Effects of high versus low inspiratory oxygen fraction on postoperative clinical outcomes in patients undergoing surgery under general anesthesia: A systematic review and meta-analysis of randomized controlled trials

Lim, Choon Hak; Han, Ju-young; Cha, Seung-ha; Kim, Yun-Hee; Yoo, Kyung Yeon; Kim, Hyun-Jung

doi:10.1016/j.jclinane.2021.110461

Cited by 18 publications

(14 citation statements)

References 67 publications

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“…5,6 Thus, some uncertainty remains regarding this balance of beneficial versus deleterious effects, and it might depend on certain patient and surgical characteristics. Although there are recent systematic reviews on this topic, 7,8 there are new trials to consider, 9,10 and these previous reviews have not extensively explored the potential effect heterogeneity between trials.…”

Section: Introductionmentioning

confidence: 99%

Fraction of inspired oxygen during general anesthesia for non‐cardiac surgery: Systematic review and meta‐analysis

Høybye

Lind

Holmberg

et al. 2022

Acta Anaesthesiol Scand

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Background: Controversy exists regarding the effects of a high versus a low intraoperative fraction of inspired oxygen (FiO 2 ) in adults undergoing general anesthesia. This systematic review and meta-analysis investigated the effect of a high versus a low FiO 2 on postoperative outcomes.Methods: PubMed and Embase were searched on March 22, 2022 for randomized clinical trials investigating the effect of different FiO 2 levels in adults undergoing general anesthesia for non-cardiac surgery. Two investigators independently reviewed studies for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and potential effect measure modification was assessed in subgroup analyses and meta-regression. The evidence certainty was evaluated using GRADE.Results: This review included 25 original trials investigating the effect of a high (mostly 80%) versus a low (mostly 30%) FiO 2 . Risk of bias was intermediate for all trials. A high FiO 2 did not result in a significant reduction in surgical site infections (OR: 0.91, 95% CI 0.81-1.02 [p = .10]). No effect was found for all other included outcomes, including mortality (OR = 1.27, 95% CI: 0.90-1.79 [p = .18]) and hospital length of stay (mean difference = 0.03 days, 95% CI À0.25 to 0.30 [p = .84). Results from subgroup analyses and meta-regression did not identify any clear effect modifiers across outcomes. The certainty of evidence (GRADE) was rated as low for most outcomes.Maria Høybye and Peter C. Lind contributed equally.

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Section: Introductionmentioning

confidence: 99%

Fraction of inspired oxygen during general anesthesia for non‐cardiac surgery: Systematic review and meta‐analysis

Høybye

Lind

Holmberg

et al. 2022

Acta Anaesthesiol Scand

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“…According to our study results, if we interpret only the LUSS results performed after surgery in the BMI ≥ 30 group, similar to the results of a recent meta-analysis, there was no significant difference in the degree of atelectasis. [15][16][17] However, we believe that the difference in LUSS before and after surgery better reflects the rate of atelectasis after surgery and is important for clinically judging the risk and benefit of patients requiring high-concentration oxygen infusion.…”

Section: Discussionmentioning

confidence: 99%

“…[16] However, this meta-analysis did not consider the degree of atelectasis of the obese patient prior to anesthesia, and the various durations of exposure to different concentrations of oxygen and various types of surgeries were included. [12,13,[15][16][17] Therefore, this study was designed to target patients undergoing surgery that does not affect lung dynamics, to avoid exposure to high concentrations of oxygen even for a short period of time in the group receiving a low FiO 2 , and to examine the effect of inhaled oxygen concentration on the development of atelectasis by differentiating obese and normal-weight patients.…”

Section: Introductionmentioning

confidence: 99%

Lung ultrasound score-based assessment of postoperative atelectasis in obese patients according to inspired oxygen concentration: A prospective, randomized-controlled study

et al. 2023

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Background: According to a recent meta-analysis, in patients with a body mass index (BMI) ≥ 30, a high fraction of inhaled oxygen (FiO2) did not increase postoperative atelectasis. However, a high FiO2 generally increases the risk of postoperative atelectasis. Therefore, this study aimed to evaluate the effect of FiO2 on the development of atelectasis in obese patients using the modified lung ultrasound score (LUSS). Methods: Patients were assigned to 4 groups: BMI ≥ 30: group A (n = 21) and group B (n = 20) and normal BMI: group C (n = 22) and group D (n = 21). Groups A and C were administered 100% O2 during preinduction and emergence and 50% O2 during anesthesia. Groups B and D received 40% O2 for anesthesia. The modified LUSS was assessed before and 20 min after arrival to the postanesthesia care unit (PACU). Results: The difference between the modified LUSS preinduction and PACU was significantly higher in group A with a BMI ≥ 30 (P = .006); however, there was an insignificant difference between groups C and D in the normal BMI group (P = .076). Conclusion: High FiO2 had a greater effect on the development of atelectasis in obese patients than did low FiO2; however, in normal-weight individuals, FiO2 did not have a significant effect on postoperative atelectasis.

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“…We believe that this absence of protective effect in these subgroups of interest strongly reduces the potential interest of systematic high intraoperative FiO 2 . This becomes even more relevant when considering the results of another recent meta-analysis focusing on the effect of high vs. low intraoperative FiO 2 on respiratory outcomes, which did not report any beneficial effect on clinical outcomes such as hospital length-of-stay or mortality, and on the contrary a higher incidence of postoperative radiographic atelectasis associated with reduced postoperative PaO 2 values 54 .…”

Section: Discussionmentioning

confidence: 99%

Updated meta-analysis on intraoperative inspired fraction of oxygen and the risk of surgical site infection in adults undergoing general and regional anesthesia

Maleh

Fasquel

Quesnel

et al. 2023

Sci Rep

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This updated meta-analysis aims at exploring whether the use of systematic high vs low intraoperative oxygen fraction (FiO2) may decrease the incidence of postoperative surgical site infection during general (GA) or regional anesthesia (RA). PubMed, Cochrane CENTRAL, ClinicalTrials.gov databases were searched from January 1st, 1999 and July, 1st 2022, for randomized and quasi-randomized controlled trials that included patients in a high and low FiO2 groups and reported the incidence of SSI. The meta-analysis was conducted with a DerSimonian and Laird random-effects model. Thirty studies (24 for GA and 6 for RA) totaling 18,055 patients (15,871 for GA and 2184 for RA) were included. We have low-to-moderate-quality evidence that high FiO2 (mainly 80%) was not associated with a reduction of SSI incidence compared to low FiO2 (mainly 30%) in all patients (RR 0.90, 95%CI 0.79–1.03). Moderate inconsistency existed between studies (I2 = 38%). Subgroup analyses showed a moderate protective effect in patients undergoing GA (RR 0.86, 95%CI 0.75–0.99) (low level of evidence), while high FiO2 was not associated with a reduction of SSI in patients undergoing RA (RR 1.17, 95%CI 0.90–1.52) (moderate level of evidence). Sensitivity analyses restricted to patients ventilated without nitrous oxide (n = 20 studies), to patients operated from abdominal surgeries (n = 21 studies), and to patients suffering from deep SSI (n = 13 studies), all showed the absence of any significant effect of high FiO2. As a conclusion there is no compelling evidence that high FiO2 can improve postoperative patient’s outcome on its own when good SSI prevention practices are properly applied. Recent well-designed and adequately powered randomized controlled trials add further weight to these results.

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Effects of high versus low inspiratory oxygen fraction on postoperative clinical outcomes in patients undergoing surgery under general anesthesia: A systematic review and meta-analysis of randomized controlled trials

Cited by 18 publications

References 67 publications

Fraction of inspired oxygen during general anesthesia for non‐cardiac surgery: Systematic review and meta‐analysis

Fraction of inspired oxygen during general anesthesia for non‐cardiac surgery: Systematic review and meta‐analysis

Lung ultrasound score-based assessment of postoperative atelectasis in obese patients according to inspired oxygen concentration: A prospective, randomized-controlled study

Updated meta-analysis on intraoperative inspired fraction of oxygen and the risk of surgical site infection in adults undergoing general and regional anesthesia

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