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Jones GAL, Wiegand M, Ray S, Gould DW, Agbeko R, Giallongo E, Charles WN, Orzol M, O'Neill L, Lampro L, Lillie J, Pappachan J, Ramnarayan P, Harrison DA, Mouncey PR, Peters MJ. Ethnicity and Observed Oxygen Saturations, Fraction of Inspired Oxygen, and Clinical Outcomes: A Post Hoc Analysis of the Oxy-PICU Trial of Conservative Oxygenation. Pediatr Crit Care Med 2024:00130478-990000000-00368. [PMID: 39028216 DOI: 10.1097/pcc.0000000000003583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2024]
Abstract
OBJECTIVES A conservative oxygenation strategy, targeting peripheral oxygen saturations (Spo2) between 88% and 92% in mechanically ventilated children in PICU, was associated with a shorter duration of organ support and greater survival compared with Spo2 greater than 94% in our recent Oxy-PICU trial. Spo2 monitors may overestimate arterial oxygen saturation (Sao2) in patients with higher levels of skin pigmentation compared with those with less skin pigmentation. We investigated if ethnicity was associated with changes in distributions of Spo2 and Fio2 and outcome. DESIGN Post hoc analysis of a pragmatic, open-label, multicenter randomized controlled trial. SETTING Fifteen PICUs across the United Kingdom and Scotland. PATIENTS Children aged 38 weeks corrected gestational age to 15 years accepted to a participating PICU as an unplanned admission and receiving invasive mechanical ventilation with supplemental oxygen for abnormal gas exchange. METHODS Hierarchical regression models for Spo2 and Fio2, and ordinal models for the primary trial outcome of a composite of the duration of organ support at 30 days and death, were used to examine the effects of ethnicity, accounting for baseline Spo2, Fio2, and mean airway pressure and trial allocation. MEASUREMENTS AND MAIN RESULTS Ethnicity data were available for 1577 of 1986 eligible children, 1408 (89.3%) of which were White, Asian, or Black. Spo2 and Fio2 distributions did not vary according to Black or Asian ethnicity compared with White children. The trial primary outcome measure also did not vary significantly with ethnicity. The point estimate for the treatment effect of conservative oxygenation in Black children was 0.64 (95% CI, 0.33-1.25) compared with 0.84 (0.68-1.04) in the overall trial population. CONCLUSIONS These data do not suggest that the association between improved outcomes and conservative oxygenation strategy in mechanically ventilated children in PICU is modified by ethnicity.
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Affiliation(s)
- Gareth A L Jones
- Paediatric ICU, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Martin Wiegand
- Department of Statistical Science, University College London, London, United Kingdom
- Collaborative Healthcare Innovation through Mathematics, EngineeRing and AI (CHIMERA), University College London, London, United Kingdom
| | - Samiran Ray
- Paediatric ICU, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- Collaborative Healthcare Innovation through Mathematics, EngineeRing and AI (CHIMERA), University College London, London, United Kingdom
- Infection, Immunity and Inflammation Research and Teaching Department, University College London Great Ormond St Institute of Child Health, London, United Kingdom
| | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Rachel Agbeko
- Department of Paediatric Intensive Care, Great North Children's Hospital, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Elisa Giallongo
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Walton N Charles
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Marzena Orzol
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Lauran O'Neill
- Paediatric ICU, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Lamprini Lampro
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Jon Lillie
- Paediatric ICU, Evelina London Children's Hospital, London United Kingdom
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, United Kingdom
| | - John Pappachan
- Paediatric ICU, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Mark J Peters
- Paediatric ICU, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- Collaborative Healthcare Innovation through Mathematics, EngineeRing and AI (CHIMERA), University College London, London, United Kingdom
- Infection, Immunity and Inflammation Research and Teaching Department, University College London Great Ormond St Institute of Child Health, London, United Kingdom
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
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Tasker RC. Editor's Choice Articles for July. Pediatr Crit Care Med 2024; 25:588-590. [PMID: 38958548 DOI: 10.1097/pcc.0000000000003545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Tasker RC, Kochanek PM. 25 Years of Pediatric Critical Care Medicine: An Evolving Journal. Pediatr Crit Care Med 2024; 25:583-587. [PMID: 38958547 DOI: 10.1097/pcc.0000000000003546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, United Kingdom
| | - Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Gould DW, Peters MJ. The Oxy-PICU Conservative Versus Liberal Oxygenation Target Trial in Critically Ill Children-A Changed World or a "So What" Result? Pediatr Crit Care Med 2024; 25:e343-e346. [PMID: 38602434 DOI: 10.1097/pcc.0000000000003518] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Mark J Peters
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
- Infection, Immunity & Inflammation Department, University College London Great Ormond St Institute of Child Health, London, United Kingdom
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Mozun R, Schlapbach LJ. A Critique of the "Conservative Versus Liberal Oxygenation Targets in Critically Ill Children" Multicenter, Randomized Clinical Trial Published in the Lancet 2024-More on "Less Is More?". Pediatr Crit Care Med 2024; 25:e338-e342. [PMID: 38602435 DOI: 10.1097/pcc.0000000000003519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Rebeca Mozun
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luregn J Schlapbach
- Department of Intensive Care and Neonatology, Children's Research Center, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
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Lakshminrusimha S, Abman SH. Oxygen Targets in Neonatal Pulmonary Hypertension: Individualized, "Precision-Medicine" Approach. Clin Perinatol 2024; 51:77-94. [PMID: 38325948 PMCID: PMC10857735 DOI: 10.1016/j.clp.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Oxygen is a specific pulmonary vasodilator. Hypoxemia causes pulmonary vasoconstriction, and normoxia leads to pulmonary vasodilation. However, hyperoxia does not enhance pulmonary vasodilation but causes oxidative stress. There are no clinical trials evaluating optimal oxygen saturation or Pao2 in pulmonary hypertension. Data from translational studies and case series suggest that oxygen saturation of 90% to 97% or Pao2 between 50 and 80 mm Hg is associated with the lowest pulmonary vascular resistance.
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Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, University of California, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, University of Colorado Anschutz Medical Campus, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Lee V, Ruppel H, Schondelmeyer AC. Pulse Oximetry in Bronchiolitis: Have We Reached Saturation? Hosp Pediatr 2024; 14:e107-e109. [PMID: 38164077 DOI: 10.1542/hpeds.2023-007505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Halley Ruppel
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Clinical Futures, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Peters MJ, Gould DW, Ray S, Thomas K, Chang I, Orzol M, O'Neill L, Agbeko R, Au C, Draper E, Elliot-Major L, Giallongo E, Jones GAL, Lampro L, Lillie J, Pappachan J, Peters S, Ramnarayan P, Sadique Z, Rowan KM, Harrison DA, Mouncey PR. Conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet 2024; 403:355-364. [PMID: 38048787 DOI: 10.1016/s0140-6736(23)01968-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND The optimal target for systemic oxygenation in critically ill children is unknown. Liberal oxygenation is widely practiced, but has been associated with harm in paediatric patients. We aimed to evaluate whether conservative oxygenation would reduce duration of organ support or incidence of death compared to standard care. METHODS Oxy-PICU was a pragmatic, multicentre, open-label, randomised controlled trial in 15 UK paediatric intensive care units (PICUs). Children admitted as an emergency, who were older than 38 weeks corrected gestational age and younger than 16 years receiving invasive ventilation and supplemental oxygen were randomly allocated in a 1:1 ratio via a concealed, central, web-based randomisation system to conservative peripheral oxygen saturations ([SpO2] 88-92%) or liberal (SpO2 >94%) targets. The primary outcome was the duration of organ support at 30 days following random allocation, a rank-based endpoint with death either on or before day 30 as the worst outcome (a score equating to 31 days of organ support), with survivors assigned a score between 1 and 30 depending on the number of calendar days of organ support received. The primary effect estimate was the probabilistic index, a value greater than 0·5 indicating more than 50% probability that conservative oxygenation is superior to liberal oxygenation for a randomly selected patient. All participants in whom consent was available were included in the intention-to-treat analysis. The completed study was registered with the ISRCTN registry (ISRCTN92103439). FINDINGS Between Sept 1, 2020, and May 15, 2022, 2040 children were randomly allocated to conservative or liberal oxygenation groups. Consent was available for 1872 (92%) of 2040 children. The conservative oxygenation group comprised 939 children (528 [57%] of 927 were female and 399 [43%] of 927 were male) and the liberal oxygenation group included 933 children (511 [56%] of 920 were female and 409 [45%] of 920 were male). Duration of organ support or death in the first 30 days was significantly lower in the conservative oxygenation group (probabilistic index 0·53, 95% CI 0·50-0·55; p=0·04 Wilcoxon rank-sum test, adjusted odds ratio 0·84 [95% CI 0·72-0·99]). Prespecified adverse events were reported in 24 (3%) of 939 patients in the conservative oxygenation group and 36 (4%) of 933 patients in the liberal oxygenation group. INTERPRETATION Among invasively ventilated children who were admitted as an emergency to a PICU receiving supplemental oxygen, a conservative oxygenation target resulted in a small, but significant, greater probability of a better outcome in terms of duration of organ support at 30 days or death when compared with a liberal oxygenation target. Widespread adoption of a conservative oxygenation saturation target (SpO2 88-92%) could help improve outcomes and reduce costs for the sickest children admitted to PICUs. FUNDING UK National Institute for Health and Care Research Health Technology Assessment Programme.
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Affiliation(s)
- Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK; Respiratory, Critical Care and Anaesthesia Unit, Infection, Inflammation, and Immunity Division, University College London Great Ormond Street Institute of Child Health, London, UK; Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
| | - Doug W Gould
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
| | - Karen Thomas
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Irene Chang
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Marzena Orzol
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Lauran O'Neill
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
| | - Rachel Agbeko
- Department of Paediatric Intensive Care, Great North Children's Hospital, The Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Carly Au
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Elizabeth Draper
- Department of Population Health Sciences, University of Leicester, Leicester, UK
| | | | - Elisa Giallongo
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Gareth A L Jones
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
| | - Lamprini Lampro
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Jon Lillie
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK; Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Jon Pappachan
- Paediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Sam Peters
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; Section of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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Tasker RC. 2023 in Review. Pediatr Crit Care Med 2023; 24:979-982. [PMID: 38054999 DOI: 10.1097/pcc.0000000000003395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Abstract
The September 2023 issue and this year has already proven to be important for improving our understanding of pediatric acute respiratory distress syndrome (PARDS); Pediatric Critical Care Medicine (PCCM) has published 16 articles so far. Therefore, my three Editor's Choice articles this month highlight yet more PCCM material about PARDS by covering the use of noninvasive ventilation (NIV), the trajectory in cytokine profile during illness, and a new look at lung mechanics. The PCCM Connections for Readers give us the opportunity to focus on some clinical biomarkers of severity and mortality risk during critical illness.
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Affiliation(s)
- Robert C Tasker
- orcid.org/0000-0003-3647-8113
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
- Selwyn College, Cambridge University, Cambridge, United Kingdom
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Holton C, Lee BR, Escobar H, Benton T, Bauer P. Admission Pao2 and Mortality Among PICU Patients and Select Diagnostic Subgroups. Pediatr Crit Care Med 2023:00130478-990000000-00177. [PMID: 37092837 DOI: 10.1097/pcc.0000000000003247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
OBJECTIVES Evaluate the relationship between admission Pao2 and mortality in a large multicenter dataset and among diagnostic subgroups. DESIGN Retrospective cohort study. SETTING North American PICUs participating in Virtual Pediatric Systems, LLC (VPS), 2015-2019. PATIENTS Noncardiac patients 18 years or younger admitted to a VPS PICU with admission Pao2. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Thirteen thousand seventy-one patient encounters were included with an overall mortality of 13.52%. Age categories were equally distributed among survivors and nonsurvivors with the exception of small differences among neonates and adolescents. Importantly, there was a tightly fitting quadratic relationship between admission Pao2 and mortality, with the highest mortality rates seen among hypoxemic and hyperoxemic patients (likelihood-ratio test p < 0.001). This relationship persisted after adjustment for illness severity using modified Pediatric Index of Mortality 3 scores. A similar U-shaped relationship was demonstrated among patients with diagnoses of trauma, head trauma, sepsis, renal failure, hemorrhagic shock, and drowning. However, among the 1,500 patients admitted following cardiac arrest, there was no clear relationship between admission Pao2 and mortality. CONCLUSIONS In a large multicenter pediatric cohort, admission Pao2 demonstrates a tightly fitting quadratic relationship with mortality. The persistence of this relationship among some but not all diagnostic subgroups suggests the pathophysiology of certain disease states may modify the hyperoxemia association.
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Affiliation(s)
- Caroline Holton
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Brian R Lee
- Division of Health Services and Outcomes Research, Children's Mercy Hospital, Kansas City, MO
| | - Hugo Escobar
- Division of Pulmonology, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Tara Benton
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
| | - Paul Bauer
- Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, MO
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Editor's Choice Articles for March. Pediatr Crit Care Med 2023; 24:183-185. [PMID: 36862440 DOI: 10.1097/pcc.0000000000003205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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13
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Jones GAL, Eaton S, Orford M, Ray S, Wiley D, Ramnarayan P, Inwald D, Grocott MPW, Griksaitis M, Pappachan J, O'Neill L, Mouncey PR, Harrison DA, Rowan KM, Peters MJ. Randomization to a Liberal Versus Conservative Oxygenation Target: Redox Responses in Critically Ill Children. Pediatr Crit Care Med 2023; 24:e137-e146. [PMID: 36728001 DOI: 10.1097/pcc.0000000000003175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
RATIONALE Optimal systemic oxygenation targets in pediatric critical illness are unknown. A U-shaped relationship exists between blood oxygen levels and PICU mortality. Redox stress or iatrogenic injury from intensive treatments are potential mechanisms of harm from hyperoxia. OBJECTIVES To measure biomarkers of oxidative status in children admitted to PICU and randomized to conservative (oxygen-hemoglobin saturation [Sp o2 ] 88-92%) versus liberal (Sp o2 > 94%) peripheral oxygenation targets. DESIGN Mechanistic substudy nested within the Oxygen in PICU (Oxy-PICU) pilot randomized feasibility clinical trial ( ClinicalTrials.gov : NCT03040570). SETTING Three U.K. mixed medical and surgical PICUs in university hospitals. PATIENTS Seventy-five eligible patients randomized to the Oxy-PICU randomized feasibility clinical trial. INTERVENTIONS Randomization to a conservative (Sp o2 88-92%) versus liberal (Sp o2 > 94%) peripheral oxygenation target. MEASUREMENTS AND MAIN RESULTS Blood and urine samples were collected at two timepoints: less than 24 hours and up to 72 hours from randomization in trial participants (March 2017 to July 2017). Plasma was analyzed for markers of ischemic/oxidative response, namely thiobarbituric acid-reactive substances (TBARS; lipid peroxidation marker) and ischemia-modified albumin (protein oxidation marker). Total urinary nitrate/nitrite was measured as a marker of reactive oxygen and nitrogen species (RONS). Blood hypoxia-inducible factor (HIF)-1a messenger RNA (mRNA) expression (hypoxia response gene) was measured by reverse transcription- polymerase chain reaction. Total urinary nitrate/nitrite levels were greater in the liberal compared with conservative oxygenation group at 72 hours (median difference 32.6 μmol/mmol of creatinine [95% CI 13.7-93.6]; p < 0.002, Mann-Whitney test). HIF-1a mRNA expression was increased in the conservative group compared with liberal in less than 24-hour samples (6.0-fold [95% CI 1.3-24.0]; p = 0.032). There were no significant differences in TBARS or ischemia-modified albumin. CONCLUSIONS On comparing liberal with conservative oxygenation targets, we show, first, significant redox response (increase in urinary markers of RONS), but no changes in markers of lipid or protein oxidation. We also show what appears to be an early hypoxic response (increase in HIF-1a gene expression) in subjects exposed to conservative rather than liberal oxygenation targets.
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Affiliation(s)
- Gareth A L Jones
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Simon Eaton
- Stem Cells and Regenerative Medicine Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Michael Orford
- Stem Cells and Regenerative Medicine Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Samiran Ray
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Daisy Wiley
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Padmanabhan Ramnarayan
- Children's Acute Transport Service, Great Ormond Street Hospital, London, United Kingdom
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - David Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Michael P W Grocott
- Anaesthesia Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton/ University of Southampton, Southampton, United Kingdom
| | - Michael Griksaitis
- Anaesthesia Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton/ University of Southampton, Southampton, United Kingdom
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - John Pappachan
- Anaesthesia Perioperative and Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton/ University of Southampton, Southampton, United Kingdom
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Lauran O'Neill
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, United Kingdom
| | - Mark J Peters
- Respiratory Critical Care and Anaesthesia Unit, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, United Kingdom
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The Local and Systemic Exposure to Oxygen in Children With Severe Bronchiolitis on Invasive Mechanical Ventilation: A Retrospective Cohort Study. Pediatr Crit Care Med 2023; 24:e115-e120. [PMID: 36661429 PMCID: PMC9848215 DOI: 10.1097/pcc.0000000000003130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Oxygen supplementation is a cornerstone treatment in critically ill children with bronchiolitis in the PICU. However, potential deleterious effects of high-dose oxygen are well-known. In this study, we aim to describe the pulmonary (local) and arterial (systemic) oxygen exposure over the duration of invasive mechanical ventilation (IMV) in children with severe bronchiolitis. Our secondary aim was to estimate potentially avoidable exposure to high-dose oxygen in these patients. DESIGN Retrospective cohort study. SETTING Single-center, tertiary-care PICU. PATIENTS Children younger than 2 years old admitted to the PICU for severe bronchiolitis receiving IMV. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Hourly measurements of Fio2 and peripheral oxygen saturation (Spo2), and arterial blood gas data were collected up to day 10 of IMV. A total of 24,451 hours of IMV were observed in 176 patients (median age of 1.0 mo [interquartile range (IQR), 1.0-2.3 mo]). The pulmonary exposure to oxygen was highest during the first day of IMV (median time-weighted average [TWA]-Fio2 0.46 [IQR, 0.39-0.53]), which significantly decreased over subsequent days. The systemic exposure to oxygen was relatively low, as severe hyperoxemia (TWA-Pao2 > 248 Torr [> 33 kPa]) was not observed. However, overuse of oxygen was common with 52.3% of patients (n = 92) having at least 1 day of possible excessive oxygen exposure and 14.8% (n = 26) with severe exposure. Furthermore, higher oxygen dosages correlated with increasing overuse of oxygen (rrepeated measures, 0.59; 95% CI, 0.54-0.63). Additionally, caregivers were likely to keep Fio2 greater than or equal to 0.50 when Spo2 greater than or equal to 97%. CONCLUSIONS Moderate to high-dose pulmonary oxygen exposure and potential overuse of oxygen were common in this cohort of severe bronchiolitis patients requiring IMV; however, this was not accompanied by a high systemic oxygen burden. Further studies are needed to determine optimal oxygenation targets to prevent overzealous use of oxygen in this vulnerable population.
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The United Kingdom Paediatric Critical Care Society Study Group: The 20-Year Journey Toward Pragmatic, Randomized Clinical Trials. Pediatr Crit Care Med 2022; 23:1067-1075. [PMID: 36343185 DOI: 10.1097/pcc.0000000000003099] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Over the past two decades, pediatric intensive care research networks have been formed across North America, Europe, Asia, and Australia/New Zealand. The U.K. Paediatric Critical Care Society Study Group (PCCS-SG) has over a 20-year tradition of fostering collaborative research, leading to the design and successful conduct of randomized clinical trials (RCTs). To date, the PCCS-SG network has delivered 13 different multicenter RCTs, covering a spectrum of study designs, methodologies, and scale. Lessons from the early years have led PCCS-SG to now focus on the entire process needed for developing an RCT, starting from robust preparatory steps such as surveys, data analysis, and feasibility work through to a definitive RCT. Pilot RCTs have been an important part of this process as well. Facilitators of successful research have included the presence of a national registry to facilitate efficient data collection; close partnerships with established Clinical Trials Units to bring together clinicians, methodologists, statisticians, and trial managers; greater involvement of transport teams to recruit patients early in trials of time-sensitive interventions; and the funded infrastructure of clinical research staff within the National Health Service to integrate research within the clinical service. The informal nature of PCCS-SG has encouraged buy-in from clinicians. Greater international collaboration and development of embedded trial platforms to speed up the generation and dissemination of trial findings are two key future strategic goals for the PCCS-SG research network.
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Ramnarayan P, Blackwood B, Khemani RG. What's new in paediatric ventilator liberation? Intensive Care Med 2022; 48:1635-1637. [PMID: 36048243 DOI: 10.1007/s00134-022-06865-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/09/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Padmanabhan Ramnarayan
- Anaesthesia, Pain Medicine and Critical Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Room 508, Imperial College Medical School Building, Norfolk Place, London, W2 1PB, UK.
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Northern Ireland, UK
| | - Robinder G Khemani
- Department of Anaesthesiology and Critical Care, Children's Hospital Los Angeles, Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, USA
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