Hyperoxia in patients with cardiogenic shock after myocardial infarction supported with venoarterial extracorporeal membrane oxygenation

Ross, Paul; Miller, Charne; Sheldrake, Jayne; McGuiness, William; Udy, Andrew; Burrell, Aidan

doi:10.1016/j.aucc.2020.04.154

Cited by 14 publications

(18 citation statements)

References 15 publications

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“…We also demonstrate a dose effect of the PaO 2 increase on the risk As mentioned above, published data on hyperoxia in patients on VA-ECMO are scarce. Hyperoxia seems frequent in the early management of VA-ECMO with almost 1 out of 2 patients concerned by the level of PaO 2 over 300 mmHg [22]. However, the impact on outcomes is uncertain regarding the results of the two main studies with some contradictions: Al Kawaz et al found a significant association between hyperoxia and mortality, whereas Munshi et al did not [15], [13].…”

Section: Discussionmentioning

confidence: 99%

Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis

Moussa

Beyls

Lamer³

et al. 2022

Crit Care

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Background The mortality rate for a patient with a refractory cardiogenic shock on venoarterial (VA) extracorporeal membrane oxygenation (ECMO) remains high, and hyperoxia might worsen this prognosis. The objective of the present study was to evaluate the association between hyperoxia and 28-day mortality in this setting. Methods We conducted a retrospective bicenter study in two French academic centers. The study population comprised adult patients admitted for refractory cardiogenic shock. The following arterial partial pressure of oxygen (PaO2) variables were recorded for 48 h following admission: the absolute peak PaO2 (the single highest value measured during the 48 h), the mean daily peak PaO2 (the mean of each day’s peak values), the overall mean PaO2 (the mean of all values over 48 h), and the severity of hyperoxia (mild: PaO2 < 200 mmHg, moderate: PaO2 = 200–299 mmHg, severe: PaO2 ≥ 300 mmHg). The main outcome was the 28-day all-cause mortality. Inverse probability weighting (IPW) derived from propensity scores was used to reduce imbalances in baseline characteristics. Results From January 2013 to January 2020, 430 patients were included and assessed. The 28-day mortality rate was 43%. The mean daily peak, absolute peak, and overall mean PaO2 values were significantly higher in non-survivors than in survivors. In a multivariate logistic regression analysis, the mean daily peak PaO2, absolute peak PaO2, and overall mean PaO2 were independent predictors of 28-day mortality (adjusted odds ratio [95% confidence interval per 10 mmHg increment: 2.65 [1.79–6.07], 2.36 [1.67–4.82], and 2.85 [1.12–7.37], respectively). After IPW, high level of oxygen remained significantly associated with 28-day mortality (OR = 1.41 [1.01–2.08]; P = 0.041). Conclusions High oxygen levels were associated with 28-day mortality in patients on VA-ECMO support for refractory cardiogenic shock. Our results confirm the need for large randomized controlled trials on this topic.

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Section: Discussionmentioning

confidence: 99%

Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis

Moussa

Beyls

Lamer³

et al. 2022

Crit Care

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“…Multiple studies have demonstrated this association in patients with sepsis [1,2] , myocardial infarction [3] , stroke [4] , traumatic brain injury [5][6][7][8][9][10][11] as well as in post cardiac arrest (CA) patients. [1,[12][13][14][15][16] Post CA patients may represent a particularly vulnerable group, as the damaging effects of ischemia-reperfusion injury may be worse in the brain. The recently published ICU ROX trial suggested potentially improved outcomes with conservative compared to liberal oxygen therapy in patients with hypoxic ischaemic encephalopathy post CA.…”

Section: Introductionmentioning

confidence: 99%

“…[23,24] However while ECPR provides both mechanical haemodynamic and oxygenation support, [25][26][27] ECPR may also be associated with signi cantly elevated arterial oxygen levels. [1,12,13] To date, little is known about the incidence of hyperoxia in patients treated with ECPR compared to CCPR, and whether there is an association between hyperoxia and poor outcomes, independent of the method of resuscitation.…”

Section: Introductionmentioning

confidence: 99%

Hyperoxia and mortality in Conventional versus Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation

Stoll

Paul

Pilcher

et al. 2021

Preprint

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BackgroundHyperoxia has been associated with adverse outcomes in post cardiac arrest (CA) patients. However, little data are available from mixed cohorts, where extracorporeal membrane oxygenation cardiopulmonary resuscitation (ECPR) and conventional CPR (CCPR) were utilised. The independence of effect of hyperoxia in this setting is not clear. Study-objective was to examine the association between hyperoxia and 30-day mortality in a mixed cohort of ECPR and CCPR patients.Methods and designThis was a retrospective cohort study of CA patients admitted to a tertiary level cardiac arrest centre in Australia from 1st January 2013 to 31st August 2018. Mean arterial oxygen levels (PaO2) and episodes of extreme hyperoxia (PaO2 ≥ 300mmHg) were analysed over the first 8 days. The primary outcome was 30-day mortality.ResultsA total of 169 post CA patients were assessed over a 6.5-year time period: 79 patients undergoing ECPR vs 90 patients undergoing CCPR. The mean age of the cohort was 54 (± 17) years; 126/169 (74%) were male and 119/169 (70%) were treated for out of hospital cardiac arrest (OHCA). Compared to CCPR, ECPR patients were younger, had a longer low flow time and higher illness severity scores on admission. Mean PaO2-levels were higher in patients in the ECPR vs CCPR group (211mmHg ± 58.4 vs 119mmHg ± 18.1; p < 0.0001) as was the proportion with at least one episode of extreme hyperoxia (58/79 (73%) vs 36/90 (40%), p < 0.01). ECPR patients presented with a higher mortality (54.4%) vs CCPR patients (34.4%). After adjusting for age, sex, BMI, highest lactate pre-treatment, use of ECMO, low flow time, pulse pressure on admission day, and severity of illness (APACHE III score), any episode of extreme hyperoxia was independently associated with a 2.57-fold increased risk of 30-day mortality (OR: 2.57, 95% CI: 1.09–6.06; p = 0.031) irrespective of the CPR-mode.ConclusionWe found extreme hyperoxia (PaO2-level ≥ 300mmHg) was more common in ECPR patients in the first 8 days post CA and was independently associated with higher 30-day mortality, irrespective of whether ECPR was employed. Prospective studies that compare different oxygen targets are needed to see if a strategy of lower oxygen exposure improves outcomes.

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“…Several observational studies have examined the association between hyperoxia during VA-ECMO and patient outcomes and the findings are inconsistent [6,[9][10][11][12]. The methodology of these studies have been highly variable and although the demonstrated effect of hyperoxia has varied a high prevalence of hyperoxia amongst VA-ECMO patients has been ubiquitous [7,[9][10][11][12].…”

mentioning

confidence: 99%

“…Unlike some previous studies, arterial oxygenation (PaO 2 ) was primarily controlled using the oxygen-air blender and recorded for 48 h post-admission. Previous observational studies in this population lacked clear protocols for oxygen titration [6,[9][10][11][12]. This created issues with defining exposure and confounding by indication.…”

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confidence: 99%

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

et al. 2022

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Hyperoxia in patients with cardiogenic shock after myocardial infarction supported with venoarterial extracorporeal membrane oxygenation

Cited by 14 publications

References 15 publications

Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis

Early hyperoxia and 28-day mortality in patients on venoarterial ECMO support for refractory cardiogenic shock: a bicenter retrospective propensity score-weighted analysis

Hyperoxia and mortality in Conventional versus Extracorporeal Membrane Oxygenation Cardiopulmonary Resuscitation

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

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