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      Severity of hyperoxia as a risk factor in patients undergoing on-pump cardiac surgery

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          Abstract

          Background.

          Hyperoxia has long been perceived as a desirable or at least an inevitable part of cardiopulmonary bypass. Recent evidence suggest that it might have multiple detrimental effects on patient homeostasis. The aim of the study was to identify the determinants of supra-physiological values of partial oxygen pressure during on-pump cardiac surgery and to assess the impact of hyperoxia on clinical outcomes.

          Materials and methods.

          Retrospective data analysis of the institutional research database was performed to evaluate the effects of hyperoxia in patients undergoing elective cardiac surgery with cardiopulmonary bypass, 246 patients were included in the final analysis. Patients were divided in three groups: mild hyperoxia (MHO, PaO 2 100–199 mmHg), moderate hyperoxia (MdHO, PaO 2 200–299 mmHg), and severe hyperoxia (SHO, PaO 2 >300 mmHg). Postoperative complications and outcomes were defined according to standardised criteria of the Society of Thoracic Surgeons.

          Results.

          The extent of hyperoxia was more immense in patients with a lower body mass index ( p = 0.001) and of female sex ( p = 0.005). A significant link between severe hyperoxia and a higher incidence of infectious complications ( p – 0.044), an increased length of hospital stay ( p – 0.044) and extended duration of mechanical ventilation ( p < 0.001) was confirmed.

          Conclusions.

          Severe hyperoxia is associated with an increased incidence of postoperative infectious complications, prolonged mechanical ventilation, and increased hospital stay.

          Translated abstract

          HIPEROKSIJA KAIP RIZIKOS VEIKSNYS PACIENTAMS, KURIEMS ATLIEKAMOS ŠIRDIES OPERACIJOS SU DIRBTINE KRAUJO APYTAKA

          Santrauka

          Įvadas. Hiperoksija ilgą laiką buvo suvokiama kaip neišvengiamas reiškinys dirbtinės kraujo apytakos metu. Pastaraisiais dešimtmečiais atliktų tyrimų duomenimis, per didelė deguonies koncentracija audiniuose gali turėti nepageidaujamų poveikių paciento homeostazei.

          Tyrimo tikslas. Nustatyti veiksnius, nulemiančius suprafiziologines parcialinio deguonies reikšmes širdies operacijų, atliekamų su dirbtine kraujo apytaka, metu ir įvertinti hiperoksijos poveikį klinikinėms išeitims.

          Darbo objektas ir metodai. Į tyrimą įtraukti ir retrospektyviai išanalizuoti 246 pacientų, kuriems atliekamos širdies operacijos su dirbtine kraujo apytaka, duomenys. Atsižvelgiant į didžiausią arterinį parcialinio deguonies slėgį, pacientai suskirstyti į nedidelės (PaO 2 100–199 mmHg), vidutinės (PaO 2 200–299 mmHg) ir ryškios (PaO 2 > 300 mmHg) hiperoksijos grupes.

          Rezultatai. Hiperoksijos rizikos veiksniai buvo žemas kūno masės indeksas ( p = 0,001) ir moteriška lytis ( p = 0,005). Didelis deguonies parcialinis slėgis statistiškai reikšmingai susijęs su infekcinių komplikacijų dažniu ( p – 0,044), ilgesne gulėjimo ligoninėje trukme ( p – 0,044) bei prailginta mechaninės plaučių ventiliacijos trukme ( p < 0,001).

          Išvados. Didelė hiperoksija susijusi su dažnesnėmis pooperacinėmis infekcinėmis komplikacijomis, ilgesne mechaninės plaučių ventiliacijos ir gulėjimo ligoninėje trukme.

          Raktažodžiai: hiperoksija, širdies chirurgija, dirbtinė kraujo apytaka, reaktyvus deguonis, infekcinės komplikacijos

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          Most cited references16

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          Are reactive oxygen species always detrimental to pathogens?

          Reactive oxygen species (ROS) are deadly weapons used by phagocytes and other cell types, such as lung epithelial cells, against pathogens. ROS can kill pathogens directly by causing oxidative damage to biocompounds or indirectly by stimulating pathogen elimination by various nonoxidative mechanisms, including pattern recognition receptors signaling, autophagy, neutrophil extracellular trap formation, and T-lymphocyte responses. Thus, one should expect that the inhibition of ROS production promote infection. Increasing evidences support that in certain particular infections, antioxidants decrease and prooxidants increase pathogen burden. In this study, we review the classic infections that are controlled by ROS and the cases in which ROS appear as promoters of infection, challenging the paradigm. We discuss the possible mechanisms by which ROS could promote particular infections. These mechanisms are still not completely clear but include the metabolic effects of ROS on pathogen physiology, ROS-induced damage to the immune system, and ROS-induced activation of immune defense mechanisms that are subsequently hijacked by particular pathogens to act against more effective microbicidal mechanisms of the immune system. The effective use of antioxidants as therapeutic agents against certain infections is a realistic possibility that is beginning to be applied against viruses.
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            Involvement of neutrophils in the pathogenesis of lethal myocardial reperfusion injury.

            Neutrophils respond to myocardial ischemia-reperfusion in a manner similar to the bacterial invasion of a host. The inflammatory-like response that follows the onset of reperfusion involves intense interactions with the coronary vascular endothelium, arterial wall, and cardiomyocytes in a very well-choreographed manner. Neutrophils have been implicated as primary and secondary mediators of lethal injury after reperfusion to coronary vascular endothelium and cardiomyocytes. The involvement of neutrophils in the pathogenesis of lethal myocardial injury has been inferred from (1) their presence and accumulation in reperfused myocardium in temporal agreement with injury induced, (2) the armamentarium of toxic agents such as oxidants and proteases that are released by neutrophils in reperfused myocardium, (3) responsivity to (recruitment by and/or activation by) inflammatory factors released by reperfused myocardium, and (4) inhibition of lethal post-ischemic myocyte or endothelial cell injury by strategies that interdict neutrophil interactions at any number of stages. However, whether neutrophils are directly involved in the pathogenesis of lethal reperfusion injury in the myocardium, are just pedestrian (first) responders to inflammatory signals released after the onset of reperfusion, or are important to an early but not clinically important phase of pathology are still points of controversy. As with the general area of myocardial protection itself, the failure to reproduce the salubrious effects of anti-neutrophil therapeutic strategies and to successfully translate these strategies into clinical practice has not only fueled the debate, but has jeopardized the further pursuit of myocardial protection therapeutics to improve post-ischemic outcomes. This review will describe the molecular responses of neutrophils to ischemia-reperfusion, discuss the cellular and tissue damage inflicted either directly or indirectly by these white cells, and discuss the physiological impact of interdiction of neutrophil-mediated interactions with myocardial cells at various levels on lethal post-ischemic injury. In addition, it will discuss the arguments for and against the involvement of neutrophils in responses to ischemia-reperfusion in experimental models, and the failure to translate experimentally successful therapy into clinical practice.
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              Obesity decreases perioperative tissue oxygenation.

              Obesity is an important risk factor for surgical site infections. The incidence of surgical wound infections is directly related to tissue perfusion and oxygenation. Fat tissue mass expands without a concomitant increase in blood flow per cell, which might result in a relative hypoperfusion with decreased tissue oxygenation. Consequently, the authors tested the hypotheses that perioperative tissue oxygen tension is reduced in obese surgical patients. Furthermore, they compared the effect of supplemental oxygen administration on tissue oxygenation in obese and nonobese patients. Forty-six patients undergoing major abdominal surgery were assigned to one of two groups according to their body mass index: body mass index less than 30 kg/m2 (nonobese) or 30 kg/m2 or greater (obese). Intraoperative oxygen administration was adjusted to arterial oxygen tensions of approximately 150 mmHg and approximately 300 mmHg in random order. Anesthesia technique and perioperative fluid management were standardized. Subcutaneous tissue oxygen tension was measured with a polarographic electrode positioned within a subcutaneous tonometer in the lateral upper arm during surgery, in the recovery room, and on the first postoperative day. Postoperative tissue oxygen was also measured adjacent to the wound. Data were compared with unpaired two-tailed t tests and Wilcoxon rank sum test; P < 0.05 was considered statistically significant. Intraoperative subcutaneous tissue oxygen tension was significantly less in the obese patients at baseline (36 vs. 57 mmHg; P = 0.002) and with supplemental oxygen administration (47 vs. 76 mmHg; P = 0.014). Immediate postoperative tissue oxygen tension was also significantly less in subcutaneous tissue of the upper arm (43 vs. 54 mmHg; P = 0.011) as well as near the incision (42 vs. 62 mmHg; P = 0.012) in obese patients. In contrast, tissue oxygen tension was comparable in each group on the first postoperative morning. Wound and tissue hypoxia were common in obese patients in the perioperative period and most pronounced during surgery. Even with supplemental oxygen tissue, oxygen tension in obese patients was reduced to levels that are associated with a substantial increase in infection risk.
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                Author and article information

                Journal
                Acta Med Litu
                Acta Med Litu
                AML
                Acta Medica Lituanica
                Lithuanian Academy of Sciences Publishers
                1392-0138
                2029-4174
                2017
                : 24
                : 3
                : 153-158
                Affiliations
                [1] 1 Clinic of Anaesthesiology and Reanimatology, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
                [2] 2 Clinic of Anaesthesiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
                Author notes
                Ieva Norkienė, 2 Santariškių St., Vilnius, LT-08406, Lithuania. E-mail: ievanork@ 123456gmail.com
                Article
                10.6001/actamedica.v24i3.3549
                5709054
                29217969
                b9da4309-ee00-4a62-80ff-baac3cb66df4
                © Lietuvos mokslų akademija, 2017
                History
                : 16 July 2017
                : 25 September 2017
                Categories
                Research Article

                hyperoxia,cardiac surgery,cardiopulmonary bypass,reactive oxygen species,infectious complications

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