Early Hyperoxemia and Outcome Among Critically Ill Children

Ramgopal, Sriram; Dezfulian, Cameron; Hickey, Robert W.; Au, Alicia K.; Venkataraman, Shekhar T.; Clark, Robert S. B.; Horvat, Christopher M.

doi:10.1097/pcc.0000000000002203

Cited by 9 publications

(29 citation statements)

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“…However, the highest Pa o 2 measurements in the liberal oxygen therapy group from that study were less than 150 mm Hg. In contrast, the present study and several prior pediatric studies ( 4 – 7 ) have demonstrated a significant association only with either extreme hyperoxemia and death. In the present study, the optimal maximum Pa o 2 value in the first 72 hours of mechanical ventilation appears to be between 100 and 400 mm Hg.…”

Section: Discussioncontrasting

confidence: 99%

“…Expert opinion has suggested that extreme hyperoxemia may be an indirect measurement of patients undergoing brain death testing or being assessed for organ donation eligibility ( 4 ). However, as relatively few PICU patients undergo brain death testing within 24 hours of admission, the findings of our sensitivity analysis, combined with prior studies of the impact of early hyperoxemia, would suggest this is less likely ( 6 , 7 ).…”

Section: Discussionmentioning

confidence: 86%

“…Previous studies have observed Pa o 2 threshold values between 300 and 550 mm Hg to be associated with increased mortality ( 4 – 7 ). Together, these results suggest that both hypoxemia and extreme hyperoxemia are associated with risk-adjusted mortality; however, the precise thresholds associated with clinical harm remain uncertain and likely vary by clinical condition ( 4 – 7 ). A recent randomized controlled trial among adults demonstrated no difference between conservative and liberal oxygen management strategies ( 3 ).…”

Section: Discussionmentioning

confidence: 94%

“…Third, we excluded patients with cardiac arrest prior to admission. Fourth, because prior work has suggested a time-dependent effect of hyperoxemia ( 4 – 7 ), we restricted the cohort to patients with invasive mechanical ventilation and Pa o 2 measurements within 24 hours of admission. Fifth, we broadened the cohort to include patients who underwent invasive mechanical ventilation and Pa o 2 measurements at any time during admission.…”

Section: Methodsmentioning

confidence: 99%

“…Several randomized controlled trials and meta-analyses of oxygen management strategies in adults have come to differing conclusions regarding the importance of hyperoxemia ( 1 – 3 ). While fewer data exist for children, there is a growing body of literature identifying a relationship between the Pa o 2 values and mortality in PICU settings ( 4 – 7 ). Limitations of these previous studies include data from single centers, variable definitions of hyperoxemia, and absent or uncalibrated risk-adjustment strategies.…”

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Maximum Pao 2 in the First 72 Hours of Intensive Care Is Associated With Risk-Adjusted Mortality in Pediatric Patients Undergoing Mechanical Ventilation

Pelletier

Ramgopal

et al. 2020

Critical Care Explorations

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A relationship between Pa o 2 and mortality has previously been observed in single-center studies. We performed a retrospective cohort study of the Pediatric Health Information System plus database including patients less than or equal to 21 years old admitted to a medical or cardiac ICU who received invasive ventilation within 72 hours of admission. We trained and validated a multivariable logistic regression mortality prediction model with very good discrimination ( C -statistic, 0.86; 95% CI, 0.79–0.92; area under the precision-recall curve, 0.39) and acceptable calibration (standardized mortality ratio, 0.96; 95% CI, 0.75–1.23; calibration belt p = 0.07). Maximum Pa o 2 measurements demonstrated a parabolic (“U-shaped”) relationship with PICU mortality (Box-Tidwell p < 0.01). Maximum Pa o 2 was a statistically significant predictor of risk-adjusted mortality (standardized odds ratio, 1.27; 95% CI, 1.23–1.32; p < 0.001). This analysis is the first multicenter pediatric study to identify a relationship between the extremes in Pa o 2 values and PICU mortality. Clinicians should remain judicious in the use of oxygen when caring for children.

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confidence: 99%

Section: Discussionmentioning

confidence: 86%

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confidence: 94%

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Maximum Pao 2 in the First 72 Hours of Intensive Care Is Associated With Risk-Adjusted Mortality in Pediatric Patients Undergoing Mechanical Ventilation

Pelletier

Ramgopal

et al. 2020

Critical Care Explorations

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Association of Arterial Hyperoxia With Outcomes in Critically Ill Children

et al. 2022

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IMPORTANCEOxygen supplementation is a cornerstone treatment in pediatric critical care.Accumulating evidence suggests that overzealous use of oxygen, leading to hyperoxia, is associated with worse outcomes compared with patients with normoxia.OBJECTIVES To evaluate the association of arterial hyperoxia with clinical outcome in critically ill children among studies using varied definitions of hyperoxia.DATA SOURCES A systematic search of EMBASE, MEDLINE, Cochrane Library, and ClinicalTrials.gov from inception to February 1, 2021, was conducted.STUDY SELECTION Clinical trials or observational studies of children admitted to the pediatric intensive care unit that examined hyperoxia, by any definition, and described at least 1 outcome of interest. No language restrictions were applied. DATA EXTRACTION AND SYNTHESISThe Meta-analysis of Observational Studies in Epidemiology guideline and Newcastle-Ottawa Scale for study quality assessment were used. The review process was performed independently by 2 reviewers. Data were pooled with a random-effects model. MAIN OUTCOMES AND MEASURESThe primary outcome was 28-day mortality; this time was converted to mortality at the longest follow-up owing to insufficient studies reporting the initial primary outcome. Secondary outcomes included length of stay, ventilator-related outcomes, extracorporeal organ support, and functional performance. RESULTSIn this systematic review, 16 studies (27 555 patients) were included. All, except 1 randomized clinical pilot trial, were observational cohort studies. Study populations included were post-cardiac arrest (n = 6), traumatic brain injury (n = 1), extracorporeal membrane oxygenation (n = 2), and general critical care (n = 7). Definitions and assessment of hyperoxia differed among included studies. Partial pressure of arterial oxygen was most frequently used to define hyperoxia and mainly by categorical cutoff. In total, 11 studies (23 204 patients) were pooled for meta-analysis.Hyperoxia, by any definition, showed an odds ratio of 1.59 (95% CI, 1.00-2.51; after Hartung-Knapp adjustment, 95% CI, 1.05-2.38) for mortality with substantial between-study heterogeneity (I 2 = 92%). This association was also found in less heterogeneous subsets. A signal of harm was observed at higher thresholds of arterial oxygen levels when grouped by definition of hyperoxia.Secondary outcomes were inadequate for meta-analysis. CONCLUSIONS AND RELEVANCEThese results suggest that, despite methodologic limitations of the studies, hyperoxia is associated with mortality in critically ill children. This finding identifies the (continued) Key Points Question What is the association between arterial hyperoxia and outcomes in critically ill children admitted to the pediatric intensive care unit? Findings This systematic review of 16 studies and meta-analysis of 11 studies comprising a total of 23 204 patients found an association between hyperoxia and mortality in children admitted to the pediatric intensive care unit. Meaning These findings suggest that hyperoxia is a...

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Hyperoxia after pediatric cardiac arrest: Association with survival and neurological outcomes

et al. 2022

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Early Hyperoxemia and Outcome Among Critically Ill Children

Abstract: Objective: To identify whether a high Pao 2 (hyperoxemia) at the time of presentation to the PICU is associated with in-hospital mortality.

Cited by 9 publications

References 16 publications

Maximum Pao 2 in the First 72 Hours of Intensive Care Is Associated With Risk-Adjusted Mortality in Pediatric Patients Undergoing Mechanical Ventilation

Maximum Pao 2 in the First 72 Hours of Intensive Care Is Associated With Risk-Adjusted Mortality in Pediatric Patients Undergoing Mechanical Ventilation

Association of Arterial Hyperoxia With Outcomes in Critically Ill Children

Hyperoxia after pediatric cardiac arrest: Association with survival and neurological outcomes

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