Hyperoxia on Venoarterial Extracorporeal Membrane Oxygenation: A Modifiable Risk?

Joyce, Christopher; Anderson, C J; Shekar, Kiran

doi:10.1097/ccm.0000000000005252

Cited by 4 publications

(3 citation statements)

References 3 publications

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“…Then, right radial P a O 2 is mainly determined by F S O 2, and its value is closed to the P POST O 2 value. In the absence of measurement of stroke volume or its surrogates (pulse pressure or end tidal CO 2 [ 25 ]), we cannot rule out that patients with higher right radial P a O 2 were those with the most severe cardiac failure, having per se a higher mortality [ 26 ]. The fact that a higher F S O 2 mean (day 1−3) was independently associated with a higher in-ICU mortality supports the hypothesis of the proper harm of ECMO-induced hyperoxemia, as F S O 2 may not be impacted by cardiac failure severity.…”

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%

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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“…Third, as VA-ECMO was mostly peripherally inserted, high P a O 2 might reflect low native cardiac output and high level of circulatory support. In this setting, hyperoxemic patients might be those most severely ill [ 34 ]. Fourth, most of these studies analyzed ECPR patients who represent a specifically medical condition in which hyperoxemia seems particularly deleterious.…”

Section: Why Targeting Extracorporeal Moderate Hyperoxemia (P ...mentioning

confidence: 99%

Optimizing PO2 during peripheral veno-arterial ECMO: a narrative review

Winiszewski

Guinot

Schmidt³

et al. 2022

Crit Care

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During refractory cardiogenic shock and cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used to restore a circulatory output. However, it also impacts significantly arterial oxygenation. Recent guidelines of the Extracorporeal Life Support Organization (ELSO) recommend targeting postoxygenator partial pressure of oxygen (PPOSTO2) around 150 mmHg. In this narrative review, we intend to summarize the rationale and evidence for this PPOSTO2 target recommendation. Because this is the most used configuration, we focus on peripheral VA-ECMO. To date, clinicians do not know how to set the sweep gas oxygen fraction (FSO2). Because of the oxygenator’s performance, arterial hyperoxemia is common during VA-ECMO support. Interpretation of oxygenation is complex in this setting because of the dual circulation phenomenon, depending on both the native cardiac output and the VA-ECMO blood flow. Such dual circulation results in dual oxygenation, with heterogeneous oxygen partial pressure (PO2) along the aorta, and heterogeneous oxygenation between organs, depending on the mixing zone location. Data regarding oxygenation during VA-ECMO are scarce, but several observational studies have reported an association between hyperoxemia and mortality, especially after refractory cardiac arrest. While hyperoxemia should be avoided, there are also more and more studies in non-ECMO patients suggesting the harm of a too restrictive oxygenation strategy. Finally, setting FSO2 to target strict normoxemia is challenging because continuous monitoring of postoxygenator oxygen saturation is not widely available. The threshold of PPOSTO2 around 150 mmHg is supported by limited evidence but aims at respecting a safe margin, avoiding both hypoxemia and severe hyperoxemia.

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Hyperoxia on Venoarterial Extracorporeal Membrane Oxygenation: A Modifiable Risk?

Cited by 4 publications

References 3 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

Optimizing PO2 during peripheral veno-arterial ECMO: a narrative review

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