OXYGENOTERAPIE V PERIOPERAČNÍM OBDOBÍ. Jiří Chvojka Plzeň

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1 OXYGENOTERAPIE V PERIOPERAČNÍM OBDOBÍ Jiří Chvojka Plzeň

3 Člov lověk je stvořen ze země,, žije však ze vzduchu. V e vzduchu je ukryt pokrm života. M ichal Sendivoj ze Skorska ( ) Cornelius Jacobszoon D rebbel ( ) Joseph Priestley ( ) A ntoine Lavoisier ( )

4 HYPOXIE

5 1928 CUNNINGHAM SANATORIUM 1942

6 Kam jsme se posunuli?

7 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 fyziologické funkce, široké rozpětí v dávkování, nežádoucí účinky

8 více než 15% pacientů přijatých do nemocnic v Británii léčeni oxygenoterapií prakticky univerzální lék podání kyslíku i bez přítomnosti hypoxie/hypoxémie Status epilepticus

10 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

11 Vliv na hojení chirurgické rány? (surgical site infection, SSI) /rok v USA (17% všech HAI, 2.nejčastější po UTI) SSI zvyšují mortalitu Prodlužují pobyt v nemocnici Zvyšují náklady na léčbu( USD/SSI) MůžeperioperačnínavýšeníFiO 2 snížitincidencissi? Potenciace oxidačního vzplanutí neutrofilů zvýšením tenze kyslíku v operační ráně Kirkland KB, Briggs JP, Trivette SL, et al. Infect Control Hosp Epidemiol BratzlerDW, Houck PM, Richards C, et al. Arch Surg2005

12 Supplemental Perioperative Oxygen To Reduce The Incidence Of Surgical-wound Infection Background Destruction by oxidation, or oxidative killing, is the most important defense against surgical pathogens and depends on the partial pressure of O2 in contaminated tissue. An easy method of improving O2 tension in adequately perfused tissue is to increase the concentration of FiO2. Methods randomly, 500 pts, colorectal resection, FiO 2 30% or 80% during the operation and for two hours afterward. Results Among 250 pts with FiO 2 80%, 13 (5.2%) had surgical-wound infections, as compared with 28 of 250 pts 30% FiO 2 (11.2% P=0.01). The absolute difference between groups was 6%, with a relative risk reduction of 54%. N EnglJ Med 2000; 342:161-7

13 Supplemental Perioperative O2 and the Risk of Surgical Wound Infection A Randomized Controlled Trial Background Supplemental perioperative oxygen has been variously reported to halve or double the risk of surgical wound infection. To test the hypothesis that supplemental oxygen reduces infection risk in patients following colorectal surgery. Methods randomly, 300 pts, colorectal resection, FiO 2 30% or 80% during the operation and for six hours afterward. Results Among 148 pts with FiO 2 80%, 22 (14.9%) had surgical-wound infections, as compared with 35 of 143 pts with FiO 2 30% (24.4% P=0.04). The absolute risk reduction was 9%, with a relative risk reduction of 39%. JAMA 2005; 294:

14 There is little cost and no risk to the administration of perioperative supplemental oxygen. Given that the intervention makes sense from a biological and scientific perspective, being easy to perform and relatively noninvasive, practical, and with an excellent risk:benefit profile, incorporating it into current quality improvement activities aimed at reducing surgical site infection should be relatively straightforward. možná. opravdu?

15 From: Surgical Site Infection and the Routine Use of Perioperative Hyperoxia in a General Surgical Population: A Randomized Controlled Trial JAMA. 2004;291(1): doi: /jama Design, Setting, and Patients Double-blind, randomized controlled trial conducted between September 2001 and May 2003 at a large university hospital in metropolitan New York City of 165 patients undergoing major intraabdominal surgical procedures under general anesthesia. Interventions Patients were randomly assigned to receive either 80% oxygen (FIO 2 of 0.80) or 35% oxygen (FIO 2 of0.35)duringsurgeryandforthefirst2hoursaftersurgery. Results The study groups were closely matched in a large number of clinical variables. The overall incidence of SSI was 18.1%. In an intention-to-treat analysis, the incidence of infection was significantly higher in the group receiving FIO 2 of 0.80 than in the group with FIO 2 of 0.35 (25.0% vs 11.3%; P =.02). FIO 2 remained a significant predictor of SSI(P =.03) in multivariate regression analysis. Patients who developed SSI had a significantly longer length 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 FIO 2 in a general surgical population does not reduce the overall incidence of SSI and may have predominantly deleterious effects. General surgical patients should continue to receive oxygen with cardiorespiratory physiology as the principal determinant.

16 Kyslík není jedinou zbraní v boji s infekcí Likvidace patogenů i na kyslíku nezávislou cestou VysokýtkáňovýpO 2 negarantujestejnépo 2 intracelulárně Nepříznivý vliv kyslíkových radikálů v operační ráně a vliv nahojenípotenciacízánětlivéhoprocesupřihyperoxii?

18 Adekvátní systémová hemodynamika negarantuje dobrou perfúzi chirurgické rány AdekvátníoxygenacearteriálníkrvenegarantujedostatečnýtpO 2 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 severe complications independently of systemic haemodynamics. Further research is needed to confirm these findings and to explore in more detail the effects of peripheral perfusion targeted resuscitation following major abdominal surgery.

19 Asepse ATB politika Kyslík Kontrola glykémie

20 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): doi: /jama Objective To assess whether use of 80% oxygen reduces the frequency of surgical site infection without increasing the frequency of pulmonary complications in patients undergoing abdominal surgery. Interventions Patients were randomly assigned to receive either 80% or 30% oxygen during and for 2 hours after surgery. Results Surgical site infection occurred in 131 of 685 patients (19.1%) assigned to receive 80% oxygen vs 141 of 701 (20.1%) assigned to receive 30% oxygen (odds ratio [OR], 0.94; 95% confidence interval [CI], ; P=.64). Conclusion Administration of 80% oxygen compared with 30% oxygen did not result in a difference in risk of surgical site infection after abdominal surgery.

21 RESULTS:Vitalstatuswasobtainedin1382of1386patientsafteramedianfollow-upof2.3years(range1.3to 3.4 years). One hundred fifty-nine of 685 patients (23.2%) died in the 80% oxygen group compared to 128 of 701 patients (18.3%) assigned to 30% oxygen (HR, 1.30 [95% confidence interval, 1.03 to 1.64], P 0.03). In patients undergoing cancer surgery, the HR was 1.45; 95% confidence interval, 1.10 to 1.90; P 0.009; and afternoncancersurgery,thehrwas1.06;95%confidenceinterval,0.69to1.65;p CONCLUSIONS: Administration of 80% oxygen in the perioperative period was associated with significantly increased long-term mortality and this appeared to be statistically significant in patients undergoing cancer surgery but not in noncancer patients.

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