and its effects on surgical site infection: study protocol for a randomised controlled trial. BMJ Open 2017; 7:e016765. [PMID: 28760799 PMCID: PMC5642673 DOI: 10.1136/bmjopen-2017-016765] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Surgical site infection (SSI) is a serious postoperative complication that increases morbidity and healthcare costs. SSIs tend to increase as the partial pressure of tissue oxygen decreases: previous trials have focused on trying to reduce them by comparing high versus conventional inspiratory oxygen fractions (FIO2) in the perioperative period but did not use a protocolised ventilatory strategy. The open-lung ventilatory approach restores functional lung volume and improves gas exchange, and therefore it may increase the partial pressure of tissue oxygen for a given FIO2. The trial presented here aims to compare the efficacy of high versus conventional FIO2 in reducing the overall incidence of SSIs in patients by implementing a protocolised and individualised global approach to perioperative open-lung ventilation. METHODS AND ANALYSIS This is a comparative, prospective, multicentre, randomised and controlled two-arm trial that will include 756 patients scheduled for abdominal surgery. The patients will be randomised into two groups: (1) a high FIO2 group (80% oxygen; FIO2 of 0.80) and (2) a conventional FIO2 group (30% oxygen; FIO2 of 0.30). Each group will be assessed intra- and postoperatively. The primary outcome is the appearance of postoperative SSI complications. Secondary outcomes are the appearance of systemic and pulmonary complications. ETHICS AND DISSEMINATION The iPROVE-O2 trial has been approved by the Ethics Review Board at the reference centre (the Hospital Clínico Universitario in Valencia). Informed consent will be obtained from all patients before their participation. If the approach using high FIO2 during individualised open-lung ventilation decreases SSIs, use of this method will become standard practice for patients scheduled for future abdominal surgery. Publication of the results is anticipated in early 2019. TRIAL REGISTRATION NUMBER NCT02776046; Pre-results.
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Affiliation(s)
- Carlos Ferrando
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Marina Soro
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carmen Unzueta
- Department of Anesthesiology and Critical Care, Hospital de la Santa Creu i Sant Pau, Valencia, Spain
| | - Jaume Canet
- Department of Anesthesiology and Critical Care, Hospital Germans Tries i Pujol, Badalona, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Argentina
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Department of Surgical Sciences, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden
| | - Julian Librero
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Navarrabiomed Fundación Miguel Servet, Pamplona, Spain
| | - Salvador Peiró
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Centro Superior de Investigación en Salud Pública (CSISP FISABIO), Valencia, Spain
| | - Natividad Pozo
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Carlos Delgado
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Maite Ibáñez
- Department of Anesthesiology, Hospital de Villajoyosa, Villajoyosa, Spain
| | - César Aldecoa
- Department of Anesthesiology and Critical Care, Hospital de Villajoyosa, Villajoyosa, Spain
| | - Ignacio Garutti
- Department of Anesthesiology and Critical Care, Hospital General Gregorio Marañon, Madrid, Spain
| | - David Pestaña
- Anesthesiology and Critical Care, Hospital Ramón y Cajal, Madrid, Spain
| | - Aurelio Rodríguez
- Anesthesiology and Critical Care, Hospital Dr. Negrín, Gran Canaria, Spain
| | | | | | - Jaume Balust
- Anesthesiology and Critical Care, Hospital Clínic i Provincial, Barcelona, Spain
| | | | - Manuel De La Matta
- Anesthesiology and Critical Care, Hospital Vírgen del Rocio, Seville, Spain
| | - Lucía Gallego
- Anesthesiology and Critical Care, Hospital Miguel Servet, Zaragoza, Spain
| | - Manuel Granell
- Anesthesiology and Critical Care, Hospital General, Valencia, Spain
| | - Pascual Martínez
- Anesthesiology and Critical Care, Hospital de Albacete, Albacete, Spain
| | - Ana Pérez
- Anesthesiology and Critical Care, Hospital of Elche, Elche, Spain
| | - Sonsoles Leal
- Anesthesiology and Critical Care, Hospital Povisa, Vigo, Spain
| | - Kike Alday
- Anesthesiology and Critical Care, Hospital La Princesa, Madrid, Spain
| | - Pablo García
- Anesthesiology and Critical Care, Hospital 12 de Octubre, Madrid, Spain
| | - Pablo Monedero
- Anesthesiology and Critical Care, Clínica Universidad de Navarra, Pamplona, Spain
| | - Rafael Gonzalez
- Anesthesiology and Critical Care, Hospital Universitario de León, León, Spain
| | - Guido Mazzinari
- Anesthesiology and Critical Care, Hospital de Manises, Manises, Spain
| | - Gerardo Aguilar
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
| | - Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Gran Canaria, Spain
- Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Francisco Javier Belda
- Department of Anesthesiology and Critical Care, Hospital Clínico Universitario, Valencia, Spain
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Guirao X. The dream of surgery without complications: A great step, much to do. Cir Esp 2017; 95:487-489. [PMID: 28738992 DOI: 10.1016/j.ciresp.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 07/02/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Xavier Guirao
- Servicio de Cirugía General y del Aparato Digestivo, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autónoma de Barcelona, Sabadell, España.
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46
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Barbateskovic M, Schjørring OLL, Jakobsen JC, Meyhoff CS, Dahl RM, Rasmussen BS, Perner A, Wetterslev J. Higher versus lower inspiratory oxygen fraction or targets of arterial oxygenation for adult intensive care patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012631] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marija Barbateskovic
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Olav Lilleholt L Schjørring
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Aalborg University Hospital; Department of Anaesthesia and Intensive Care Medicine; Hobrovej 18-22 Aalborg Denmark 9000
| | - Janus C Jakobsen
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Sjaelland Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
| | - Christian S Meyhoff
- Bispebjerg Hospital, University of Copenhagen; Department of Anaesthesiology; Copenhagen NV Denmark
| | - Rikke M Dahl
- Herlev Hospital, University of Copenhagen; Department of Anaesthesiology; Herlev Ringvej 75, Pavillon 10, I65F10 Herlev Denmark 2730
| | - Bodil S Rasmussen
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Aalborg University Hospital; Department of Anaesthesia and Intensive Care Medicine; Hobrovej 18-22 Aalborg Denmark 9000
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
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Abstract
Oxygen is an element, which is used liberally during several medical procedures. The use of oxygen during perioperative care is a controversial issue. Anesthesiologists use oxygen to prevent hypoxemia during surgical procedures, but the effects of its liberal use can be harmful. Another argument for using high oxygen concentrations is to prevent surgical site infections by increasing oxygen levels at the incision site. Although inconclusive, literature concerning the use of high oxygen concentrations during anesthesia show that this approach may cause hemodynamic changes, altered microcirculation and increased oxidative stress. In intensive care it has been shown that high oxygen concentrations may be associated with increased mortality in certain patient populations such as post cardiac arrest patients. In this paper, a review of literature had been undertaken to warn anesthesiologists about the potential harmful effects of high oxygen concentrations.
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Affiliation(s)
- Yalim Dikmen
- Istanbul University, Cerrahpasa Medical School, Department of Anesthesiology and Reanimation, Turkey
| | - Aybike Onur
- Istanbul University, Cerrahpasa Medical School, Department of Anesthesiology and Reanimation, Turkey
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48
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Cardiac surgery, a right target for hyperoxia? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:162. [PMID: 27306619 PMCID: PMC4910213 DOI: 10.1186/s13054-016-1347-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
In perioperative cardiac surgery period, supra-physiological arterial oxygen partial pressures is common practice, although there is no clear evidence of any benefit. Smit et al. have shown that a “conservative” approach did not improve hemodynamics, decrease oxidative stress or myocardial tissue damage, but was not associated with major deleterious event either. Here, we outline major oxygen friend or foes properties, which may partly explain the study results, and place the clinical trial from Smit et al. in a global context.
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49
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Kendale SM, Blitz JD. Increasing body mass index and the incidence of intraoperative hypoxemia. J Clin Anesth 2016; 33:97-104. [PMID: 27555141 DOI: 10.1016/j.jclinane.2016.03.020] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/08/2016] [Indexed: 02/07/2023]
Abstract
STUDY OBJECTIVE Obese patients regularly present for surgery and have greater hypoxemia risk. This study aimed to identify the risk and incidence of intraoperative hypoxemia with increasing body mass index (BMI). DESIGN This was a retrospective cohort study. SETTING Operating room. PATIENTS A total of 15,238 adult patients who underwent general anesthesia for elective noncardiac surgery at a single large urban academic institution between January 2013 and December 2014. INTERVENTIONS Unadjusted and risk-adjusted logistic regression analyses explored the relationship between increasing categories of BMI and intraoperative hypoxemia, severe hypoxemia, and prolonged hypoxemia. MEASUREMENTS Intraoperative pulse oximeter readings and preoperative patient characteristics. MAIN RESULTS With normal BMI, 731 (16%) patients experienced hypoxemia compared with 1150 (28%) obese patients. Adjusted odds ratio (AOR) of intraoperative hypoxemia increased with each category of BMI from 1.27 (95% confidence interval [CI], 1.12-1.44) in overweight patients to 2.63 (95% CI, 2.15-3.23) in patients with class III obesity. AOR of severe hypoxemia was significant with class I obesity (AOR, 1.32; 95% CI, 1.08-1.60), class II obesity (AOR, 2.01; 95% CI, 1.59-2.81), and class III obesity (AOR, 2.27; 95% CI, 1.75-2.93). AOR of prolonged hypoxemia increased with BMI from 3.29 (95% CI, 1.79-6.23) with class I obesity to 9.20 (95% CI, 4.74-18) with class III obesity. CONCLUSIONS Despite existing practices to limit hypoxemia in obese patients, the odds of experiencing intraoperative hypoxemia increase significantly with increasing categories of BMI. Further practices may need to be developed to minimize the risk of intraoperative hypoxemia in obese patients.
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Affiliation(s)
- Samir M Kendale
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, New York University School of Medicine, 550 First Ave, New York, NY 10016.
| | - Jeanna D Blitz
- Department of Anesthesiology, Perioperative Care, & Pain Medicine, New York University School of Medicine, 550 First Ave, New York, NY 10016
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50
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Hafner S, Beloncle F, Koch A, Radermacher P, Asfar P. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care 2015; 5:42. [PMID: 26585328 PMCID: PMC4653126 DOI: 10.1186/s13613-015-0084-6] [Citation(s) in RCA: 123] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 11/02/2015] [Indexed: 12/22/2022] Open
Abstract
This review summarizes the (patho)-physiological effects of ventilation with high FiO2 (0.8–1.0), with a special focus on the most recent clinical evidence on its use for the management of circulatory shock and during medical emergencies. Hyperoxia is a cornerstone of the acute management of circulatory shock, a concept which is based on compelling experimental evidence that compensating the imbalance between O2 supply and requirements (i.e., the oxygen dept) is crucial for survival, at least after trauma. On the other hand, “oxygen toxicity” due to the increased formation of reactive oxygen species limits its use, because it may cause serious deleterious side effects, especially in conditions of ischemia/reperfusion. While these effects are particularly pronounced during long-term administration, i.e., beyond 12–24 h, several retrospective studies suggest that even hyperoxemia of shorter duration is also associated with increased mortality and morbidity. In fact, albeit the clinical evidence from prospective studies is surprisingly scarce, a recent meta-analysis suggests that hyperoxia is associated with increased mortality at least in patients after cardiac arrest, stroke, and traumatic brain injury. Most of these data, however, originate from heterogenous, observational studies with inconsistent results, and therefore, there is a need for the results from the large scale, randomized, controlled clinical trials on the use of hyperoxia, which can be anticipated within the next 2–3 years. Consequently, until then, “conservative” O2 therapy, i.e., targeting an arterial hemoglobin O2 saturation of 88–95 % as suggested by the guidelines of the ARDS Network and the Surviving Sepsis Campaign, represents the treatment of choice to avoid exposure to both hypoxemia and excess hyperoxemia.
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Affiliation(s)
- Sebastian Hafner
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany. .,Klinik für Anästhesiologie, Universitätsklinikum Ulm, Albert-Einstein-Allee 23, 89081, Ulm, Germany.
| | - François Beloncle
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, Cedex 9, 49933, Angers, France. .,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214-INSERM U1083, Université Angers, PRES L'UNAM, Nantes, France.
| | - Andreas Koch
- Sektion Maritime Medizin, Institut für Experimentelle Medizin, Christian-Albrechts-Universität, 24118, Kiel, Germany. .,Schifffahrtmedizinisches Institut der Marine, 24119, Kronshagen, Germany.
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstrasse 8-1, 89081, Ulm, Germany.
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, 4 rue Larrey, Cedex 9, 49933, Angers, France. .,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214-INSERM U1083, Université Angers, PRES L'UNAM, Nantes, France.
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