Oxygenation of the critically ill in selected intensive care units in the UK: are we usual?

Post, Benjamin; Palmer, Edward; Harris, Steve; Singer, Mervyn; Martin, Daniel

doi:10.1016/j.bja.2020.06.033

Cited by 3 publications

(4 citation statements)

References 6 publications

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“…ICU patient episodes conducted from 2014-19 in England demonstrated an overall average SpO 2 of 96.2% 15 which was similar to the average SpO 2 of 97% in the control group in the present study. 3.…”

Section: Discussionsupporting

confidence: 84%

“…A summary of key clinical outcomes by randomisation group.Information is missing from one participant in the conservative group. b Information is missing from one participant in the conservative group and one in the control group.ICU patient episodes conducted from 2014-19 inEngland demonstrated an overall average SpO 2 of 96.2%15 which was similar to the average SpO 2 of 97% in the control group in the present study. 3.…”

supporting

confidence: 85%

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A feasibility randomised controlled trial of targeted oxygen therapy in mechanically ventilated critically ill patients

Martin

McNeil

Brew‐Graves

et al. 2021

Journal of the Intensive Care Society

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Background Despite oxygen being the commonest drug administered to critically ill patients we do not know which oxygen saturation (SpO2) target results in optimal survival outcomes in those receiving mechanical ventilation. We therefore conducted a feasibility randomised controlled trial in the United Kingdom (UK) to assess whether it would be possible to host a larger national multi-centre trial to evaluate oxygenation targets in mechanically ventilated patients. Methods We set out to recruit 60 participants across two sites into a trial in which they were randomised to receive conservative oxygenation (SpO2 88–92%) or usual care (control – SpO2 ≥96%). The primary outcome was feasibility; factors related to safety and clinical outcomes were also assessed. Results A total of 34 patients were recruited into the study until it was stopped due to time constraints. A number of key barriers to success were identified during the course of the study. The conservative oxygenation intervention was feasible and appeared to be safe in this small patient cohort and it achieved wide separation of the median time-weighted average (IQR) SpO2 at 91% (90–92%) in conservative oxygenation group versus 97% (96–97%) in control group. Conclusion Whilst conservative oxygenation was a feasible and safe intervention which achieved clear group separation in oxygenation levels, the model used in this trial will require alterations to improve future participant recruitment rates in the UK.

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Section: Discussionsupporting

confidence: 84%

supporting

confidence: 85%

A feasibility randomised controlled trial of targeted oxygen therapy in mechanically ventilated critically ill patients

Martin

McNeil

Brew‐Graves

et al. 2021

Journal of the Intensive Care Society

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“…Another factor that may affect the interpretation of meta-analyses of COT trials is the change in usual practice that has occurred during the period that these trials have been conducted. A greater awareness of the potential harm of high concentration oxygen appears to have driven a drift towards COT in everyday practice, [30][31][32] which makes formally evaluating it harder as time goes on. For COT, the apparent shift towards a more conservative approach to oxygenation in usual practice may have made it difficult to distinguish from COT protocols in some of these trials.…”

Section: Discussionmentioning

confidence: 99%

The effect of conservative oxygen therapy on mortality in adult critically ill patients: A systematic review and meta-analysis of randomised controlled trials

Martin,

Mckenna,

Rowan

et al. 2023

Journal of the Intensive Care Society

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Background: Oxygen is the commonest intervention provided to critically ill patients requiring mechanical ventilation. Despite this, it is unclear how much oxygen should be administered to patients in order to promote the best clinical outcomes and it has been suggested that a strategy of conservative oxygen therapy (COT) may be advantageous. We therefore sought to answer the question of whether COT versus usual or liberal oxygen therapy was beneficial to adult patients receiving mechanical ventilation on an intensive care unit (ICU) by performing a systematic review and meta-analysis. Methods: Studies were included if they were randomised controlled trials comparing COT to liberal or usual oxygen therapy strategies in acutely ill adults (aged ⩾18 years) admitted to an ICU, and reported an outcome of interest. Studies were excluded if they were limited to a specific single disease diagnosis. The review was registered on PROSPERO (CRD42022308436). Risk of bias was assessed using a modified Cochrane Risk of Bias assessment tool. Effect estimates were pooled using a random effects model with the between study variance estimated using restricted maximum likelihood and standard errors calculated using the method of Hartung-Knapp/Sidik-Jonkman. Between study heterogeneity was quantified using the I2 statistic. The certainty in the body of evidence was assessed using GRADE criteria. Results: Nine eligible studies with 5727 participants fulfilled all eligibility criteria. Trials varied in their definitions of COT and liberal or usual oxygen therapy. The pooled estimate of risk ratio for 90 day mortality for COT versus comparator was 0.99 (95% confidence interval 0.88–1.12, 95% prediction interval 0.82–1.21). There was low heterogeneity among studies ( I2 = 22.4%). The finding that mortality was similar for patients managed with COT or usual/liberal oxygen therapy was graded as moderate certainty. Conclusions: In critically ill adults admitted to an ICU, COT is neither beneficial nor harmful when compared to usual or liberal oxygen therapy. Trials to date have been inconsistent in defining both COT and liberal or usual oxygen therapy, which may have had an impact on the results of this meta-analysis. Future research should focus on unifying definitions and outcome measures.

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“…However, giving too much oxygen causes hyperoxemia (arterial hyperoxia), for which a definition based on a partial pressure of arterial oxygen (PaO 2 ) value has not been rigorously provided, although normoxemia is defined as a PaO 2 of 80-100 mm Hg [2]. Although hyperoxemia has been linked to deleterious effects such as systemic vasoconstriction, increased oxidative stress [3,4], and increased mortality [5][6][7], hyperoxemia is still common in general wards [8,9] and intensive care units (ICUs) [10][11][12][13][14]. In recent studies, a PaO 2 of 300 mm Hg or more was reported in 11-26% of the patients [15][16][17][18][19] and 46% of PaO 2 measurements were hyperoxic [12] (defined as PaO 2 > 110 mm Hg in that study).…”

Section: Introductionmentioning

confidence: 99%

The Effect of Hyperoxemia on Neurological Outcomes of Adult Patients: A Systematic Review and Meta-Analysis

et al. 2022

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Hyperoxemia commonly occurs in clinical practice and is often left untreated. Many studies have shown increased mortality in patients with hyperoxemia, but data on neurological outcome in these patients are conflicting, despite worsened neurological outcome found in preclinical studies. To investigate the association between hyperoxemia and neurological outcome in adult patients, we performed a systematic review and meta-analysis of observational studies. We searched MEDLINE, Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov from inception to May 2020 for observational studies correlating arterial oxygen partial pressure (PaO2) with neurological status in adults hospitalized with acute conditions. Studies of chronic pulmonary disease or hyperbaric oxygenation were excluded. Relative risks (RRs) were pooled at the study level by using a random-effects model to compare the risk of poor neurological outcome in patients with hyperoxemia and patients without hyperoxemia. Sensitivity and subgroup analyses and assessments of publication bias and risk of bias were performed. Maximum and mean PaO2 in patients with favorable and unfavorable outcomes were compared using standardized mean difference (SMD). Of 6255 records screened, 32 studies were analyzed. Overall, hyperoxemia was significantly associated with an increased risk of poor neurological outcome (RR 1.13, 95% confidence interval [CI] 1.05–1.23, statistical heterogeneity I2 58.8%, 22 studies). The results were robust across sensitivity analyses. Patients with unfavorable outcome also showed a significantly higher maximum PaO2 (SMD 0.17, 95% CI 0.04–0.30, I2 78.4%, 15 studies) and mean PaO2 (SMD 0.25, 95% CI 0.04–0.45, I2 91.0%, 13 studies). These associations were pronounced in patients with subarachnoid hemorrhage (RR 1.34, 95% CI 1.14–1.56) and ischemic stroke (RR 1.41, 95% CI 1.14–1.74), but not in patients with cardiac arrest, traumatic brain injury, or following cardiopulmonary bypass. Hyperoxemia is associated with poor neurological outcome, especially in patients with subarachnoid hemorrhage and ischemic stroke. Although our study cannot establish causality, PaO2 should be monitored closely because hyperoxemia may be associated with worsened patient outcome and consequently affect the patient’s quality of life.

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Oxygenation of the critically ill in selected intensive care units in the UK: are we usual?

Cited by 3 publications

References 6 publications

A feasibility randomised controlled trial of targeted oxygen therapy in mechanically ventilated critically ill patients

A feasibility randomised controlled trial of targeted oxygen therapy in mechanically ventilated critically ill patients

The effect of conservative oxygen therapy on mortality in adult critically ill patients: A systematic review and meta-analysis of randomised controlled trials

The Effect of Hyperoxemia on Neurological Outcomes of Adult Patients: A Systematic Review and Meta-Analysis

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