A quasiexperimental study of targeted normoxia in critically ill trauma patients

Abstract

BACKGROUND:Avoidance of hypoxia and hyperoxia may reduce morbidity and mortality in critically ill civilian and military trauma patients. The objective of this study was to determine if a multimodal quality improvement intervention increases adherence to a consensusbased, targeted normoxia strategy. We hypothesized that this intervention would safely improve compliance with targeted normoxia. METHODS:This is a pre/postquasiexperimental pilot study to improve adherence to normoxia, defined as a pulse oximetry (SpO 2 ) of 90% to 96% or an arterial partial pressure oxygen (PaO 2 ) of 60 to 100 mm Hg. We used a multimodal informatics and educational intervention guiding clinicians to safely titrate supplemental oxygen to normoxia based on SpO 2 monitoring in critically ill trauma patients admitted to the surgical-trauma or neurosurgical intensive care unit within 24 hours of emergency department arrival. The primary outcome was effectiveness in delivering targeted normoxia (i.e., an increase in the probability of being in the targeted normoxia range and/or a reduction in the probability of being on a higher fraction-inspired oxygen concentration [FiO 2 ]). RESULTS:Analysis included 371 preintervention subjects and 201 postintervention subjects. Preintervention and postintervention subjects were of similar age, race/ethnicity, and sex and had similar comorbidities and Acute Physiologic and Chronic Health Evaluation II scores. Overall, the adjusted probability of being hyperoxic while on supplemental oxygen was reduced during the postintervention period (adjusted odds ratio, 0.74; 95% confidence interval, 0.57-0.97). There was a higher probability of being on room air (FiO 2 , 0.21) in the postintervention period (adjusted odds ratio, 1.38; 95% confidence interval, 0.83-2.30). In addition, there was a decreased amount of patient time spent on higher levels of FiO 2 (FiO 2 , >40%) without a concomitant increase in hypoxia. CONCLUSION:A multimodal intervention targeting normoxia in critically ill trauma patients increased normoxia and lowered the use of supplemental oxygen. A large clinical trial is needed to validate the impact of this protocol on patient-centered clinical outcomes. (J

Early veno-venous extracorporeal membrane oxygenation is an effective strategy for traumatically injured patients presenting with refractory respiratory failure

“…Despite not only requiring respiratory stabilization, but also further hemorrhage control, the cohort had good outcomes. Short periods of hypoxia and/or hypercarbia and delays in initiation of life-saving interventions while attempting conventional ventilator management can worsen trauma patient outcomes 36–41 . Early VV is a resuscitation strategy that stabilizes these patients in the acute setting for further interventions.…”

“…Short periods of hypoxia and/or hypercarbia and delays in initiation of life-saving interventions while attempting conventional ventilator management can worsen trauma patient outcomes. [36][37][38][39][40][41] Early VV is a resuscitation strategy that stabilizes these patients in the acute setting for further interventions. Like DCR and DCS, EVV focuses on rapid correction of potentially fatal physiologic derangements while not definitively correcting the underlying cause.…”

Does statistical difference in the pre/post-quasi-experimental study mean the utility of multimodal educational intervention in targeted normoxia in critically ill trauma patients?

“…We read with great interest the article by Dylla et al, 1 who reported the results of a quasiexperimental study that determined whether multimodal educational intervention to medical staff would improve the compliance with targeted normoxia. In this interesting study, the authors divided critically ill trauma patients into two groups: a preintervention group that included 371 patients who were admitted to the hospital from January 1, 2018, to December 31, 2018, and a postintervention group with 201 patients who were admitted to the hospital from January 1, 2019, to July 1, 2019.…”

Response to: “Does statistical difference in a pre/post quasiexperimental study mean utility of a multimodal education intervention in targeted normoxia in critically ill trauma patients?”

“…Kuroda, Tsutsumi, and Banno for discussing these important issues regarding the careful interpretation of the results of our pre/post quasiexperimental study of targeted normoxia in critically ill trauma patients. 1,2 This study was designed to be a pilot study to evaluate a multimodal approach to targeted normoxia in critically ill trauma patients. As such, consideration of the limitations of such a study design and the associated conclusions is needed.…”

“…We appreciate the opportunity to respond to this letter and thank Drs. Kuroda, Tsutsumi, and Banno for discussing these important issues regarding the careful interpretation of the results of our pre/post quasiexperimental study of targeted normoxia in critically ill trauma patients 1,2 . This study was designed to be a pilot study to evaluate a multimodal approach to targeted normoxia in critically ill trauma patients.…”