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British Journal of Anaesthesia, ▪ (▪): 1e2 (2018)


Hyperoxia is a modifiable anaesthetic risk factor that varies in the

practice of individual anaesthetists
A. K. Staehr-Rye1,2,*, T. Kurth3, F. T. Scheffenbichler1, L. S. Rasmussen4 and
M. Eikermann1,5
Department of Anaesthesia, Critical Care, Pain Medicine, Massachusetts General Hospital, 55 Fruit Street,
Boston, MA 02114, USA, 2Department of Anaesthesiology, Herlev and Gentofte Hospital, University of

Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark, 3Institute of Public Health, Charite
Universitatzmedizin Berlin, Germany, 4Department of Anaesthesia, Centre of Head and Orthopaedics,
Rigshospitalet, University of Copenhagen, Denmark and 5Klinik fur Anaesthesie und Intensivmedizin,
Universitaetsklinikum Essen, Essen, Germany
*Corresponding author. E-mail:

We thank Acka1 and de Jonge and colleagues2 for their in- the preference of the anaesthetist. Additional data show that
terest in our study analysing the association between intra- this assumption does not hold true. To quantify the distribu-
operative inspiratory oxygen fraction and risk of respiratory tion of inter-provider variability in utilization of high FIO2, we
complications.3 We agree with both that for cause and effect plotted the proportion of cases where the individual anaes-
relationships, more targeted research is needed. We do not thesia provider administered high FIO2 defined as median FIO2
follow the arguments of Acka that the results are probably >0.63 (upper quintile), a statistical approach we have reported
caused by an epiphenomenon triggering high FIO2 rather than before.4e6 The data show that the median FIO2 varied widely
an effect of high FIO2. Acka mentions that patients receiving across practitioners within our cohort. A small number of
the highest FIO2 were different from the patients receiving anaesthesia providers consistently used lower FIO2, whilst
lower FIO2 in terms of several characteristics such as comor- another group regularly used higher FIO2. Similar distributions
bidities, volatile anaesthetic dose, duration of surgery, pro- were observed before and after propensity-matched adjust-
cedural severity, etc. That is correct. We anticipated that a ment using covariates that can influence FIO2 (including pro-
high FIO2 would be used in the sickest patients, and in the cedure duration, procedural severity score, diagnosis of
primary analysis we therefore adjusted for several covariates chronic obstructive pulmonary disorder before surgery,
including procedural risks, comorbidities, and anaesthesia- admission status, PEEP, tidal volume, surgical service, body
related risk factors. In a subgroup analysis, we included mass index, weight, and minimum alveolar concentration of
adjustment for minutes with hypotension and oxygenation inhaled anaesthetics) suggesting that this variability is
(ratio of PaO2 and FIO2) as additional potential confounding driven more by individual preference than by patient or
factors, and this did not change the results. These analyses procedure characteristics. That is concerning because
show that the association between FIO2 and respiratory harmful effects of high FIO2 have been detected in a number
complications is robust and not an epiphenomenon of a high of studies.6e8
FIO2 requirement. When analysing blood gas samples in De Jonge and colleagues are concerned about suboptimal
approximately 6000 patients, we saw that >30% of the pa- confounder control. Our statistical analyses have been a priori
tients in the high FIO2 group had in fact a PaO2 above 40 defined and all sensitivity analyses have been clearly indi-
kPadthis hyperoxia indicates that these patients did not need cated. Our rationale for confounding control is strictly based
this high FIO2. on clinical knowledge, and we have not used data mining for
Acka assumes that the concentration of FIO2 is mainly any aspect of the analysis. We are not concerned about
driven by patient and procedural characteristics and not by collinearity; we exclude any collinearity related bias by

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2 - Correspondence

analysing the condition index and the variance decomposition References

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Declaration of interest ogenesis, prediction, and prevention. Curr Opin Crit Care
None declared. 2014; 20: 56e62

doi: 10.1016/j.bja.2017.12.028