Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit

Klitgaard, Thomas L; Schjørring, Olav L; Nielsen, Frederik M; Meyhoff, Christian S; Perner, Anders; Wetterslev, Jørn; Rasmussen, Bodil S; Barbateskovic, Marija

doi:10.1002/14651858.cd012631.pub3

Cited by 13 publications

(21 citation statements)

References 164 publications

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“…We aimed for diversity in the panel, including with respect to gender, stage of practice, profession, and geography 7,8 . Methodologists from the GUIDE Group (AG, ZAD, WA, EBC, and SO) and authors of the used updated systematic review and meta‐analysis (OLS and BSR) 5 provided methodologic support to the panel. Four patient representatives—two former patients (MPP and KB) and two relatives (MH and TPP)—provided valuable insights regarding outcome selection and prioritization, and values and preferences through meetings with the methods chair 9 …”

Section: Methodsmentioning

confidence: 99%

“…The systematic review did not use predefined thresholds of oxygenation for the two groups but included trials in adult ICU patients with a clinically relevant differentiation between a higher versus lower oxygenation target 5 …”

Section: Methodsmentioning

confidence: 99%

“…We used the recently published Cochrane systematic review and meta‐analysis of randomized clinical trials (RCTs) on this topic to inform the guideline 5 . Furthermore, we identified and used a recently published systematic review on the long‐term effects of higher versus lower oxygenation targets to inform the outcomes of HRQoL, functional outcomes, cognition, and PICS 13 …”

Section: Methodsmentioning

confidence: 99%

“…The Cochrane review included subgroup analyses to explore potential sources of heterogeneity of treatment effects according to: (1) risk of bias, (2) ICU population, (3) patient type, (4) oxygen delivery system, (5) type of intervention, and (6) oxygenation thresholds used in the two arms 5 …”

Section: Methodsmentioning

confidence: 99%

“…After the publication of these two trials, 3,4 the Intensive Care Medicine Rapid Practice Guideline (ICM‐RPG) steering committee prioritized an ICM‐RPG on the use of higher versus lower oxygenation targets in adult ICU patients, based on a recently published Cochrane systematic review and meta‐analysis 5 . The aim was to summarize and evaluate the available evidence and provide evidence‐based recommendations to guide clinical practice.…”

Section: Introductionmentioning

confidence: 99%

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Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline

Møller,

Granholm,

Al Duhailib

et al. 2023

Acta Anaesthesiol Scand

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The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM‐RPG) was to provide evidence‐based clinical guidance about the use of higher versus lower oxygenation targets for adult patients in the intensive care unit (ICU). The guideline panel comprised 27 international panelists, including content experts, ICU clinicians, methodologists, and patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines, including the use of the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence, and used the Evidence‐to‐Decision framework to generate recommendations. A recently published updated systematic review and meta‐analysis constituted the evidence base. Through teleconferences and web‐based discussions, the panel provided input on the balance and magnitude of the desirable and undesirable effects, the certainty of evidence, patients' values and preferences, costs and resources, equity, feasibility, acceptability, and research priorities. The updated systematic review and meta‐analysis included data from 17 randomized clinical trials with 10,248 participants. There was little to no difference between the use of higher versus lower oxygenation targets for all outcomes with available data, including all‐cause mortality, serious adverse events, stroke, functional outcomes, cognition, and health‐related quality of life (very low certainty of evidence). The panel felt that values and preferences, costs and resources, and equity favored the use of lower oxygenation targets. The ICM‐RPG panel issued one conditional recommendation against the use of higher oxygenation targets: “We suggest against the routine use of higher oxygenation targets in adult ICU patients (conditional recommendation, very low certainty of evidence). Remark: an oxygenation target of SpO2 88%–92% or PaO2 8 kPa/60 mmHg is relevant and safe for most adult ICU patients.”

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Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline

Møller,

Granholm,

Al Duhailib

et al. 2023

Acta Anaesthesiol Scand

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Early Restrictive vs Liberal Oxygen for Trauma Patients

Arleth,

Baekgaard,

Siersma

et al. 2024

JAMA

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ImportanceEarly administration of supplemental oxygen for all severely injured trauma patients is recommended, but liberal oxygen treatment has been associated with increased risk of death and respiratory complications.ObjectiveTo determine whether an early 8-hour restrictive oxygen strategy compared with a liberal oxygen strategy in adult trauma patients would reduce death and/or major respiratory complications.Design, Setting, and ParticipantsThis randomized controlled trial enrolled adult trauma patients transferred directly to hospitals, triggering a full trauma team activation with an anticipated hospital stay of a minimum of 24 hours from December 7, 2021, to September 12, 2023. This multicenter trial was conducted at 15 prehospital bases and 5 major trauma centers in Denmark, the Netherlands, and Switzerland. The 30-day follow-up period ended on October 12, 2023. The primary outcome was assessed by medical specialists in anesthesia and intensive care medicine blinded to the randomization.InterventionsIn the prehospital setting or on trauma center admission, patients were randomly assigned 1:1 to a restrictive oxygen strategy (arterial oxygen saturation target of 94%) (n = 733) or liberal oxygen strategy (12-15 L of oxygen per minute or fraction of inspired oxygen of 0.6-1.0) (n = 724) for 8 hours.Main Outcomes and MeasuresThe primary outcome was a composite of death and/or major respiratory complications within 30 days. The 2 key secondary outcomes, death and major respiratory complications within 30 days, were assessed individually.ResultsAmong 1979 randomized patients, 1508 completed the trial (median [IQR] age, 50 [31-65] years; 73% male; and median Injury Severity Score was 14 [9-22]). Death and/or major respiratory complications within 30 days occurred in 118 of 733 patients (16.1%) in the restrictive oxygen group and 121 of 724 patients (16.7%) in the liberal oxygen group (odds ratio, 1.01 [95% CI, 0.75 to 1.37]; P = .94; absolute difference, 0.56 percentage points [95% CI, −2.70 to 3.82]). No significant differences were found between groups for each component of the composite outcome. Adverse and serious adverse events were similar across groups, with the exception of atelectasis, which was less common in the restrictive oxygen group compared with the liberal oxygen group (27.6% vs 34.7%, respectively).Conclusions and RelevanceIn adult trauma patients, an early restrictive oxygen strategy compared with a liberal oxygen strategy initiated in the prehospital setting or on trauma center admission for 8 hours did not significantly reduce death and/or major respiratory complications within 30 days.Trial RegistrationClinicalTrials.gov Identifier: NCT05146700

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Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19

Nielsen,

Klitgaard,

Siegemund

et al. 2024

JAMA

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ImportanceSupplemental oxygen is ubiquitously used in patients with COVID-19 and severe hypoxemia, but a lower dose may be beneficial.ObjectiveTo assess the effects of targeting a Pao2 of 60 mm Hg vs 90 mm Hg in patients with COVID-19 and severe hypoxemia in the intensive care unit (ICU).Design, Setting, and ParticipantsMulticenter randomized clinical trial including 726 adults with COVID-19 receiving at least 10 L/min of oxygen or mechanical ventilation in 11 ICUs in Europe from August 2020 to March 2023. The trial was prematurely stopped prior to outcome assessment due to slow enrollment. End of 90-day follow-up was June 1, 2023.InterventionsPatients were randomized 1:1 to a Pao2 of 60 mm Hg (lower oxygenation group; n = 365) or 90 mm Hg (higher oxygenation group; n = 361) for up to 90 days in the ICU.Main Outcomes and MeasuresThe primary outcome was the number of days alive without life support (mechanical ventilation, circulatory support, or kidney replacement therapy) at 90 days. Secondary outcomes included mortality, proportion of patients with serious adverse events, and number of days alive and out of hospital, all at 90 days.ResultsOf 726 randomized patients, primary outcome data were available for 697 (351 in the lower oxygenation group and 346 in the higher oxygenation group). Median age was 66 years, and 495 patients (68%) were male. At 90 days, the median number of days alive without life support was 80.0 days (IQR, 9.0-89.0 days) in the lower oxygenation group and 72.0 days (IQR, 2.0-88.0 days) in the higher oxygenation group (P = .009 by van Elteren test; supplemental bootstrapped adjusted mean difference, 5.8 days [95% CI, 0.2-11.5 days]; P = .04). Mortality at 90 days was 30.2% in the lower oxygenation group and 34.7% in the higher oxygenation group (risk ratio, 0.86 [98.6% CI, 0.66-1.13]; P = .18). There were no statistically significant differences in proportion of patients with serious adverse events or in number of days alive and out of hospital.Conclusion and RelevanceIn adult ICU patients with COVID-19 and severe hypoxemia, targeting a Pao2 of 60 mm Hg resulted in more days alive without life support in 90 days than targeting a Pao2 of 90 mm Hg.Trial RegistrationClinicalTrials.gov Identifier: NCT04425031

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Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit

Cited by 13 publications

References 164 publications

Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline

Higher versus lower oxygenation targets in adult ICU patients: A rapid practice guideline

Early Restrictive vs Liberal Oxygen for Trauma Patients

Lower vs Higher Oxygenation Target and Days Alive Without Life Support in COVID-19

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