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• W2940658459 abstract "Editor—The 2016 WHO ‘Guidelines on perioperative oxygen therapy’1Allegranzi B. Zayed B. Bischoff P. et al.New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective.Lancet Infect Dis. 2016; 16: e288-e303Abstract Full Text Full Text PDF PubMed Scopus (441) Google Scholar have generated considerable controversy.2Myles P.S. Kurz A. Supplemental oxygen and surgical site infection: getting to the truth.Br J Anaesth. 2017; 119: 13-15Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 3Ball L. Lumb A.B. Pelosi P. Intraoperative fraction of inspired oxygen: bringing back the focus on patient outcome.Br J Anaesth. 2017; 119: 16-18Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar In this context, we congratulate the authors of two carefully conducted and tightly focused systematic reviews and meta-analyses of high vs low perioperative oxygen therapy published in the March 2019 issue of the British Journal of Anaesthesia.4Mattishent K. Thavarajah M. Sinha A. et al.Safety of 80% vs 30-35% fraction of inspired oxygen in patients undergoing surgery: a systematic review and meta-analysis.Br J Anaesth. 2019; 122: 311-324Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar, 5de Jonge S. Egger M. Latif A. et al.Effectiveness of 80% vs 30–35% fraction of inspired oxygen in patients undergoing surgery: an updated systematic review and meta-analysis.Br J Anaesth. 2019; 122: 325-334Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Rigorous secondary examination of published trial data in this area is an important activity and should be applauded. However, we question the conclusion that ‘… there is little evidence on safety-related issues to discourage its use in this population.’5de Jonge S. Egger M. Latif A. et al.Effectiveness of 80% vs 30–35% fraction of inspired oxygen in patients undergoing surgery: an updated systematic review and meta-analysis.Br J Anaesth. 2019; 122: 325-334Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar First, the ‘matrix of outcomes’ (Table 4) summarising the safety data from the 15 primary trials reviewed by Mattishent and colleagues4Mattishent K. Thavarajah M. Sinha A. et al.Safety of 80% vs 30-35% fraction of inspired oxygen in patients undergoing surgery: a systematic review and meta-analysis.Br J Anaesth. 2019; 122: 311-324Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar reports NR (Not Reported) for 89 out of 120 possible outcome cells. In our view, this absence of evidence for almost three quarters of the possible safety outcomes is not consistent with the reassuring comments about evidence of absence of harm made in this paper. Moreover, the risk of harm from high levels of perioperative oxygen therapy has been highlighted by a number of commentators2Myles P.S. Kurz A. Supplemental oxygen and surgical site infection: getting to the truth.Br J Anaesth. 2017; 119: 13-15Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 3Ball L. Lumb A.B. Pelosi P. Intraoperative fraction of inspired oxygen: bringing back the focus on patient outcome.Br J Anaesth. 2017; 119: 16-18Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 6Martin D.S. Grocott M.P. Oxygen therapy in anaesthesia: the yin and yang of O2.Br J Anaesth. 2013; 111: 867-871Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar and emphasised by the findings of the recent improving oxygen therapy in acute-illness (IOTA) systematic review and meta-analysis.7Chu D.K. Kim L.H. Young P.J. et al.Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.Lancet. 2018; 391: 1693-1705Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar The IOTA authors concluded ‘In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes’,7Chu D.K. Kim L.H. Young P.J. et al.Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.Lancet. 2018; 391: 1693-1705Abstract Full Text Full Text PDF PubMed Scopus (404) Google Scholar albeit from an analysis from which studies of patients undergoing elective surgery were excluded. Second, both systematic reviews comprise a majority of small (<500 patients), single-centre studies, a situation well recognised to be associated with a substantial risk of bias when compared with subsequent definitive large studies.8Egger M. Davey Smith G. Schneider M. Minder C. Bias in meta-analysis detected by a simple, graphical test.BMJ. 1997; 315: 629-634Crossref PubMed Scopus (34421) Google Scholar Furthermore, the integrity of data from several of these studies in this area authored by Schietroma and colleagues12Retraction note: Colorectal infraperitoneal anastomosis: the effects of perioperative supplemental oxygen administration on the anastomotic dehiscence.J Gastrointest Surg. 2014; 18: 219Crossref PubMed Scopus (5) Google Scholar, 13Schietroma M. Piccione F. Carlei F. Sista F. Cecilia E.M. Amicucci G. Peritonitis from perforated peptic ulcer and immune response.J Invest Surg. 2013; 26: 294-304Crossref PubMed Scopus (24) Google Scholar, 14Schietroma M. Cecilia E.M. Sista F. Carlei F. Pessia B. Amicucci G. Retraction notice to High-concentration supplemental perioperative oxygen and surgical site infection following elective colorectal surgery for rectal cancer: a prospective, randomized, double-blind, controlled, single-site trial.Am J Surg. 2018; 215: 534Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 15RETRACTED: How does high-concentration supplemental perioperative oxygen influence surgical outcomes after thyroid surgery? A prospective, randomized, double-blind, controlled, monocentric trial..J Am Coll Surg. 2017; 225: 359Abstract Full Text Full Text PDF Scopus (1) Google Scholar has been called into question by the recent article by Myles and colleagues.9Myles P.S. Carlisle J.B. Scarr B. Evidence for compromised data integrity in studies of liberal peri-operative inspired oxygen.Anaesthesia. 2019; 74: 573-584Crossref PubMed Scopus (28) Google Scholar Although not included within the British Journal of Anaesthesia systematic reviews, such uncertainty about data integrity in relevant studies further muddies the waters with respect to extracting a clear message from the accumulated literature. Third, the summarised literature is notable for focusing on two extremes of oxygen therapy: 30–35% and 80% fraction of inspired oxygen (FiO2). Neither of these approaches is representative of what we currently know to be standard care (observational data from the UK suggests that 41–55% FiO2 is administered in most cases),10Morkane C.M. McKenna H. Cumpstey A.F. Oldman A.H. Grocott M.P.W. Martin D.S. Pan London Perioperative Audit and Research Network (PLAN). Intraoperative oxygenation in adult patients undergoing surgery (iOPS): a retrospective observational study across 29 UK hospitals.Perioper Med (Lond). 2018; 7: 17Google Scholar and neither of which has any clear biological rationale. Studies taking a titration or dose-response approach to this problem are lacking. Finally, the focus on a restricted set of outcomes comprising ‘safety’ and reduction of surgical site infection over other, perhaps more clinically relevant and patient-centred, outcomes risks the unintended consequence of inadvertent harm. The PeriOperative ISchemic Evaluation (POISE) trial of perioperative beta-blockade was an excellent example of a well-intentioned intervention that caused substantial harm when implemented.11POISE Study Group Devereaux P.J. Yang H. et al.Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial.Lancet. 2008; 371: 1839-1847Abstract Full Text Full Text PDF PubMed Scopus (1713) Google Scholar International initiatives to address the complex and intricate question of oxygen dosage around the time of surgery are important, but we urge caution about over-interpreting the results of currently published studies. Oxygen is a ubiquitous therapy in modern anaesthesia: modest harms or benefits resulting from difference in perioperative dosing may have a substantial impact on healthcare outcomes. Adequately powered definitive trials including comparator oxygen dosages representative of usual care and targeted at patient-focused outcomes are long overdue in this area. The authors declare that they have no conflicts of interest." @default.
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• W2940658459 title "Perioperative oxygen therapy: meaningful outcomes and unintended consequences?" @default.
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