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Intraoperative PaO2 is not related to the development of surgical site infections after major cardiac surgery
Journal of Cardiothoracic Surgery volume 6, Article number: 4 (2011)
The perioperative use of high inspired oxygen fraction (FIO2) for preventing surgical site infections (SSIs) has demonstrated a reduction in their incidence in some types of surgery however there exist some discrepancies in this respect. The aim of this study was to analyze the relationship between PaO2 values and SSIs in cardiac patients.
We designed a prospective study in which 1,024 patients undergoing cardiac surgery were analyzed.
SSIs were observed in 5.3% of patients. There was not significant difference in mortality at 30 days between patients with and without SSIs. In the uni and multivariate analysis no differences in function of the inspired oxygen fraction administrated were observed.
We observed that the PaO2 in adult cardiac surgery patients was not related to SSI rate.
The potential clinical benefits of the perioperative use of high inspired oxygen fraction (FIO2) for preventing surgical site infections (SSIs) have attracted great interest in recent years. Trials by Greif et al.  and Belda et al.  demonstrated that SSIs decreased significantly following colon surgery in patients who received 80% oxygen intraoperatively and for the first hours following surgery.
In the sphere of cardiac surgery, SSIs are serious complications associated with extended hospital stay, increased hospital costs, and higher mortality and morbidity rates . Thus, in 2005 our Department of Anesthesiology and Reanimation adopted a clinical strategy of administering 50% oxygen without nitrous oxide during anesthesia and for the first 6 postoperative hours in an effort to decrease SSIs.
In contrast to the findings of Belda et al. , clinical trials by Pryor et al.  and, more recently, by Meyhoff et al. , found no difference in SSI risk when 80% oxygen rather than 30% oxygen was administered during abdominal surgery and for 2 hours postoperatively. Their findings suggested that perioperative hyperoxia was not effective in reducing SSIs. These reports add to the evidence base surrounding the potential role of high FIO2 in SSI prevention.
The rationale for administering high FIO2 to prevent SSIs is to produce a high PaO2 and thereby increase the PsqO2 (tissue oxygen partial pressure), since oxidative killing by neutrophils is the primary defense against surgical pathogens. The risk of infection is thus inversely related to PsqO2. Our aim in this study was to analyze the relationship between PaO2 values and SSIs.
We designed a prospective study that analyzed the data from 1,024 consecutive patients who underwent cardiac surgery with extracorporeal circulation at our institution from January 30, 2007 to June 30, 2009. Transplant patients were excluded. The patients were categorized according to the presence or absence of SSIs. The study was approved by the hospital's Research Commission, and all participants provided informed written consent. The Center for Disease Control and Prevention (CDC) criteria  were used to define SSIs. The SPSS software package (version 15) was used for statistical analysis. A p ≤ 0.05 was considered significant.
To assess risk factors for SSI, we used one-way analysis of variance for univariate continuous variables and the chi-square test for categorical variables. In addition, we conducted Fisher's exact test whenever the chi-square expected value of at least one cell was less than 5.
We avoided multicollinearity among the explanatory variables by performing collinearity diagnostic analyses. We performed the stepwise selection of variables from the models with the following criteria: Tolerance greater than 0.4 or variance inflation less than 2.5, condition number less than 10, and a variance of two or more variables no greater than 0.5.
SSIs developed after cardiac surgery in 54 (5.3%) patients, 28 (2.8%) superficial or deep incision SSIs and 26 (2.5%) organ/space SSIs. The intraoperative and postoperative PaO2 values were not associated with an increased risk of SSI either by univariate or multivariate analysis (Table 1). The 30-day mortality rate was similar in both groups: patients without SSIs, n = 72 (7.4%) vs. patients with SSIs, n = 4 (7.4%); (P = .11).
Our results agree with the results of the trials conducted by Pryor et al.  and Meyhoff et al.  in that perioperative hyperoxia was not effective in reducing SSIs. PsqO2 is typically lower than the PaO2 level by a factor of two to four. As might be expected, tissue oxygenation improves much less than arterial oxygen in response to supplemental oxygen administration. Sternal wound oxygenation increased by an average of 4 mm Hg (from 23 to 27 mm Hg) with supplemental oxygen at 50% .
The data from prior studies [4, 5], as well as the present results, leads us to question our policy to routinely administer a high inspired oxygen fraction to cardiac surgery patients in order to prevent SSIs. In summary, the PaO2 in adult cardiac surgery patients is not related to SSI rate. The strategy of administering supplemental inspired oxygen to reduce the incidence of SSIs does not appear to be clinically useful.
Greif R, Akça O, Horn EP, Kurz A, Sessler DI Outcomes Research Group: Supplemental perioperative oxygen to reduce the incidence of surgical-wound infection. N Engl J Med. 2000, 342 (3): 161-167. 10.1056/NEJM200001203420303.
Belda FJ, Aguilera L, García de la Asunción J, Alberti J, Vicente R, Ferrándiz L, Rodríguez R, Company R, Sessler DI, Aguilar G, Botello SG, Ortí R, Spanish Reduccion de la Tasa de Infeccion Quirurgica Group: Supplemental perioperative oxygen and the risk of surgical wound infection: a randomized controlled trial. JAMA. 2005, 294 (16): 2035-2042. 10.1001/jama.294.16.2035.
Bakri MH, Nagem H, Sessler DI, Mahboobi R, Dalton J, Akça O, Roselli EE, Insler SR: Transdermal oxygen does not improve sternal wound oxygenation in patients recovering from cardiac surgery. Anesth Analg. 2008, 106 (6): 1619-1626. 10.1213/ane.0b013e3181732e82.
Pryor KO, Fahey TJ, Lien CA, Goldstein PA: Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: a randomized controlled trial. JAMA. 2004, 291 (1): 79-87. 10.1001/jama.291.1.79.
Meyhoff CS, Wetterslev J, Jorgensen LN, PROXI Trial Group: 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): 1543-50. 10.1001/jama.2009.1452.
Garner JS, Jarvis WR, Emori TG: CDC definitions of nosocomial infections. APIC infection control and applied epidemiology: principles and practice. Edited by: Olmsted RN. 1996, Mosby, St. Louis, A1-A20.
The authors declare that they have no competing interests.
JB and ET had full access to all of the study data and takes responsibility for the integrity of the data and the accuracy of the data analysis. Both authors contributed equally to the study. Study concept and design: ET, JB, FJA, IGC, JIGH. Data acquisition: JB, ET, FJA, IGC, IF, JIGH. Analysis and interpretation of data: ET, IF, SF, FJA, IGC, JB, JIGH. Drafting of the manuscript: ET, FJA, IGC, JB, JIGH. Critical revision of the manuscript for important intellectual content: ET, FJA, IGC, JB, JIGH Administrative, technical, or material support: ET, FJA, IF, IGC, JB, JIGH. Study supervision: ET, SF, FJA, IGC, JB, JIGH.
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Bustamante, J., Tamayo, E., Álvarez, F.J. et al. Intraoperative PaO2 is not related to the development of surgical site infections after major cardiac surgery. J Cardiothorac Surg 6, 4 (2011) doi:10.1186/1749-8090-6-4
- High FIO2
- Increase Hospital Cost
- Extend Hospital Stay
- Incision SSIs
- PaO2 Level