Effect of Intraoperative High Inspired Oxygen Fraction on Surgical Site Infection, Postoperative Nausea and Vomiting, and Pulmonary Function

Abstract

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

O2 and N2O: Between the Rock and the Hard Place

“…Should a high FiO 2 be used and promote a decreased probability of surgical site infection [7]. Or, in case of a documented high pulmonary vascular resistance, should a high FiO 2 be used to try and mitigate this situation [8].…”

“…Pre-oxygenation to prevent hypoxia during laryngoscopy [3] Formation of atelectasis & shunt [3] Post-oxygenation to reduce emergence hypoxia [3] Alveolar collapse & shunt [3] May decrease surgical wound infection [7] Risk of Acute Lung Injury [10] Decrease pulmonary vascular resistance [8] Higher lung inflammation in spontaneous ventilation [9] Use oxygen judiciously, if possible find other means to improve oxygenation before increasing FiO2, remember the advantages of PEEP and recruiting maneuvers [3]. …”

WHO Needs High FIO2?

“…Several meta-analysis have shown that the administration of high FIO 2 (0.8) compared to lower (0.3) seems to reduce surgical site infection (33). The effect might be due to an increase in partial pressure of tissue oxygen PtsO 2 because an increase in partial pressure of arterial oxygen (PaO 2 ), which in turn increases the bacterycidal capacity of neutrophils and reduces local oxydative stress as we have recently shown (34,35).…”

To Give or Not To Give - Is that the Question?: The Changing Face of Emergency Oxygen Therapy

“…On-going clinical trials continue to seek to establish the efficacy of oxygen on mortality, surgical site infections, nausea and atelectasis with varying results [43][44][45]. Likewise on-going research is attempting to position the use of hyperoxygenation in cluster headache [46] and the use of hyperbaric oxygen for various chronic wounds [47][48].…”