TopMedTalk

Effect of intraoperative hyperoxia on the incidence of surgical site infections: a meta-analysis

B. Cohen, Y.N. Schacham, K. Ruetzler, S. Ahuja, D. Yang, E.J. Mascha, A.B. Barclay, M.H. Hung, D.I.

BACKGROUND
Whether supplemental intraoperative oxygen reduces surgical site infections remains unclear. Recent recommendations from the World Health Organization and Center for Disease Control to routinely use high inspired oxygen concentrations to reduce infection risk have been widely criticized. We therefore performed a meta-analysis to evaluate the influence of inspired oxygen on infection risk, including a recent large trial.

METHODS
A systematic literature search was performed. Primary analysis included all eligible trials. Sensitivity analyses distinguished studies of colorectal and non-colorectal surgeries, and excluded studies with high risk of bias. Another post-hoc sensitivity analysis excluded studies from one author that appear questionable.

RESULTS
The primary analysis included 26 trials (N=14,710). The RR [95%CI] for wound infection was 0.81 [0.70, 0.94] in the high vs. low inspired oxygen groups. The effect remained significant in colorectal patients (N=10,469), 0.79 [0.66, 0.96], but not in other patients (N=4,241), 0.86 [0.69, 1.09]. When restricting the analysis to studies with low risk of bias, either by strict inclusion criteria (N=5,047) or by researchers’ judgment (N=12,547), no significant benefit remained: 0.84 [0.67, 1.06] and 0.89 [0.76, 1.05], respectively.

CONCLUSIONS
When considering all available data, intraoperative hyperoxia reduced wound infection incidence. However, no significant benefit remained when analysis was restricted to objective- or investigator-identified low-bias studies, although those analyses were not as well-powered. Meta-analysis of the most reliable studies does not suggest that supplemental oxygen substantively reduces wound infection risk, but more research is needed to fully answer this question.

DOI: https://doi.org/10.1016/j.bja.2018.02.027

Fluid Matters - the 'nil by mouth' or 'NPO' debate

This piece is taken from "The Great Fluid Debate", it's about changes in practice that have been implimented both in the UK and at various medical centres in the US. Hear how and why the old 'nil by mouth' or 'NPO' policy has changed in many instances.

From water to carbohydrate drinks, to black coffee, the thinking has changed in many institutions but part of the battle is in educating patients and their well meaning friends and relatives.

Chaired by Professor Monty Mythen and featuring; Dr Tim Miller, anesthsiologist from Duke University Medical Centre; Professor Mike Grocott, Professor of Anaesthesia and Critical Care at the University of Southampton; Professors Paul Wischmeyer and Stuart Grant, from the Department of Anesthesiology, Duke University and featuring questions from the audience.

Join in the debate: [email protected]

Fluid Matters - the ‘nil by mouth’ or ‘NPO’ debate

This piece is taken from "The Great Fluid Debate", it's about changes in practice that have been implimented both in the UK and at various medical centres in the US. Hear how and why the old 'nil by mouth' or ‘NPO’ policy has changed in many instances.

From water to carbohydrate drinks, to black coffee, the thinking has changed in many institutions but part of the battle is in educating patients and their well meaning friends and relatives.

Chaired by Professor Monty Mythen and featuring; Dr Tim Miller, anesthsiologist from Duke University Medical Centre; Professor Mike Grocott, Professor of Anaesthesia and Critical Care at the University of Southampton; Professors Paul Wischmeyer and Stuart Grant, from the Department of Anesthesiology, Duke University and featuring questions from the audience.

Join in the debate: [email protected]

How do we develop a way to teach perioperative medicine and once that's in place, how should it be overseen? What sort of official endorsement might it need?

Developing a broad knowledge of the process is distinct from being a specialist, how do we develop that further - without developing a schism? This complicated topic is discussed alongside more detail regarding the future for this area.

Presented by Monty Mythen and Mike Grocott with their guests; Joel Symmons, Staff Consultant Anaesthetist in the Department of Anaesthesia and Perioperative Medicine at the Alfred Hospital, Perioperative Medicine Short Course Convenor, and a Senior Lecturer in Anaesthesia at Monash University, and Paul Myles, Head of Alfred Health's and Monash University's Department of Anaesthesia and Perioperative Medicine.

This piece is taken from a longer podcast which you can hear here: https://www.topmedtalk.com/rcoh-14-how-should-we-teach-perioperative-medicine/

How do we develop a way to teach perioperative medicine and once that's in place, how should it be overseen? What sort of official endorsement might it need?

Developing a broad knowledge of the process is distinct from being a specialist, how do we develop that further - without developing a schism? This complicated topic is discussed alongside more detail regarding the future for this area.

Presented by Monty Mythen and Mike Grocott with their guests; Joel Symmons, Staff Consultant Anaesthetist in the Department of Anaesthesia and Perioperative Medicine at the Alfred Hospital, Perioperative Medicine Short Course Convenor, and a Senior Lecturer in Anaesthesia at Monash University, and Paul Myles, Head of Alfred Health's and Monash University's Department of Anaesthesia and Perioperative Medicine.

This piece is taken from a longer podcast which you can hear here: https://www.topmedtalk.com/rcoh-14-how-should-we-teach-perioperative-medicine/

This piece starts with the question: Is there a hierarchy amongst the various elements of an enhanced recovery pathway? The conversation that follows tackles some of the essential elements of perioperative care.

This conversation is taken from a longer piece to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-2/

For further expert discussion regarding the Drink, Eat, Mobilise, Sleep (DrEaMS) concept there is another short piece you can find here: https://www.topmedtalk.com/standardised-outcomes-from-surgery-drink-eat-mobilise-dream/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features questioner Dr Vishal Patil, Consultant Anaesthetist at Cambridge University Hospitals NHS Foundation Trust, alongside Professor Monty Mythen and his two guests; Dr Simeon West, consultant anaethetist at (University College London Hospitals) UCLH who sits on the board at Regional Anaesthesia UK (RAUK) and Mark Harper Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for thearaputic purposes.

This piece starts with the question: Is there a hierarchy amongst the various elements of an enhanced recovery pathway? The conversation that follows tackles some of the essential elements of perioperative care.

This conversation is taken from a longer piece to be found here: https://www.topmedtalk.com/live-from-the-iseh-part-2/

For further expert discussion regarding the Drink, Eat, Mobilise, Sleep (DrEaMS) concept there is another short piece you can find here: https://www.topmedtalk.com/standardised-outcomes-from-surgery-drink-eat-mobilise-dream/

This edition of TopMedTalk was recorded at The Institute of Sport Exercise and Health (ISEH) live from an Enhanced Recovery After Surgery (ERAS) leadership forum.

The conversation features questioner Dr Vishal Patil, Consultant Anaesthetist at Cambridge University Hospitals NHS Foundation Trust, alongside Professor Monty Mythen and his two guests; Dr Simeon West, consultant anaethetist at (University College London Hospitals) UCLH who sits on the board at Regional Anaesthesia UK (RAUK) and Mark Harper Consultant Anaesthetist at Brighton and Sussex University Hospitals, with a research interest in the prevention of perioperative hypothermia and the use of cold water adaptation for thearaputic purposes.

This is an excerpt from 'The Great American Fluid Debate' which was hosted at Duke University Medical Centre's "Controversies in Perioperative Medicine" conference of this year. The debate is framed as "restrictive versus liberal" but, as you'll hear, those terms are questioned by panel members. How do the results of 'The Relief Trial' figure in this debate? Is the pendulum of progress swinging too far - from overly liberal to too restrictive? What can the research and detailed data around these questions tell us?

The two pieces Monty mentions in the podcast, featuring Paul Myles, are found here:

"THE RESULTS"

https://www.topmedtalk.com/the-relief-trial-results/

"YOUR ESSENTIAL DEEP DIVE"

https://www.topmedtalk.com/rcoa-11-the-relief-trial-your-essential-deep-dive-into-the-results/

And you can find the other piece here:

"JOURNAL CLUB; BALANCED VERSUS SALINE"

https://www.topmedtalk.com/journal-club-saline-solution/

Presented by Monty Mythen featuring; Mike Grocott, Professor of Anaesthesia and critical care at the University of Southampton; Professor Paul Wischmeyer from the Department of Anesthesiology, Duke University; Professor Stuart Grant, MB ChB, FRCA Director, Medical Student Education, Duke University School of medicine and Tim Miller, anaesthsiologist from Duke University Medical Centre.

Send us your feedback: [email protected]

This is an excerpt from 'The Great American Fluid Debate' which was hosted at Duke University Medical Centre's "Controversies in Perioperative Medicine" conference of this year. The debate is framed as "restrictive versus liberal" but, as you'll hear, those terms are questioned by panel members. How do the results of 'The Relief Trial' figure in this debate? Is the pendulum of progress swinging too far - from overly liberal to too restrictive? What can the research and detailed data around these questions tell us?

The two pieces Monty mentions in the podcast, featuring Paul Myles, are found here:

"THE RESULTS"

https://www.topmedtalk.com/the-relief-trial-results/

"YOUR ESSENTIAL DEEP DIVE"

https://www.topmedtalk.com/rcoa-11-the-relief-trial-your-essential-deep-dive-into-the-results/

And you can find the other piece here:

"JOURNAL CLUB; BALANCED VERSUS SALINE"

https://www.topmedtalk.com/journal-club-saline-solution/

Presented by Monty Mythen featuring; Mike Grocott, Professor of Anaesthesia and critical care at the University of Southampton; Professor Paul Wischmeyer from the Department of Anesthesiology, Duke University; Professor Stuart Grant, MB ChB, FRCA Director, Medical Student Education, Duke University School of medicine and Tim Miller, anaesthsiologist from Duke University Medical Centre.

Send us your feedback: [email protected]

What is 'the morpheus consortium'? What's the current thinking on pain management and the 'opioid crisis'? On reflection were people wrong to emphasise the message that 'pain is the fifth vital sign'? How did 'pain management' instead become 'opioid management'?

The UK has had a slightly different ride to the US in this respect, although not without its problems, could that be due to this 'fifth vital sign' message being less popular on the other side of the atlantic? Is it important to manage expectations and emphasise patient comfort rather than a total absence of any pain whatsoever?

Also here, there's a fascinating discussion of anemia and sex discrimination within its treatment. What is a normal level of hemoglobin in a patient and should this vary depending upon gender?

Presented by Monty Mythen with his guests Mike Grocott, Professor of Anaesthesia and critical care at the University of Southampton and a member of The Morpheus Consortium; Dr. Padma Gulur, anesthesiologist and a Pain Medicine Specialist who sees patients at Davis Ambulatory Surgical Center, Duke Pain Medicine and Duke Perioperative Pain Care; Annemarie Thompson, MD, Director, Residency Program, Professor of Anesthesiology at Duke University School of Medicine.