OXYGENOTERAPIE V PERIOPERAČNÍM OBDOBÍ

Jiří ChvojkaPlzeň

„„„„ČČČČlovlovlovlověěěěk je stvok je stvok je stvok je stvořřřřen ze zemen ze zemen ze zemen ze zem ěěěě, ž ije však ze vzduchu. V e vzduchu je ukryt pokrm ž ivota .“, ž ije však ze vzduchu. V e vzduchu je ukryt pokrm ž ivota .“, ž ije však ze vzduchu. V e vzduchu je ukryt pokrm ž ivota .“, ž ije však ze vzduchu. V e vzduchu je ukryt pokrm ž ivota .“

M ichal Sendivoj ze Skorska

(1566-1636)

Cornelius Jacobszoon D rebbel

(1572-1633)

Joseph Priestley

(1733-1804)

A ntoine L avoisier

(1743-1794)

HYPOXIE

1928

1942

CUNNINGHAM SANATORIUMCUNNINGHAM SANATORIUMCUNNINGHAM SANATORIUMCUNNINGHAM SANATORIUM

Kam jsme se posunuli?

KYSLÍK

• Ročně v USA více než 21 milionů celkových anestezií

• Jeden z nejužívanějších léčivých prostředků

• Kyslík je lék

• Je lékem v pravém slova smyslu, má své biochemické a fyziologickéfunkce, široké rozpětí v dávkování, nežádoucí účinky

• více než 15% pacientů přijatých do nemocnic v Británii léčeni oxygenoterapií• prakticky „univerzální“ lék• podání kyslíku i bez přítomnosti hypoxie/hypoxémie

• Status epilepticus

Benefit kyslíku

• Produkce kyslíkových radikálů• Oxidační vzplanutí• Výbava neutrofilů, makrofágů• Likvidace bakterií ve fagozomu oxidáza-dependentní cestou• Podmínkou vysoká tenze kyslíku v daném prostředí• Částečná ztráta obranyschopnosti neutrofilů při hypoxii

Vliv na hojení chirurgické rány? (surgical site infection, SSI)

• 300 000/rok v USA (17% všech HAI, 2.nejčastější po UTI)

• SSI zvyšují mortalitu

• Prodlužují pobyt v nemocnici

• Zvyšují náklady na léčbu (3000 – 29000 USD/SSI)

• Může perioperační navýšení FiO2 snížit incidenci SSI?

• Potenciace oxidačního vzplanutí neutrofilů zvýšením tenze kyslíku v operační ráně

Kirkland KB, Briggs JP, Trivette SL, et al. Infect Control Hosp Epidemiol 1999.

Bratzler DW, Houck PM, Richards C, et al. Arch Surg 2005

Supplemental Perioperative Oxygen To Reduce The Incidence Of Surgical-wound Infection

• Background Destruction by oxidation, or oxidative killing, is the most importantdefense against surgical pathogens and depends on the partial pressure ofO2 in contaminated tissue. An easy method of improving O2 tension inadequately perfused tissue is to increase the concentration of FiO2.

• Methods randomly, 500 pts, colorectal resection, FiO2 30% or 80% during theoperation and for two hours afterward.

• Results Among 250 pts with FiO2 80%, 13 (5.2%) had surgical-wound infections,as compared with 28 of 250 pts 30% FiO2 (11.2% P=0.01). The absolutedifference between groups was 6%, with a relative risk reduction of 54%.

N Engl J Med 2000; 342:161-7

Supplemental Perioperative O2 and the Risk of Surgical Wound Infection A Randomized Controlled Trial

• Background Supplemental perioperative oxygen has been variously reported tohalve or double the risk of surgical wound infection. To test the hypothesis thatsupplemental oxygen reduces infection risk in patients following colorectalsurgery.

• Methods randomly, 300 pts, colorectal resection, FiO2 30% or 80% during theoperation and for six hours afterward.

• Results Among 148 pts with FiO2 80%, 22 (14.9%) had surgical-woundinfections, as compared with 35 of 143 pts with FiO2 30% (24.4% P=0.04). Theabsolute risk reduction was 9%, with a relative risk reduction of 39%.

JAMA 2005; 294:2035-2042

“There is little cost and no risk to the administration ofperioperative supplemental oxygen. Given that the interventionmakes sense from a biological and scientific perspective, beingeasy to perform and relatively noninvasive, practical, and with anexcellent risk:benefit profile, incorporating it into current qualityimprovement activities aimed at reducing surgical site infectionshould be relatively straightforward. “

“There is little cost and no risk to the administration ofperioperative supplemental oxygen. Given that the interventionmakes sense from a biological and scientific perspective, beingeasy to perform and relatively noninvasive, practical, and with anexcellent risk:benefit profile, incorporating it into current qualityimprovement activities aimed at reducing surgical site infectionshould be relatively straightforward. “

…možná. …opravdu?

• Design, Setting, and Patients Double-blind, randomized controlled trial conducted between September 2001 andMay 2003 at a large university hospital in metropolitan New York City of 165 patients undergoing major intra-abdominal surgical procedures under general anesthesia.

• Interventions Patients were randomly assigned to receive either 80% oxygen (FIO2 of 0.80) or 35% oxygen (FIO2

of 0.35) during surgery and for the first 2 hours after surgery.

• Results The study groups were closely matched in a large number of clinical variables. The overall incidence ofSSI was 18.1%. In an intention-to-treat analysis, the incidence of infection was significantly higher in the groupreceiving FIO2 of 0.80 than in the group with FIO2 of 0.35 (25.0% vs 11.3%; P = .02). FIO2 remained a significantpredictor of SSI (P = .03) in multivariate regression analysis. Patients who developed SSI had a significantly longerlength of hospitalization after surgery (mean [SD], 13.3 [9.9] vs 6.0 [4.2] days; P<.001).

• Conclusions The routine use of high perioperative FIO2 in a general surgical population does not reduce theoverall incidence of SSI and may have predominantly deleterious effects. General surgical patients shouldcontinue to receive oxygen with cardiorespiratory physiology as the principal determinant.

From: Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population: A Randomized Controlled TrialFrom: Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population: A Randomized Controlled Trial

JAMA. 2004;291(1):79-87. doi:10.1001/jama.291.1.79JAMA. 2004;291(1):79-87. doi:10.1001/jama.291.1.79

From: Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population: A Randomized Controlled Trial

JAMA. 2004;291(1):79-87. doi:10.1001/jama.291.1.79

• Kyslík není jedinou “zbraní” v boji s infekcí• Likvidace patogenů i na kyslíku nezávislou cestou• Vysoký tkáňový pO2 negarantuje stejné pO2 intracelulárně• Nepříznivý vliv kyslíkových radikálů v operační ráně a vliv

na hojení potenciací zánětlivého procesu při hyperoxii?

• Adekvátní systémová hemodynamika negarantuje dobrou perfúzi chirurgické rány• Adekvátní oxygenace arteriální krve negarantuje dostatečný tpO2

• Neznáme tenzi kyslíku intracelulárně• Významná role mikrocirkulace

• Conclusions: In a group of patients assessed following major abdominal surgery,peripheral perfusion alterations were associated with the development of severecomplications independently of systemic haemodynamics. Further research isneeded to confirm these findings and to explore in more detail the effects ofperipheral perfusion–targeted resuscitation following major abdominal surgery.

Asepse

ATB politika

Kontrola glykémie

Kyslík

From: Effect of High Perioperative Oxygen Fraction on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery: The PROXI Randomized Clinical TrialFrom: Effect of High Perioperative Oxygen Fraction on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery: The PROXI Randomized Clinical Trial

JAMA. 2009;302(14):1543-1550. doi:10.1001/jama.2009.1452JAMA. 2009;302(14):1543-1550. doi:10.1001/jama.2009.1452

From: Effect of High Perioperative Oxygen Fraction on Surgical Site Infection and Pulmonary Complications After Abdominal Surgery: The PROXI Randomized Clinical Trial

JAMA. 2009;302(14):1543-1550. doi:10.1001/jama.2009.1452

• Objective To assess whether use of 80% oxygen reducesthe frequency of surgical site infection without increasingthe frequency of pulmonary complications in patientsundergoing abdominal surgery.

• Interventions Patients were randomly assigned to receiveeither 80% or 30% oxygen during and for 2 hours aftersurgery.

• Results Surgical site infection occurred in 131 of 685patients (19.1%) assigned to receive 80% oxygen vs 141of 701 (20.1%) assigned to receive 30% oxygen (oddsratio [OR], 0.94; 95% confidence interval [CI], 0.72-1.22;P = .64).

• Conclusion Administration of 80% oxygen compared with30% oxygen did not result in a difference in risk ofsurgical site infection after abdominal surgery.

• RESULTS: Vital status was obtained in 1382 of 1386 patients after a median follow-up of 2.3 years (range 1.3 to3.4 years). One hundred fifty-nine of 685 patients (23.2%) died in the 80% oxygen group compared to 128 of701 patients (18.3%) assigned to 30% oxygen (HR, 1.30 [95% confidence interval, 1.03 to 1.64], P \ 0.03). Inpatients undergoing cancer surgery, the HR was 1.45; 95% confidence interval, 1.10 to 1.90; P \ 0.009; andafter noncancer surgery, the HR was 1.06; 95% confidence interval, 0.69 to 1.65; P \ 0.79.

• CONCLUSIONS: Administration of 80% oxygen in the perioperative period was associated with significantlyincreased long-term mortality and this appeared to be statistically significant in patients undergoing cancersurgery but not in noncancer patients.