Larvin Joseph, Edwards Mark, Martin Daniel S, Feelisch Martin, Grocott Michael P W, Cumpstey Andrew F
Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK.
Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
BJA Open. 2024 Mar 20;10:100277. doi: 10.1016/j.bjao.2024.100277. eCollection 2024 Jun.
Oxygen is the most used drug in anaesthesia. Despite such widespread use, optimal perioperative oxygen administration remains highly controversial because of concerns about the competing harms of both hyperoxia and hypoxia. Notwithstanding a Cochrane review concluding that routinely administering a fractional inspired oxygen concentration (FiO) >0.6 intraoperatively might increase postoperative morbidity and mortality, the World Health Organization (WHO) currently recommends all anaesthetised patients receive 0.8 FiO during and immediately after surgery to reduce surgical site infections. Results from the largest trial available at the time of these two reviews (suggesting long-term survival may be worse with high FiO, particularly in patients with malignant disease) were considered 'biologically implausible' by the WHO's Guideline Development Group. In addition, the integrity of some perioperative oxygen studies has been challenged. Resolving these controversies is of fundamental importance to all perioperative clinicians. This narrative review is based on the inaugural William Mapleson lecture delivered by the senior author (AC) at the 2023 annual meeting of the Royal College of Anaesthetists in Birmingham. We present the current evidence for perioperative oxygen administration and contrast this with how oxygen therapy is targeted in other specialties (e.g. intensive care medicine). We will explore whether anaesthetists follow the WHO recommendations and consider how oxygen administration affects the stress response to surgery. We reason that novel clinical trial designs in combination with targeted experimental medicine studies will be required to improve our understanding of how best to optimise individualised perioperative oxygenation-a cornerstone of anaesthesia.
氧气是麻醉中使用最广泛的药物。尽管使用如此普遍，但由于对高氧和低氧的相互危害存在担忧，围手术期最佳氧疗仍极具争议。尽管Cochrane综述得出结论，术中常规给予吸入氧分数（FiO）>0.6可能会增加术后发病率和死亡率，但世界卫生组织（WHO）目前建议所有接受麻醉的患者在手术期间及术后立即接受FiO为0.8的氧疗，以减少手术部位感染。这两项综述发表时可得的最大规模试验结果（表明高FiO可能会使长期生存率降低，尤其是恶性疾病患者）被WHO指南制定小组认为“生物学上不可信”。此外，一些围手术期氧疗研究的完整性也受到了质疑。解决这些争议对所有围手术期临床医生至关重要。这篇叙述性综述基于资深作者（AC）在2023年伯明翰皇家麻醉师学院年会上发表的首届威廉·梅普森讲座。我们展示了围手术期氧疗的当前证据，并将其与其他专科（如重症医学）的氧疗目标进行对比。我们将探讨麻醉医生是否遵循WHO的建议，并考虑氧疗如何影响对手术的应激反应。我们认为，需要结合新颖的临床试验设计和针对性的实验医学研究，以增进我们对如何最佳优化个体化围手术期氧合（麻醉的基石）的理解。
