Intraoperative Oxygen Treatment, Oxidative Stress, and Organ Injury Following Cardiac Surgery
Authors: Lopez Marcos G. , Shotwell Matthew S. , Hennessy Cassandra , Pretorius Mias , McIlroy David R. , Kimlinger Melissa J. , Mace Eric H. , Absi Tarek , Shah Ashish S. , Brown Nancy J. , Billings Frederic T. ,   ROCS trial investigators, Deegan Robert , Eagle Susan S. , Hernandez Antonio , Gelfand Brian J. , Kertai Miklos D. , Kingeter Meredith , LeFevre Ryan , Lombard Frederic W. , Mantinan Michael F. , Mishra Kelly K. , Shaw Andrew D. , Siegrist Kara K. , Sileshi Ban , Freundlich Robert E. , Wanderer Jonathan P. 
Published: August 2024

ImportanceLiberal oxygen (hyperoxia) is commonly administered to patients during surgery, and oxygenation is known to impact mechanisms of perioperative organ injury.ObjectiveTo evaluate the effect of intraoperative hyperoxia compared to maintaining normoxia on oxidative stress, kidney injury, and other organ dysfunctions after cardiac surgery.Design, Setting, and ParticipantsThis was a participant- and assessor-blinded, randomized clinical trial conducted from April 2016 to October 2020 with 1 year of follow-up at a single tertiary care medical center. Adult patients (&amp;gt;18 years) presenting for elective open cardiac surgery without preoperative oxygen requirement, acute coronary syndrome, carotid stenosis, or dialysis were included. Of 3919 patients assessed, 2501 were considered eligible and 213 provided consent. Of these, 12 were excluded prior to randomization and 1 following randomization whose surgery was cancelled, leaving 100 participants in each group.InterventionsParticipants were randomly assigned to hyperoxia (1.00 fraction of inspired oxygen [FiO2]) or normoxia (minimum FiO2 to maintain oxygen saturation 95%-97%) throughout surgery.Main Outcomes and MeasuresParticipants were assessed for oxidative stress by measuring F2-isoprostanes and isofurans, for acute kidney injury (AKI), and for delirium, myocardial injury, atrial fibrillation, and additional secondary outcomes. Participants were monitored for 1 year following surgery.ResultsTwo hundred participants were studied (median [IQR] age, 66 [59-72] years; 140 male and 60 female; 82 [41.0%] with diabetes). F2-isoprostanes and isofurans (primary mechanistic end point) increased on average throughout surgery, from a median (IQR) of 73.3 (53.1-101.1) pg/mL at baseline to a peak of 85.5 (64.0-109.8) pg/mL at admission to the intensive care unit and were 9.2 pg/mL (95% CI, 1.0-17.4; P = .03) higher during surgery in patients assigned to hyperoxia. Median (IQR) change in serum creatinine (primary clinical end point) from baseline to postoperative day 2 was 0.01 mg/dL (−0.12 to 0.19) in participants assigned hyperoxia and −0.01 mg/dL (−0.16 to 0.19) in those assigned normoxia (median difference, 0.03; 95% CI, −0.04 to 0.10; P = .45). AKI occurred in 21 participants (21%) in each group. Intraoperative oxygen treatment did not affect additional acute organ injuries, safety events, or kidney, neuropsychological, and functional outcomes at 1 year.ConclusionsAmong adults receiving cardiac surgery, intraoperative hyperoxia increased intraoperative oxidative stress compared to normoxia but did not affect kidney injury or additional measurements of organ injury including delirium, myocardial injury, and atrial fibrillation.Trial RegistrationClinicalTrials.gov Identifier: NCT02361944