Intraoperative Inspiratory Oxygen Fraction and Myocardial Injury After Noncardiac Surgery: Results From an International Observational Study in Relation to Recent Controlled Trials : Anesthesia & Analgesia

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Original Research Articles: Original Clinical Research Report

Intraoperative Inspiratory Oxygen Fraction and Myocardial Injury After Noncardiac Surgery: Results From an International Observational Study in Relation to Recent Controlled Trials

Pedersen, Sofie S. MD*; Holse, Cecilie MD*; Mathar, Clara E. MB*; Chan, Matthew T. V. MBBS, PhD†; Sessler, Daniel I. MD‡; Liu, Yingzhi MPH§; Zhang, Lin PhD∥; Kurz, Andrea MD‡,¶; Jacka, Mike MD#; Torborg, Alexandra FCA(SA)**; Biyase, Thuli BS**; Montes, Felix R. MD††; Wang, Chew Yin FRCA‡‡; Pettit, Shirley MSc§§; Devereaux, P. J. MD, PhD§§; Meyhoff, Christian S. MD, PhD*

Author Information

From the *Department of Anaesthesia and Intensive Care, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark

†Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong Special Administrative Region, China

‡Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio

Departments of §Anesthesia and Intensive Care

∥Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China

Department of General Anesthesiology, Cleveland Clinic, Cleveland, Ohio

#Walter C. Mackenzie Health Sciences Centre, Edmonton, University of Alberta, Canada

**Discipline of Anaesthesiology and Critical Care, Inkosi Albert Luthuli Central Hospital, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Congella, KwaZulu-Natal, South Africa

††Fundacion Cardioinfantil, Bogota, Colombia

‡‡Department of Anaesthesiology, University of Malaya, Kuala Lumpur, Malaysia

§§Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada

∥∥Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.

Published online 13 April 2022.

Funding: This study was funded by a small project grant from Bispebjerg and Frederiksberg Hospital Research Council.

Conflicts of Interest: See Disclosures at the end of the article.

Clinical trial registration: https://www.clinicaltrials.gov/ct2/show/NCT00512109

Reprints will not be available from the authors.

Address correspondence to Christian S. Meyhoff, MD, PhD, Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Bispebjerg Bakke 23, DK-2400 Copenhagen, Denmark. Address e-mail to [email protected].

Anesthesia & Analgesia 135(5):p 1021-1030, November 2022. | DOI: 10.1213/ANE.0000000000006042

Abstract

BACKGROUND: 

Two trials reported that a high inspiratory oxygen fraction (Fio2) does not promote myocardial infarction or death. Observational studies can provide larger statistical strength, but associations can be due to unobserved confounding. Therefore, we evaluated the association between intraoperative Fio2 and cardiovascular complications in a large international cohort study to see if spurious associations were observed.

METHODS: 

We included patients from the Vascular events In noncardiac Surgery patIents cOhort evaluatioN (VISION) study, who were ≥45 years of age, scheduled for overnight hospital admission, and had intraoperative Fio2 recorded. The primary outcome was myocardial injury after noncardiac surgery (MINS), and secondary outcomes included mortality and pneumonia, all within 30 postoperative days. Data were analyzed with logistic regression, adjusted for many baseline cardiovascular risk factors, and illustrated in relation to findings from 2 recent controlled trials.

RESULTS: 

We included 6588 patients with mean age of 62 years of whom 49% had hypertension. The median intraoperative Fio2 was 0.46 (5%–95% range, 0.32–0.94). There were 808 patients (12%) with MINS. Each 0.10 increase in median Fio2 was associated with a confounder-adjusted increase in odds for MINS: odds ratio (OR), 1.17 (95% confidence interval [CI], 1.12–1.23; P < .0001). MINS occurred in contrast with similar frequencies and no significant difference in controlled trials (2240 patients, 194 events), in which patients were given 80% vs 30% oxygen. Mortality was 2.4% and was not significantly associated with a median Fio2 (OR, 1.07; 95% CI, 0.97–1.19 per 0.10 increase; P = .18), and 2.9% of patients had pneumonia (OR, 1.05; 95% CI, 0.95–1.15 per 0.10 increase; P = .34).

CONCLUSIONS: 

We observed an association between intraoperative Fio2 and risk of myocardial injury within 30 days after noncardiac surgery, which contrasts with recent controlled clinical trials. Fio2 was not significantly associated with mortality or pneumonia. Unobserved confounding presumably contributed to the observed association between Fio2 and myocardial injury that is not supported by trials.

Copyright © 2022 International Anesthesia Research Society

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