Hyperoxia during venoarterial ECMO: Culprit or co-variate? A comment from the BLENDER investigators

Premraj, Lavienraj; Brown, Alastair; Burrell, Aidan; Fraser, John F.; Pilcher, David

doi:10.1186/s13054-022-04213-8

Cited by 3 publications

(6 citation statements)

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“…Then down titration of F S O 2 might theoretically result in unknown low P POST O 2 , and hepato-splanchnic hypoxia [ 15 ]. One could also argue that for now, the safe P POST O 2 target is still unknown, as randomized trials are ongoing [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study

Winiszewski,

Vieille,

Guinot

et al. 2024

Ann. Intensive Care

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Backgound Hyperoxemia is common and associated with poor outcome during veno-arterial extracorporeal membrane oxygenation (VA ECMO) support for cardiogenic shock. However, little is known about practical daily management of oxygenation. Then, we aim to describe sweep gas oxygen fraction (FSO2), postoxygenator oxygen partial pressure (PPOSTO2), inspired oxygen fraction (FIO2), and right radial arterial oxygen partial pressure (PaO2) between day 1 and day 7 of peripheral VA ECMO support. We also aim to evaluate the association between oxygenation parameters and outcome. In this retrospective multicentric study, each participating center had to report data on the last 10 eligible patients for whom the ICU stay was terminated. Patients with extracorporeal cardiopulmonary resuscitation were excluded. Primary endpoint was individual mean FSO2 during the seven first days of ECMO support (FSO2 mean (day 1−7)). Results Between August 2019 and March 2022, 139 patients were enrolled in 14 ECMO centers in France, and one in Switzerland. Among them, the median value for FSO2 mean (day 1−7) was 70 [57; 79] % but varied according to center case volume. Compared to high volume centers, centers with less than 30 VA-ECMO runs per year were more likely to maintain FSO2 ≥ 70% (OR 5.04, CI 95% [1.39; 20.4], p = 0.017). Median value for right radial PaO2 mean (day 1−7) was 114 [92; 145] mmHg, and decreased from 125 [86; 207] mmHg at day 1, to 97 [81; 133] mmHg at day 3 (p < 0.01). Severe hyperoxemia (i.e. right radial PaO2 ≥ 300 mmHg) occurred in 16 patients (12%). PPOSTO2, a surrogate of the lower body oxygenation, was measured in only 39 patients (28%) among four centers. The median value of PPOSTO2 mean (day 1−7) value was 198 [169; 231] mmHg. By multivariate analysis, age (OR 1.07, CI95% [1.03–1.11], p < 0.001), FSO2 mean (day 1−3)(OR 1.03 [1.00-1.06], p = 0.039), and right radial PaO2 mean (day 1−3) (OR 1.03, CI95% [1.00-1.02], p = 0.023) were associated with in-ICU mortality. Conclusion In a multicentric cohort of cardiogenic shock supported by VA ECMO, the median value for FSO2 mean (day 1−7) was 70 [57; 79] %. PPOSTO2 monitoring was infrequent and revealed significant hyperoxemia. Higher FSO2 mean (day 1−3) and right radial PaO2 mean (day 1−3) were independently associated with in-ICU mortality.

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Section: Discussionmentioning

confidence: 99%

Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study

Winiszewski,

Vieille,

Guinot

et al. 2024

Ann. Intensive Care

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“…Therefore, the primary determinant of D o 2 (via ECMO circuit) is the ECMO blood flow rate (27, 38, 39, 47, 48). When ECMO blood flow (L/min) is increased, D o 2 increases proportionately (Equation 1).…”

Section: The Determinants Of Oxygenation and Circuit Physiologymentioning

confidence: 99%

“…Although unvalidated by RCTs, the Pa o 2 target of 150 mm Hg appears to fall within the hypothetical safety zone (5, 24, 25, 56, 65, 70, 72). As previously noted, studies that describe associations between hyperoxia and outcome differ in methodology and may unknowingly attribute mortality to hyperoxia rather than more severe disease (27, 37). Still, taken together the evidence suggests that targeting a Pa o 2 of less than 300 mm Hg avoids sequelae of hyperoxia.…”

Section: A Suggested Approachmentioning

confidence: 99%

“…The extent to which this association is driven by consequences of direct hyperoxic injury rather than disease severity is heavily debated (26–28). Mechanistically, hyperoxia during venoarterial ECMO/ECPR may potentiate mortality and poor neurologic outcome by: 1) exacerbating reperfusion injury and neurometabolic failure (3, 29, 30), 2) worsening pulmonary injury via pulmonary neutrophil sequestration (31–33), and 3) propagating systemic inflammation in patients with underlying sepsis or acute respiratory distress syndrome (19, 33–36).…”

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confidence: 99%

“…Mechanistically, hyperoxia during venoarterial ECMO/ECPR may potentiate mortality and poor neurologic outcome by: 1) exacerbating reperfusion injury and neurometabolic failure (3, 29, 30), 2) worsening pulmonary injury via pulmonary neutrophil sequestration (31–33), and 3) propagating systemic inflammation in patients with underlying sepsis or acute respiratory distress syndrome (19, 33–36). Equally, hyperoxia may simply indicate low cardiac output states in which the patient is dependent on high ECMO blood flows (27). ABG samples in these patients necessarily express Pa o 2 values well above normal.…”

mentioning

confidence: 99%

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Oxygenation During Venoarterial Extracorporeal Membrane Oxygenation: Physiology, Current Evidence, and a Pragmatic Approach to Oxygen Titration

Premraj,

Brown,

Fraser

et al. 2023

Critical Care Medicine

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OBJECTIVES: This review aims to: 1) identify the key circuit and patient factors affecting systemic oxygenation, 2) summarize the literature reporting the association between hyperoxia and patient outcomes, and 3) provide a pragmatic approach to oxygen titration, in patients undergoing peripheral venoarterial extracorporeal membrane oxygenation (ECMO). DATA SOURCES: Searches were performed using PubMed, SCOPUS, Medline, and Google Scholar. STUDY SELECTION: All observational and interventional studies investigating the association between hyperoxia, and clinical outcomes were included, as well as guidelines from the Extracorporeal Life Support Organization. DATA EXTRACTION: Data from relevant literature was extracted, summarized, and integrated into a concise narrative review. For ease of reference a summary of relevant studies was also produced. DATA SYNTHESIS: The extracorporeal circuit and the native cardiorespiratory circuit both contribute to systemic oxygenation during venoarterial ECMO. The ECMO circuit’s contribution to systemic oxygenation is, in practice, largely determined by the ECMO blood flow, whereas the native component of systemic oxygenation derives from native cardiac output and residual respiratory function. Interactions between ECMO outflow and native cardiac output (as in differential hypoxia), the presence of respiratory support, and physiologic parameters affecting blood oxygen carriage also modulate overall oxygen exposure during venoarterial ECMO. Physiologically those requiring venoarterial ECMO are prone to hyperoxia. Hyperoxia has a variety of definitions, most commonly Pao 2 greater than 150 mm Hg. Severe hypoxia (Pao 2 > 300 mm Hg) is common, seen in 20%. Early severe hyperoxia, as well as cumulative hyperoxia exposure was associated with in-hospital mortality, even after adjustment for disease severity in both venoarterial ECMO and extracorporeal cardiopulmonary resuscitation. A pragmatic approach to oxygenation during peripheral venoarterial ECMO involves targeting a right radial oxygen saturation target of 94–98%, and in selected patients, titration of the fraction of oxygen in the mixture via the air-oxygen blender to target postoxygenator Pao 2 of 150–300 mm Hg. CONCLUSIONS: Hyperoxia results from a range of ECMO circuit and patient-related factors. It is common during peripheral venoarterial ECMO, and its presence is associated with poor outcome. A pragmatic approach that avoids hyperoxia, while also preventing hypoxia has been described for patients receiving peripheral venoarterial ECMO.

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Summary of Complications in Extracorporeal Membrane Oxygenation Therapy for Bleeding

古丽亚尔

2023

ACM

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Hyperoxia during venoarterial ECMO: Culprit or co-variate? A comment from the BLENDER investigators

Cited by 3 publications

References 15 publications

Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study

Oxygenation management during veno-arterial ECMO support for cardiogenic shock: a multicentric retrospective cohort study

Oxygenation During Venoarterial Extracorporeal Membrane Oxygenation: Physiology, Current Evidence, and a Pragmatic Approach to Oxygen Titration

Summary of Complications in Extracorporeal Membrane Oxygenation Therapy for Bleeding

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