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Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infection

Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infection. Greif R, Akca O, Horn EP, Kurz A, Sessler DI The New England Journal of Medicine Volume 342 (3) pp 161-167; 20/01/2000 Presentation: Michael Miroshnik Michael Bennett.

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Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infection

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  1. Supplemental Perioperative Oxygen to Reduce the Incidence of Surgical Wound Infection Greif R, Akca O, Horn EP, Kurz A, Sessler DI The New England Journal of Medicine Volume 342 (3) pp 161-167; 20/01/2000 Presentation: Michael Miroshnik Michael Bennett

  2. Background • Wound infection is a common and serious complication of surgery • In colorectal surgery, wound infection rates range from 9 to 27% • Delaying discharge 5-20 days • The first few hours after tissue is contaminated constitutes the critical period of infection establishment

  3. Background • Bactericidal activity of neutrophils is mediated by oxidative killing • Superoxide radicals produced from molecular oxygen • NADPH-linked oxygenase • Rate of reaction proportional to the pTO2 in the range 0 - >300mmHg • FiO2 -> paO2 -> pTO2

  4. Hypothesis • Supplemental oxygen during the perioperative period decreases the incidence of wound infection in patients undergoing elective colorectal resection

  5. Materials & Methods • 500 patients undergoing elective open colorectal resection enrolled 96’ - 98’ • 3 treatment centers in Europe • Exclusions • Minor colon surgery (e.g. polypectomy) • Recent fever, infection • Serious malnutrition (Alb <33 or >20% BW loss) • Bowel obstruction

  6. Materials & Methods • Anaesthetic & operative treatment standardised • Standard mechanical bowel prep • Prophylactic IV Abs • Computer randomised into 2 groups after anaesthetic induction • 30% FiO2 & 80% FiO2 • Assigned O2 received during operation & 2 hours thereafter

  7. Evaluation • ABGs 1hr post induction & 2hrs post extubation • Subcut pO2 sensor & PTFE implant in 54 patients • Muscle pO2 sensor in 24 patients

  8. Materials & Methods • Double blind protocol • Wounds evaluated daily until discharge • Independent physician assessors • Further evaluation at 2 week follow up • Wounds with culture +ve pus considered ‘infected’

  9. Assignment & Analysis

  10. Results • Clinical characteristics, surgical procedures & haemodynamic values similar in the 2 groups • PaO2 & PTO2 significantly higher in 80% FiO2 group • Overall incidence of wound infection was 8% (41/500) • Two-tailed chi-square tests for analysis of data

  11. Absolute difference in infection rates of 6.0% (95% CI 1.2 - 10.8; P <0.012) • Relative difference of 54%

  12. Conclusions • The administration of supplemental oxygen during colorectal resection and for two hours afterward reduced the incidence of wound infection by HALF • The cost and risk associated with administering supplemental O2 is trivial • Independent study of 30 patients showed no atelectasis or pulmonary fx with supplemental O2

  13. Conclusions • Healing in the absence of infection was not improved by supplemental oxygen • O2 substrate for prolyl & lysyl hydroxylases • Effect saturated at pO2 20-25mmHg

  14. Positive Commentary • Large, well constructed, multicentre, double blind, randomised, controlled, prospective study • Good process of randomisation • Large number of potential confounders identified and controlled • 30 listed • Excellent follow up

  15. Positive Commentary • ‘Intention to treat’ analysis • FiO2ed from assigned value in 39 pts • 38 in 30%FiO2 group; 1 in 80%FiO2 group • Statistically and clinically significant result which is relevant to current surgical practice

  16. Negative Commentary • Important confounders not controlled • Diabetes • CRF or immunosuppressive Rx • Prophylactic antibiotic regimes • Choice: Different IV Abs used • Duration: IV Abs given for 2.7 +/- 2.3 days after the skin incision

  17. Negative Commentary • Little comment/analysis of death & ICU admission rates

  18. Negative Commentary • Surgical/ID Depts not involved in study • Poor definition of an ‘infected’ wound • 10 patients produced culture -ve pus • 6 in 30%FiO2 group; 4 in 80%FiO2 group • Poor delineation of operations included • 3 patients withdrawing from study assumed to have no infection • 2 in 30%FiO2 group; 1 in 80%FiO2 group

  19. Discussion

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