Trials on oxygen targets in the critically ill patients: do they change our knowledge and practice?

Girardis, Massimo; Man, A. M. E. de; Singer, Mervyn

doi:10.1007/s00134-023-06999-9

Cited by 8 publications

(9 citation statements)

References 12 publications

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“…Although it is not intention of this manuscript to review the effects of hyperoxemia in critically ill patients, in virtually all trials conducted so far, the comparison between strategies of liberal and conservative oxygenation targets brought con icting results [49]. The little or no effect seen on clinical outcomes in most trials is likely due to small differences in the oxygenation and/or saturation targets.…”

Section: Discussionmentioning

confidence: 99%

Exposure to hyperoxemia worsens survival and neurological outcome in patients supported by veno-arterial extracorporeal membrane oxygenation: a meta-analysis

Tigano

Caruso

Liotta

et al. 2023

Preprint

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Background Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is a rescue treatment in refractory cardiogenic shock (CS) or refractory cardiac arrest (CA). Exposure to hyperoxemia is common during VA-ECMO, and its impact on patient’s outcome remains unclear. Methods We conducted a systematic review (PubMed and Scopus) and metanalysis investigating the effects of exposure to hyperoxemia on mortality and poor neurological outcome in patients supported by VA-ECMO. Whenever provided, we used the Odds Ratio (OR) adjusted for confounders. Results are reported as OR and 95% confidence interval (CI). Subgroup analyses were conducted according to VA-ECMO indication and hyperoxemia thresholds. Results Data from 11 observational studies were included. Ten studies reported data on mortality (6 on refractory CA and 4 on CS), and 4 on neurological outcome. Hyperoxemia exposure was associated with higher mortality (OR:1.81, 95%CI [1.22–2.71]; p = 0.003; I2 = 81%) and worse neurological outcome (OR:1.97, 95%CI [1.30–2.96]; p = 0.001; I2 = 0%). Magnitude and effect of these findings remained valid in subgroup analyses conducted according to different hyperoxemia thresholds (> 200 or > 300 mmHg) and VA-ECMO indication, although the association with mortality remained uncertain in the refractory CA population (p = 0.07). Analysis restricted only to studies providing data in adjusted OR confirmed the increased mortality (OR:1.72, 95%CI [1.00-2.97]; p = 0.05) and poorer neurological outcome (OR:1.99, 95%CI [1.18–3.37]; p = 0.01) in patients exposed to hyperoxemia. Conclusions Hyperoxemia exposure after initiation of VA-ECMO is associated with an almost doubled increased probability of poor neurological outcome and mortality. Clinical efforts should be made to avoid severe hyperoxemia during VA-ECMO support.

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Section: Discussionmentioning

confidence: 99%

Exposure to hyperoxemia worsens survival and neurological outcome in patients supported by veno-arterial extracorporeal membrane oxygenation: a meta-analysis

Tigano

Caruso

Liotta

et al. 2023

Preprint

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“…2 However, data from randomized controlled trials are conflicting and do not provide evidence on the causal relation between hyperoxemia and mortality. 3…”

Section: To the Editormentioning

confidence: 99%

“…2 However, data from randomized controlled trials are conflicting and do not provide evidence on the causal relation between hyperoxemia and mortality. 3 We would like to provide some physiological considerations about the interplay between the native cardiopulmonary function, ECMO circuit, and arterial oxygenation during femorofemoral VA ECMO.…”

Section: To the Editormentioning

confidence: 99%

Letter by Giani et al Regarding Article, “Exposure to Arterial Hyperoxia During Extracorporeal Membrane Oxygenator Support and Mortality in Patients With Cardiogenic Shock”

Giani

Pozzi

Rezoagli

2023

Circ: Heart Failure

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“…Use of supplemental oxygen for patients with suspected myocardial infarction has also been shown to be of no benefit . The oxygenation targets in these studies were similar to those chosen by Nielsen et al, although their high oxygen target likely correlated with an oxygen saturation of 97% to 99%, which is higher than some other studies and provides a good separation of the 2 target groups …”

mentioning

confidence: 99%

“…12 The oxygenation targets in these studies were similar to those chosen by Nielsen et al, 4 although their high oxygen target likely correlated with an oxygen saturation of 97% to 99%, which is higher than some other studies and provides a good separation of the 2 target groups. 5,11,13 Could higher oxygen targets help in some ways (eg, greater oxygen delivery) but hurt or harm patients in other ways, thereby negating any advantage? 9 High levels of supplemental oxygen resulting in a fraction of inspired oxygen greater than 0.6 have been shown to contribute to lung injury.…”

mentioning

confidence: 99%

Oxygen Supplementation in COVID-19—How Much Is Enough?

Schwartzstein

2024

JAMA

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Humans are aerobic animals; we need oxygen to support metabolism and generate energy. Simply put, breathing oxygen is necessary for life. Consequently, it would make sense that diseases that inhibit the transfer of oxygen from the lung to the blood should be treated with supplementary oxygen to overcome problems associated with hypoxemia, and one should strive to achieve "normal" levels of arterial oxygen (PaO 2 ). But is that reasoning supported by the understanding of physiology and the weight of clinical evidence?Stating that human tissues are dependent on oxygen refers to the need for oxygen delivery to vital organs; oxygen delivery encompasses the oxygen content of the blood as well as cardiac output. Because total oxygen content consists of oxygen bound to hemoglobin as well as oxygen dissolved in plasma, with the former far exceeding the latter, one might reason that transfusing patients with anemia to a normal level of hemoglobin would result in better outcomes. The evidence suggests otherwise, however, and the threshold for transfusion of red blood cells is well below "normal" values of hemoglobin. [1][2][3] From an evolutionary perspective, it might be argued that humans are built to tolerate mild degrees of hypoxemia. The oxygen-hemoglobin saturation curve has a characteristic sigmoid shape. A decrease in PaO 2 from 90 mm Hg to 60 mm Hg still leaves one with near-normal oxygen saturation and oxygen content of the blood; long before supplemental oxygen was available, humans had pneumonia, asthma, or heart failure and tolerated mild to moderate decrements in PaO 2 . Nevertheless, the sickest patients, those with acute hypoxemic respiratory failure, must benefit from restoring oxygen saturation to normal values, or at least that is what clinical intuition might tell us.The study by Nielsen et al 4 reported in this issue of JAMA builds on prior work of the HOT-COVID trial 5 to assess the impact of targeting PaO 2 to 90 mm Hg vs 60 mm Hg in patients with COVID-19 pneumonia and hypoxemic respiratory failure. This study was a large multicenter trial involving medical intensive care units (ICUs) in 5 European countries. Acute hypoxemic respiratory failure was defined as necessitating supplemental oxygen of at least 10 L/min in an open system or mechanical ventilatory support (either invasive or noninvasive). The protocol required randomization of participants to supplemental oxygen to achieve high PaO 2 (90 mm Hg) or low PaO 2 (60 mm Hg) targets. Arterial lines were placed in all patients; this is one of the strengths of the study given the technical issues that often confound interpretation of pulse oximetry (eg, inadequate waveforms; erroneous measurements 15.

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Trials on oxygen targets in the critically ill patients: do they change our knowledge and practice?

Cited by 8 publications

References 12 publications

Exposure to hyperoxemia worsens survival and neurological outcome in patients supported by veno-arterial extracorporeal membrane oxygenation: a meta-analysis

Exposure to hyperoxemia worsens survival and neurological outcome in patients supported by veno-arterial extracorporeal membrane oxygenation: a meta-analysis

Letter by Giani et al Regarding Article, “Exposure to Arterial Hyperoxia During Extracorporeal Membrane Oxygenator Support and Mortality in Patients With Cardiogenic Shock”

Oxygen Supplementation in COVID-19—How Much Is Enough?

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