Background: Intraoperative high inspired oxygen fraction (FIo 2 ) is thought to reduce the incidence of surgical site infection (SSI) and postoperative nausea and vomiting, and to promote postoperative atelectasis. Methods: The authors searched for randomized trials (till September 2012) comparing intraoperative high with normal FIo 2 in adults undergoing surgery with general anesthesia and reporting on SSI, nausea or vomiting, or pulmonary outcomes. Results: The authors included 22 trials (7,001 patients) published in 26 reports. High FIo 2 ranged from 80 to 100% (median, 80%); normal FIo 2 ranged from 30 to 40% (median, 30%). In nine trials (5,103 patients, most received prophylactic antibiotics), the incidence of SSI decreased from 14.1% with normal FIo 2 to 11.4% with high FIo 2 ; risk ratio, 0.77 (95% CI, 0.59-1.00). After colorectal surgery, the incidence of SSI decreased from 19.3 to 15.2%; risk ratio, 0.78 (95% CI, 0.60-1.02). In 11 trials (2,293 patients), the incidence of nausea decreased from 24.8% with normal FIo 2 to 19.5% with high FIo 2 ; risk ratio, 0.79 (95% CI, 0.66-0.93). In patients receiving inhalational anesthetics without prophylactic antiemetics, high FIo 2 provided a significant protective effect against both nausea and vomiting. Nine trials (3,698 patients) reported on pulmonary outcomes. The risk of atelectasis was not increased with high FIo 2 . Conclusions: Intraoperative high FIo 2 further decreases the risk of SSI in surgical patients receiving prophylactic antibiotics, has a weak beneficial effect on nausea, and does not increase the risk of postoperative atelectasis. IT has been claimed that patients undergoing surgery with general anesthesia were benefiting from a higher than normal inspired oxygen fraction (FIo 2 ).1,2 Some authors have suggested that a high FIo 2 was a simple, inexpensive, and lowrisk intervention, and that the broader use of this technique should be encouraged in patients undergoing major abdominal procedures.3 Randomized trials have reported on a reduced risk of surgical site infection (SSI) in patients who were ventilated with 80% FIo 2 during surgery. 4,5 It was also shown that patients who were ventilated with high FIo 2 intraoperatively had a reduced incidence of postoperative nausea and vomiting (PoNV). 6,7 other authors were more cautious. 8,9 Skepticism has been partly related to the fact that high FIo 2 may have deleterious What This Article Tells Us That Is New• Intraoperative high inspired oxygen fraction decreases the risk of surgical site infection in surgical patients receiving prophylactic antibiotics, has a weak beneficial effect on nausea, and does not increase the risk of postoperative atelectasis

BACKGROUND Blood transfusions are associated with morbidity and mortality. However, restrictive thresholds could harm patients less able to tolerate anemia. Using a context-specific approach (according to patient characteristics and clinical settings), the authors conducted a systematic review to quantify the effects of transfusion strategies. METHODS The authors searched MEDLINE, EMBASE, CENTRAL, and grey literature sources to November 2015 for randomized controlled trials comparing restrictive versus liberal transfusion strategies applied more than 24 h in adult surgical or critically ill patients. Data were independently extracted. Risk ratios were calculated for 30-day complications, defined as inadequate oxygen supply (myocardial, cerebral, renal, mesenteric, and peripheral ischemic injury; arrhythmia; and unstable angina), mortality, composite of both, and infections. Statistical combination followed a context-specific approach. Additional analyses explored transfusion protocol heterogeneity and cointerventions effects. RESULTS Thirty-one trials were regrouped into five context-specific risk strata. In patients undergoing cardiac/vascular procedures, restrictive strategies seemed to increase the risk of events reflecting inadequate oxygen supply (risk ratio [RR], 1.09; 95% CI, 0.97 to 1.22), mortality (RR, 1.39; 95% CI, 0.95 to 2.04), and composite events (RR, 1.12; 95% CI, 1.01 to 1.24-3322, 3245, and 3322 patients, respectively). Similar results were found in elderly orthopedic patients (inadequate oxygen supply: RR, 1.41; 95% CI, 1.03 to 1.92; mortality: RR, 1.09; 95% CI, 0.80 to 1.49; composite outcome: RR, 1.24; 95% CI, 1.00 to 1.54-3465, 3546, and 3749 patients, respectively), but not in critically ill patients. No difference was found for infections, although a protective effect may exist. Risk estimates varied with successful/unsuccessful transfusion protocol implementation. CONCLUSIONS Restrictive transfusion strategies should be applied with caution in high-risk patients undergoing major surgery.

The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.

A trend toward reduced reoperation rates for SSI was observed after checklist implementation in this high standard care environment; no influence on other outcome measures was observed.

Background The effect of anesthetic drugs on cancer outcomes remains unclear. This trial aimed to assess postoperative circulating tumor cell counts—an independent prognostic factor for breast cancer—to determine how anesthesia may indirectly affect prognosis. It was hypothesized that patients receiving sevoflurane would have higher postoperative tumor cell counts. Methods The parallel, randomized controlled trial was conducted in two centers in Switzerland. Patients aged 18 to 85 yr without metastases and scheduled for primary breast cancer surgery were eligible. The patients were randomly assigned to either sevoflurane or propofol anesthesia. The patients and outcome assessors were blinded. The primary outcome was circulating tumor cell counts over time, assessed at three time points postoperatively (0, 48, and 72 h) by the CellSearch assay. Secondary outcomes included maximal circulating tumor cells value, positivity (cutoff: at least 1 and at least 5 tumor cells/7.5 ml blood), and the association between natural killer cell activity and tumor cell counts. This trial was registered with ClinicalTrials.gov (NCT02005770). Results Between March 2014 and April 2018, 210 participants were enrolled, assigned to sevoflurane (n = 107) or propofol (n = 103) anesthesia, and eventually included in the analysis. Anesthesia type did not affect circulating tumor cell counts over time (median circulating tumor cell count [interquartile range]; for propofol: 1 [0 to 4] at 0 h, 1 [0 to 2] at 48 h, and 0 [0 to 1] at 72 h; and for sevoflurane: 1 [0 to 4] at 0 h, 0 [0 to 2] at 48 h, and 1 [0 to 2] at 72 h; rate ratio, 1.27 [95% CI, 0.95 to 1.71]; P = 0.103) or positivity. In one secondary analysis, administrating sevoflurane led to a significant increase in maximal tumor cell counts postoperatively. There was no association between natural killer cell activity and circulating tumor cell counts. Conclusions In this randomized controlled trial investigating the effect of anesthesia on an independent prognostic factor for breast cancer, there was no difference between sevoflurane and propofol with respect to circulating tumor cell counts over time. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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T he consequences of endotracheal tube (ETT) cuff leak can range from a bubbling noise to a life-threatening ventilator failure. Whereas the definitive solution is replacement of the ETT, such a measure is often not needed or not safe to perform. Many times, the leak is not caused by a structural defect in the ETT. Cuff underinflation, cephalad migration of the ETT (partial tracheal extubation), misplaced orogastric or nasogastric tubes, wide discrepancy between ETT and tracheal diameters, or increased peak airway pressure can lead to leaks around intact cuffs. Correction of such problems will stop the leak without having to replace the ETT. Nonetheless, ETT cuff, pilot balloon, and inflation system damage owing to inadvertent trauma or manufacturing defects may be responsible. Conservative management ideas (management without ETT replacement) have been published earlier. However, when a large structural defect is identified or conservative measures fail, ETT replacement becomes necessary. This can be done with direct laryngoscopy if laryngeal visualization is adequate. A difficult exchange with possible airway loss should be expected and prepared for when there are signs and/or a history of difficult intubation. A risk-benefit analysis of each situation is warranted before making decisions on how best to proceed. Alternative back-up ventilator plans should be made in advance, and the necessary equipment should be ready before the exchange. Various management concerns and plans are presented, as is a simple algorithm for managing leaky ETT cuffs.

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