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O'Driscoll BR, Kirton L. Automated Oxygen Administration in Hospitals: Will It Replace Manual Systems in the Near Future? Respir Care 2024; 69:1214-1217. [PMID: 39181719 PMCID: PMC11349593 DOI: 10.4187/respcare.12230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Affiliation(s)
- B Ronan O'Driscoll
- Salford Royal HospitalNorthern Care Alliance NHS Foundation TrustSalford, United Kingdom ronan.o'
| | - Louis Kirton
- Medical Research Institute of New ZealandWellington, New ZealandVictoria UniversityWellington, New Zealand
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2
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Bouchard PA, Parent-Racine G, Paradis-Gagnon C, Simon M, Lacasse Y, Lellouche F, Maltais F. Clinical Implementation of Automated Oxygen Titration in a Tertiary Care Hospital. Respir Care 2024; 69:1081-1091. [PMID: 38490735 PMCID: PMC11349596 DOI: 10.4187/respcare.11331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 03/13/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND When treating acute respiratory failure, both hypoxemia and hyperoxemia should be avoided. SpO2 should be monitored closely and O2 flows adjusted accordingly. Achieving this goal might be easier with automated O2 titration compared with manual titration of fixed-flow O2. We evaluated the feasibility of using an automated O2 titration device in subjects treated for acute hypoxemic respiratory failure in a tertiary care hospital. METHODS Health-care workers received education and training about oxygen therapy, and were familiarized with an automated O2 titration device (FreeO2,). A coordinator was available from 8:00 am to 5:00 pm during weekdays to provide technical assistance. The ability of the device to maintain SpO2 within the prescribed therapeutic window was recorded. Basic clinical information was recorded. RESULTS Subjects were enrolled from November 2020 to August 2022. We trained 508 health-care workers on the use of automated O2 titration, which was finally used on 872 occasions in 763 subjects, distributed on the respiratory, COVID-19, and thoracic surgery wards, and in the emergency department. Clinical information could be retrieved for 609 subjects (80%) who were on the system for a median (interquartile range) of 3 (2-6) d, which represented 2,567 subject-days of clinical experience with the device. In the 82 subjects (14%) for whom this information was available, the system maintained SpO2 within the prescribed targets 89% of the time. Ninety-six subjects experienced clinical deterioration as defined by the need to be transferred to the ICU and/or requirement of high flow nasal oxygen but none of these events were judged to be related to the O2 device. CONCLUSIONS Automated O2 titration could be successfully implemented in hospitalized subjects with hypoxemic respiratory failure from various causes. This experience should foster further improvement of the device and recommendations for an optimized utilization.
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Affiliation(s)
- Pierre-Alexandre Bouchard
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Geneviève Parent-Racine
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Cassiopée Paradis-Gagnon
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Mathieu Simon
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Yves Lacasse
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - François Lellouche
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - François Maltais
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec, Québec, Canada
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Nielsen FM, Klitgaard TL, Bruun NH, Møller MH, Schjørring OL, Rasmussen BS. Lower or higher oxygenation targets in the intensive care unit: an individual patient data meta-analysis. Intensive Care Med 2024; 50:1275-1286. [PMID: 38990335 PMCID: PMC11306534 DOI: 10.1007/s00134-024-07523-3] [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] [Received: 03/23/2024] [Accepted: 06/11/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Optimal oxygenation targets for patients with acute hypoxemic respiratory failure in the intensive care unit (ICU) are not clearly defined due to substantial variability in design of previous trials. This study aimed to perform a pre-specified individual patient data meta-analysis of the Handling Oxygenation Targets in the ICU (HOT-ICU) and the Handling Oxygenation Targets in coronavirus disease 2019 (COVID-19) (HOT-COVID) trials to compare targeting a partial pressure of arterial oxygen (PaO2) of 8-12 kPa in adult ICU patients, assessing both benefits and harms. METHODS We assessed 90-day all-cause mortality and days alive without life support in 90 days using a generalised mixed model. Heterogeneity of treatment effects (HTE) was evaluated in 14 subgroups, and results graded using the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN). RESULTS At 90 days, mortality was 40.4% (724/1792) in the 8 kPa group and 40.9% (733/1793) in the 12 kPa group (risk ratio, 0.99; 95% confidence interval [CI] 0.92-1.07; P = 0.80). No difference was observed in number of days alive without life support. Subgroup analyses indicated more days alive without life support in COVID-19 patients targeting 8 kPa (P = 0.04) (moderate credibility), and lower mortality (P = 0.03) and more days alive without life support (P = 0.02) in cancer-patients targeting 12 kPa (low credibility). CONCLUSION This study reported no overall differences comparing a PaO2 target of 8-12 kPa on mortality or days alive without life support in 90 days. Subgroup analyses suggested HTE in patients with COVID-19 (moderate credibility) and cancer (low credibility).
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Affiliation(s)
- Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark.
| | - Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark
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Kirton L, Kung S, Bird G, Black M, Semprini R, Eathorne A, Weatherall M, Semprini A, Beasley R. Automated oxygen titration with non-invasive ventilation in hypoxaemic adults with cardiorespiratory disease: a randomised cross-over trial. BMJ Open Respir Res 2024; 11:e002196. [PMID: 38897612 PMCID: PMC11191803 DOI: 10.1136/bmjresp-2023-002196] [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] [Received: 11/15/2023] [Accepted: 05/31/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND Closed-loop oxygen control systems automatically adjust the fraction of inspired oxygen (FiO2) to maintain oxygen saturation (SpO2) within a predetermined target range. Their performance with low and high-flow oxygen therapies, but not with non-invasive ventilation, has been established. We compared the effect of automated oxygen on achieving and maintaining a target SpO2 range with nasal high flow (NHF), bilevel positive airway pressure (bilevel) and continuous positive airway pressure (CPAP), in stable hypoxaemic patients with chronic cardiorespiratory disease. METHODS In this open-label, three-way cross-over trial, participants with resting hypoxaemia (n=12) received each of NHF, bilevel and CPAP treatments, in random order, with automated oxygen titrated for 10 min, followed by 36 min of standardised manual oxygen adjustments. The primary outcome was the time taken to reach target SpO2 range (92%-96%). Secondary outcomes included time spent within target range and physiological responses to automated and manual oxygen adjustments. RESULTS Two participants were randomised to each of six possible treatment orders. During automated oxygen control (n=12), the mean (±SD) time to reach target range was 114.8 (±87.9), 56.6 (±47.7) and 67.3 (±61) seconds for NHF, bilevel and CPAP, respectively, mean difference 58.3 (95% CI 25.0 to 91.5; p=0.002) and 47.5 (95% CI 14.3 to 80.7; p=0.007) seconds for bilevel and CPAP versus NHF, respectively. Proportions of time spent within target range were 68.5% (±16.3), 65.6% (±28.7) and 74.7% (±22.6) for NHF, bilevel and CPAP, respectively.Manually increasing, then decreasing, the FiO2 resulted in similar increases and then decreases in SpO2 and transcutaneous carbon dioxide (PtCO2) with NHF, bilevel and CPAP. CONCLUSION The target SpO2 range was achieved more quickly when automated oxygen control was initiated with bilevel and CPAP compared with NHF while time spent within the range across the three therapies was similar. Manually changing the FiO2 had similar effects on SpO2 and PtCO2 across each of the three therapies. TRIAL REGISTRATION NUMBER ACTRN12622000433707.
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Affiliation(s)
- Louis Kirton
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Stacey Kung
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Georgina Bird
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Melissa Black
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Ruth Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Alex Semprini
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
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Kirton LW, Cruz RS, Navarra L, Eathorne A, Cook J, Beasley R, Young PJ. Effect of automated titration of oxygen on time spent in a prescribed oxygen saturation range in adults in the ICU after cardiac surgery. CRIT CARE RESUSC 2024; 26:64-70. [PMID: 39072230 PMCID: PMC11282340 DOI: 10.1016/j.ccrj.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 07/30/2024]
Abstract
Objective The objective of this study was to determine whether automated titration of the fraction of inspired oxygen (FiO2) increases the time spent with oxygen saturation (SpO2) within a predetermined target SpO2 range compared with manually adjusted high-flow oxygen therapy in postoperative cardiac surgical patients managed in the intensive care unit (ICU). Design Single-centre, open-label, randomised clinical trial. Setting Tertiary centre ICU. Participants Recently extubated adults following elective cardiac surgery who required supplemental oxygen. Interventions Automatically adjusted FiO2 (using an automated oxygen control system) compared with manual FiO2 titration, until cessation of oxygen therapy, ICU discharge, or 24 h (whichever was sooner). Main outcome measures The primary outcome was the proportion of time receiving oxygen therapy with the SpO2 in a SpO2 target range of 92-96 %. Results Among 65 participants, the percentage of time per patient spent in the target SpO2 range was a median of 97.7 % (interquartile range: 87.9-99.2 %) and 91.3 % (interquartile range: 77.1-96.1 %) in the automated (n = 28) and manual (n = 28) titration groups, respectively. The estimated effect of automated FiO2, compared to manual FiO2 titration, was to increase the percentage of time spent in the target range by a median of 4.8 percentage points (95 % confidence interval: 1.6 to 10.3 percentage points, p = 0.01). Conclusion In patients recently extubated after cardiac surgery, automated FiO2 titration significantly increased time spent in a target SpO2 range of 92-96 % compared to manual FiO2 titration.
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Affiliation(s)
- Louis W. Kirton
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Raulle Sol Cruz
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Te Whatu Ora, Capital and Coast, Wellington, New Zealand
| | - Leanlove Navarra
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Te Whatu Ora, Capital and Coast, Wellington, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Julie Cook
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Paul J. Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Te Whatu Ora, Capital and Coast, Wellington, New Zealand
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Thomas T, Khor YH, Buchan C, Smallwood N. Implementing High-Flow Nasal Oxygen Therapy in Medical Wards: A Scoping Review to Understand Hospital Protocols and Procedures. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2024; 21:705. [PMID: 38928951 PMCID: PMC11203406 DOI: 10.3390/ijerph21060705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024]
Abstract
Acute hypoxemic respiratory failure (ARF) is a common cause for hospital admission. High-flow nasal oxygen (HFNO) is increasingly used as a first-line treatment for patients with ARF, including in medical wards. Clinical guidance is crucial when providing HFNO, and health services use local health guidance documents (LHGDs) to achieve this. It is unknown what hospital LHGDs recommend regarding ward administration of HFNO. This study examined Australian hospitals' LHGDs regarding ward-based HFNO administration to determine content that may affect safe delivery. A scoping review was undertaken on 2 May 2022 and updated on 29 January 2024 to identify public hospitals' LHGDs regarding delivery of HFNO to adults with ARF in medical wards in two Australian states. Data were extracted and analysed regarding HFNO initiation, monitoring, maintenance and weaning, and management of clinical deterioration. Of the twenty-six included LHGDs, five documents referenced Australian Oxygen Guidelines. Twenty LHGDs did not define a threshold level of hypoxaemia where HFNO use was recommended over conventional oxygen therapy. Thirteen did not provide target oxygen saturation ranges whilst utilising HFNO. Recommendations varied regarding maximal levels of inspired oxygen and flow rates in the medical ward. Eight LHGDs did not specify any system to identify and manage deteriorating patients. Five LHGDs did not provide guidance for weaning patients from HFNO. There was substantial variation in the LHGDs regarding HFNO care for adult patients with ARF in Australian hospitals. These findings have implications for the delivery of high-quality, safe clinical care in hospitals.
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Affiliation(s)
- Toby Thomas
- Melbourne Medical School, University of Melbourne, Corner Grattan Street and Royal Parade, Melbourne 3010, Australia;
| | - Yet Hong Khor
- Respiratory Research @Alfred, School of Translational Medicine, The Alfred Centre, Monash University, Melbourne 3004, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg 3084, Australia
- Institute for Breathing and Sleep, Heidelberg 3084, Australia
| | - Catherine Buchan
- Respiratory Research @Alfred, School of Translational Medicine, The Alfred Centre, Monash University, Melbourne 3004, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg 3084, Australia
| | - Natasha Smallwood
- Respiratory Research @Alfred, School of Translational Medicine, The Alfred Centre, Monash University, Melbourne 3004, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Heidelberg 3084, Australia
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Simon Machado R, Mathias K, Joaquim L, de Quadros RW, Rezin GT, Petronilho F. Hyperoxia and brain: the link between necessity and injury from a molecular perspective. Neurotox Res 2024; 42:25. [PMID: 38619632 DOI: 10.1007/s12640-024-00702-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 11/15/2023] [Accepted: 03/25/2024] [Indexed: 04/16/2024]
Abstract
Oxygen (O2) supplementation is commonly used to treat hypoxia in patients with respiratory failure. However, indiscriminate use can lead to hyperoxia, a condition detrimental to living tissues, particularly the brain. The brain is sensitive to reactive oxygen species (ROS) and inflammation caused by high concentrations of O2, which can result in brain damage and mitochondrial dysfunction, common features of neurodegenerative disorders. Hyperoxia leads to increased production of ROS, causing oxidative stress, an imbalance between oxidants and antioxidants, which can damage tissues. The brain is particularly vulnerable to oxidative stress due to its lipid composition, high O2 consumption rate, and low levels of antioxidant enzymes. Moreover, hyperoxia can cause vasoconstriction and decreased O2 supply to the brain, posing a challenge to redox balance and neurodegenerative processes. Studies have shown that the severity of hyperoxia-induced brain damage varies with inspired O2 concentration and duration of exposure. Therefore, careful evaluation of the balance between benefits and risks of O2 supplementation, especially in clinical settings, is crucial.
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Affiliation(s)
- Richard Simon Machado
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil.
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão, SC, Brazil.
| | - Khiany Mathias
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil
| | - Larissa Joaquim
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil
| | | | - Gislaine Tezza Rezin
- Laboratory of Neurobiology of Inflammatory and Metabolic Processes, Graduate Program in Health Sciences, Health Sciences Unit, University of South Santa Catarina, Tubarão, SC, Brazil
| | - Fabricia Petronilho
- Laboratory of Experimental Neurology, Graduate Program in Health Sciences, Health Sciences Unit, University of Southern Santa Catarina, Criciuma, SC, Brazil
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Hilderink BN, Crane RF, van den Bogaard B, Pillay J, Juffermans NP. Hyperoxemia and hypoxemia impair cellular oxygenation: a study in healthy volunteers. Intensive Care Med Exp 2024; 12:37. [PMID: 38619625 PMCID: PMC11018572 DOI: 10.1186/s40635-024-00619-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/28/2024] [Indexed: 04/16/2024] Open
Abstract
INTRODUCTION Administration of oxygen therapy is common, yet there is a lack of knowledge on its ability to prevent cellular hypoxia as well as on its potential toxicity. Consequently, the optimal oxygenation targets in clinical practice remain unresolved. The novel PpIX technique measures the mitochondrial oxygen tension in the skin (mitoPO2) which allows for non-invasive investigation on the effect of hypoxemia and hyperoxemia on cellular oxygen availability. RESULTS During hypoxemia, SpO2 was 80 (77-83)% and PaO2 45(38-50) mmHg for 15 min. MitoPO2 decreased from 42(35-51) at baseline to 6(4.3-9)mmHg (p < 0.001), despite 16(12-16)% increase in cardiac output which maintained global oxygen delivery (DO2). During hyperoxic breathing, an FiO2 of 40% decreased mitoPO2 to 20 (9-27) mmHg. Cardiac output was unaltered during hyperoxia, but perfused De Backer density was reduced by one-third (p < 0.01). A PaO2 < 100 mmHg and > 200 mmHg were both associated with a reduction in mitoPO2. CONCLUSIONS Hypoxemia decreases mitoPO2 profoundly, despite complete compensation of global oxygen delivery. In addition, hyperoxemia also decreases mitoPO2, accompanied by a reduction in microcirculatory perfusion. These results suggest that mitoPO2 can be used to titrate oxygen support.
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Affiliation(s)
- Bashar N Hilderink
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands.
| | - Reinier F Crane
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
| | | | - Janesh Pillay
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nicole P Juffermans
- Department of Intensive Care, OLVG Hospital, Amsterdam, The Netherlands
- Laboratory of Translational Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
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Arasi F, Bennett E, Rokoduru A, Kaspar A. Assessment of knowledge, attitude and practice for oxygen therapy among medical staff at the Colonial War Memorial Hospital in Fiji. Intern Med J 2024; 54:657-663. [PMID: 37615066 DOI: 10.1111/imj.16210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/31/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND Oxygen therapy (OT) is a commonly prescribed essential medicine for people of all ages in the management of hypoxia. The adverse effects of inappropriate OT supplementation may be underestimated by health professionals and lead to poor health outcomes among hospitalised patients. Knowledge, attitude and practice (KAP) assessments of medical staff members to OT guidelines are essential to ensure optimal patient care. AIMS To perform a KAP assessment of OT administration among doctors and nurses employed at the national hospital of Fiji in 2021. METHODS Prospective cross-sectional study design. KAP assessment was performed with an online questionnaire and clinical observation. RESULTS The study population (N = 116) consisted of doctors (20.7%) and nurses (79.3%) representing the acute medical, burns, cardiac care, intensive care, surgical and postanaesthetic recovery units. Overall, the proportion of participants who obtained a good score (>70%) was 87% for knowledge, 87.93% for attitudes and 84% for practice. Best knowledge scores were obtained for general OT indications (71%) and scenarios where immediate oxygen application is required (70%). Lowest knowledge scores were for OT contraindications (14%) and oxygen saturation for acute myocardial infarction (32%), asthma (36%) and healthy newborns (43%). The most positive attitudes were in response to the statement that OT guidelines are essential (96%). A total of 78 (80.4%) patients were being cared for with good OT practice. CONCLUSIONS Good KAP scores were obtained for medical staff in Fiji regarding OT administration. Ongoing professional education activities should include updated training of OT contraindications and optimal oxygen saturation levels for special patient groups.
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Affiliation(s)
- Fa'amuamua Arasi
- Department of Anaesthesia & Intensive Care, Colonial War Memorial Hospital, Suva, Fiji
- Department of Anaesthesia, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
- Surgical Unit, Tupua Tamasese Meaole Hospital, Ministry of Health, Apia, Samoa
| | - Elizabeth Bennett
- Department of Anaesthesia & Intensive Care, Colonial War Memorial Hospital, Suva, Fiji
- Department of Anaesthesia, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Avelina Rokoduru
- Pacific Sexual and Reproductive Health Research Centre, Fiji National University, Suva, Fiji
| | - Annette Kaspar
- Surgical Unit, Tupua Tamasese Meaole Hospital, Ministry of Health, Apia, Samoa
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O'Driscoll BR, Kirton L, Weatherall M, Bakerly ND, Turkington P, Cook J, Beasley R. Effect of a lower target oxygen saturation range on the risk of hypoxaemia and elevated NEWS2 scores at a university hospital: a retrospective study. BMJ Open Respir Res 2024; 11:e002019. [PMID: 38423953 PMCID: PMC10910590 DOI: 10.1136/bmjresp-2023-002019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 02/09/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The optimal target oxygen saturation (SpO2) range for hospital inpatients not at risk of hypercapnia is unknown. The objective of this study was to assess the impact on oxygen usage and National Early Warning Score 2 (NEWS2) of changing the standard SpO2 target range from 94-98% to 92-96%. METHODS In a metropolitan UK hospital, a database of electronic bedside SpO2 measurements, oxygen prescriptions and NEWS2 records was reviewed. Logistic regression was used to compare the proportion of hypoxaemic SpO2 values (<90%) and NEWS2 records ≥5 in 2019, when the target SpO2 range was 94-98%; with 2022, when the target range was 92-96%. RESULTS In 2019, 218 of 224 936 (0.10%) observations on room air and 162 of 11 328 (1.43%) on oxygen recorded an SpO2 <90%, and in 2022, 251 of 225 970 (0.11%) and 233 of 12 845 (1.81%), respectively (risk difference 0.04%, 95% CI 0.02% to 0.07%). NEWS2 ≥5 was observed in 3009 of 236 264 (1.27%) observations in 2019 and 4061 of 238 815 (1.70%) in 2022 (risk difference 0.43%, 0.36% to 0.50%; p<0.001). The proportion of patients using supplemental oxygen with hyperoxaemia (SpO2 100%) was 5.4% in 2019 and 3.9% in 2022 (OR 0.71, 0.63 to 0.81; p<0.001). DISCUSSION The proportion of observations with SpO2 <90% or NEWS2 ≥5 was greater with the 92-96% range; however, absolute differences were very small and of doubtful clinical relevance, in contrast to hyperoxaemia for which the proportion was markedly less in 2022. These findings support proposals that the British Thoracic Society oxygen guidelines could recommend a lower target SpO2 range.
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Affiliation(s)
- B Ronan O'Driscoll
- Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Salford, UK ronan.o'
| | - Louis Kirton
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University, Wellington, New Zealand
| | - Mark Weatherall
- Victoria University, Wellington, New Zealand
- University of Otago Wellington, Wellington, New Zealand
| | - Nawar Diar Bakerly
- Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Salford, UK
- Manchester Metropolitan University, Manchester, UK
| | - Peter Turkington
- Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Salford, UK
| | - Julie Cook
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University, Wellington, New Zealand
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Ford VJ, Klein HG, Danner RL, Applefeld WN, Wang J, Cortes-Puch I, Eichacker PQ, Natanson C. Controls, comparator arms, and designs for critical care comparative effectiveness research: It's complicated. Clin Trials 2024; 21:124-135. [PMID: 37615179 PMCID: PMC10891304 DOI: 10.1177/17407745231195094] [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: 08/25/2023]
Abstract
BACKGROUND Comparative effectiveness research is meant to determine which commonly employed medical interventions are most beneficial, least harmful, and/or most costly in a real-world setting. While the objectives for comparative effectiveness research are clear, the field has failed to develop either a uniform definition of comparative effectiveness research or an appropriate set of recommendations to provide standards for the design of critical care comparative effectiveness research trials, spurring controversy in recent years. The insertion of non-representative control and/or comparator arm subjects into critical care comparative effectiveness research trials can threaten trial subjects' safety. Nonetheless, the broader scientific community does not always appreciate the importance of defining and maintaining critical care practices during a trial, especially when vulnerable, critically ill populations are studied. Consequently, critical care comparative effectiveness research trials sometimes lack properly constructed control or active comparator arms altogether and/or suffer from the inclusion of "unusual critical care" that may adversely affect groups enrolled in one or more arms. This oversight has led to critical care comparative effectiveness research trial designs that impair informed consent, confound interpretation of trial results, and increase the risk of harm for trial participants. METHODS/EXAMPLES We propose a novel approach to performing critical care comparative effectiveness research trials that mandates the documentation of critical care practices prior to trial initiation. We also classify the most common types of critical care comparative effectiveness research trials, as well as the most frequent errors in trial design. We present examples of these design flaws drawn from past and recently published trials as well as examples of trials that avoided those errors. Finally, we summarize strategies employed successfully in well-designed trials, in hopes of suggesting a comprehensive standard for the field. CONCLUSION Flawed critical care comparative effectiveness research trial designs can lead to unsound trial conclusions, compromise informed consent, and increase risks to research subjects, undermining the major goal of comparative effectiveness research: to inform current practice. Well-constructed control and comparator arms comprise indispensable elements of critical care comparative effectiveness research trials, key to improving the trials' safety and to generating trial results likely to improve patient outcomes in clinical practice.
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Affiliation(s)
- Verity J Ford
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Harvey G Klein
- Department of Transfusion Medicine, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Robert L Danner
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Willard N Applefeld
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey Wang
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Irene Cortes-Puch
- Division of Pulmonary, Critical Care and Sleep Medicine, UC Davis Medical Center, Sacramento, CA, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Charles Natanson
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, MD, USA
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12
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Xing Z, Cai L, Wu Y, Shen P, Fu X, Xu Y, Wang J. Development and validation of a nomogram for predicting in-hospital mortality of patients with cervical spine fractures without spinal cord injury. Eur J Med Res 2024; 29:80. [PMID: 38287435 PMCID: PMC10823604 DOI: 10.1186/s40001-024-01655-4] [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] [Received: 09/11/2023] [Accepted: 01/10/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The incidence of cervical spine fractures is increasing every day, causing a huge burden on society. This study aimed to develop and verify a nomogram to predict the in-hospital mortality of patients with cervical spine fractures without spinal cord injury. This could help clinicians understand the clinical outcome of such patients at an early stage and make appropriate decisions to improve their prognosis. METHODS This study included 394 patients with cervical spine fractures from the Medical Information Mart for Intensive Care III database, and 40 clinical indicators of each patient on the first day of admission to the intensive care unit were collected. The independent risk factors were screened using the Least Absolute Shrinkage and Selection Operator regression analysis method, a multi-factor logistic regression model was established, nomograms were developed, and internal validation was performed. A receiver operating characteristic (ROC) curve was drawn, and the area under the ROC curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to evaluate the discrimination of the model. Moreover, the consistency between the actual probability and predicted probability was reflected using the calibration curve and Hosmer-Lemeshow (HL) test. A decision curve analysis (DCA) was performed, and the nomogram was compared with the scoring system commonly used in clinical practice to evaluate the clinical net benefit. RESULTS The nomogram indicators included the systolic blood pressure, oxygen saturation, respiratory rate, bicarbonate, and simplified acute physiology score (SAPS) II. The results showed that our model had satisfactory predictive ability, with an AUC of 0.907 (95% confidence interval [CI] = 0.853-0.961) and 0.856 (95% CI = 0.746-0.967) in the training set and validation set, respectively. Compared with the SAPS-II system, the NRI values of the training and validation sets of our model were 0.543 (95% CI = 0.147-0.940) and 0.784 (95% CI = 0.282-1.286), respectively. The IDI values of the training and validation sets were 0.064 (95% CI = 0.004-0.123; P = 0.037) and 0.103 (95% CI = 0.002-0.203; P = 0.046), respectively. The calibration plot and HL test results confirmed that our model prediction results showed good agreement with the actual results, where the HL test values of the training and validation sets were P = 0.8 and P = 0.95, respectively. The DCA curve revealed that our model had better clinical net benefit than the SAPS-II system. CONCLUSION We explored the in-hospital mortality of patients with cervical spine fractures without spinal cord injury and constructed a nomogram to predict their prognosis. This could help doctors assess the patient's status and implement interventions to improve prognosis accordingly.
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Affiliation(s)
- Zhibin Xing
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lingli Cai
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yuxuan Wu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Pengfei Shen
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Xiaochen Fu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yiwen Xu
- The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jing Wang
- The First Affiliated Hospital of Jinan University, Guangzhou, China.
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13
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O'Driscoll R, Bakerly ND. Automated audit of hospital oxygen use devised during the COVID-19 pandemic. BMJ Open Respir Res 2023; 10:e001866. [PMID: 38154912 PMCID: PMC10759130 DOI: 10.1136/bmjresp-2023-001866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/20/2023] [Indexed: 12/30/2023] Open
Abstract
BACKGROUND The British Thoracic Society (BTS) has organised intermittent audits of hospital oxygen use in UK hospitals since 2008. Manual audits are time-consuming and subject to human errors. Oxygen prescribing and bedside observations including National Early Warning Scores (NEWS2 scores) are undertaken within an integrated electronic medical record (EMR) at this hospital. METHODS The hospital's Business Information team were commissioned in late 2019 to devise a bespoke automated audit of oxygen prescribing and use. A summary report displays the oxygen saturation alongside the oxygen prescription status of every patient in the hospital except for critical care units which do not use NEWS2. The display has a 'traffic-light' colour scheme (green within target range, amber or red if below range or if above range on supplemental oxygen), with a graph showing oxygen use and saturation levels for patients with each prescribed target range. Clinicians can access raw data including oxygen saturation, oxygen device and flow rate for each individual patient. RESULTS Over 51 audits involving 34 352 sets of observations, an average of 6.0% involved use of oxygen and 88.6% of these had a valid oxygen prescription. During the first wave of the COVID-19 pandemic in spring 2020, the monthly percentage of observations involving oxygen use increased to a peak of 10.4% followed by a rise to 10.6% during the second wave and 7.4% during the third (Omicron) wave. Oxygen use returned to baseline after each wave. CONCLUSIONS In hospitals with integrated EMRs, it is possible to automate all fundamental aspects of the BTS oxygen audits and to monitor oxygen use at individual patient level and a hospital-wide level. This could be particularly valuable during major events such as the COVID-19 pandemic. This methodology could be extended to other clinical audits where the audit questions relate to routinely collected EMR data.
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Affiliation(s)
- Ronan O'Driscoll
- Respiratory Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK ronan.o'
| | - Nawar Diar Bakerly
- Respiratory Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
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14
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Lellouche F, Bouchard PA, Branson RD. Impact of S pO2 Targets and Pulse Oximeter Brand on Oxygen Flow Requirements and Oxygenation. Respir Care 2023; 69:respcare.11358. [PMID: 37748791 PMCID: PMC10753597 DOI: 10.4187/respcare.11358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023]
Affiliation(s)
- François Lellouche
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec (Québec), Canada.
| | - Pierre-Alexandre Bouchard
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec (Québec), Canada
| | - Richard D Branson
- Department of Surgery, Division of Trauma & Critical Care, University Cincinnati, Cincinnati, Ohio
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15
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Kotani Y, Turi S, Ortalda A, Baiardo Redaelli M, Marchetti C, Landoni G, Bellomo R. Positive single-center randomized trials and subsequent multicenter randomized trials in critically ill patients: a systematic review. Crit Care 2023; 27:465. [PMID: 38017475 PMCID: PMC10685543 DOI: 10.1186/s13054-023-04755-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND It is unclear how often survival benefits observed in single-center randomized controlled trials (sRCTs) involving critically ill patients are confirmed by subsequent multicenter randomized controlled trials (mRCTs). We aimed to perform a systemic literature review of sRCTs with a statistically significant mortality reduction and to evaluate whether subsequent mRCTs confirmed such reduction. METHODS We searched PubMed for sRCTs published in the New England Journal of Medicine, JAMA, or Lancet, from inception until December 31, 2016. We selected studies reporting a statistically significant mortality decrease using any intervention (drug, technique, or strategy) in adult critically ill patients. We then searched for subsequent mRCTs addressing the same research question tested by the sRCT. We compared the concordance of results between sRCTs and mRCTs when any mRCT was available. We registered this systematic review in the PROSPERO International Prospective Register of Systematic Reviews (CRD42023455362). RESULTS We identified 19 sRCTs reporting a significant mortality reduction in adult critically ill patients. For 16 sRCTs, we identified at least one subsequent mRCT (24 trials in total), while the interventions from three sRCTs have not yet been addressed in a subsequent mRCT. Only one out of 16 sRCTs (6%) was followed by a mRCT replicating a significant mortality reduction; 14 (88%) were followed by mRCTs with no mortality difference. The positive finding of one sRCT (6%) on intensive glycemic control was contradicted by a subsequent mRCT showing a significant mortality increase. Of the 14 sRCTs referenced at least once in international guidelines, six (43%) have since been either removed or suggested against in the most recent versions of relevant guidelines. CONCLUSION Mortality reduction shown by sRCTs is typically not replicated by mRCTs. The findings of sRCTs should be considered hypothesis-generating and should not contribute to guidelines.
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Affiliation(s)
- Yuki Kotani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy
- Department of Intensive Care Medicine, Kameda Medical Center, 929 Higashi-cho, Kamogawa, Chiba, 296-8602, Japan
| | - Stefano Turi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Cristiano Marchetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
- School of Medicine, Vita-Salute San Raffaele University, Via Olgettina 58, 20132, Milan, Italy.
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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16
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Trottier M, Bouchard PA, L'Her E, Lellouche F. Automated Oxygen Titration During CPAP and Noninvasive Ventilation in Healthy Subjects With Induced Hypoxemia. Respir Care 2023; 68:1553-1560. [PMID: 37311626 PMCID: PMC10589107 DOI: 10.4187/respcare.09866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Automated oxygen titration to maintain a stable SpO2 has been developed for spontaneously breathing patients but has not been evaluated during CPAP and noninvasive ventilation (NIV). METHODS We performed a randomized controlled crossover, double-blind study on 10 healthy subjects with induced hypoxemia during 3 situations: spontaneous breathing with oxygen support, CPAP (5 cm H2O), and NIV (7/3 cm H2O). We conducted in random order 3 dynamic hypoxic challenges of 5 min (FIO2 0.08 ± 0.02, 0.11± 0.02, and 0.14 ± 0.02). For each condition, we compared automated oxygen titration and manual oxygen titration by experienced respiratory therapists (RTs), with the aim to maintain the SpO2 at 94 ± 2%. In addition, we included 2 subjects hospitalized for exacerbation of COPD under NIV and a subject managed after bariatric surgery with CPAP and automated oxygen titration. RESULTS The percentage of time in the SpO2 target was higher with automated compared with manual oxygen titration for all conditions, on average 59.6 ± 22.8% compared to 44.3 ± 23.9% (P = .004). Hyperoxemia (SpO2 > 96%) was less frequent with automated titration for each mode of oxygen administration (24.0 ± 24.4% vs 39.1 ± 25.3%, P < .001). During the manual titration periods, the RT made several changes to oxygen flow (5.1 ± 3.3 interventions that lasted 122 ± 70 s/period) compared to none during the automated titration to maintain oxygenation in the targeted SpO2 . Time in the SpO2 target was higher with stable hospitalized subjects in comparison with healthy subjects under dynamic-induced hypoxemia. CONCLUSIONS In this proof-of-concept study, automated oxygen titration was used during CPAP and NIV. The performances to maintain the SpO2 target were significantly better compared to manual oxygen titration in the setting of this study protocol. This technology may allow decreasing the number of manual interventions for oxygen titration during CPAP and NIV.
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Affiliation(s)
- Miguel Trottier
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Pierre-Alexandre Bouchard
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Erwan L'Her
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada; LATIM INSERM UMR 1101, Université de Bretagne Occidentale, Brest, France; and the Centre Hospitalier Universitaire de Brest, Brest, France
| | - François Lellouche
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada.
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17
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Cheng X, Zhang Y, Deng H, Feng Y, Chong W, Hai Y, Hao P, He J, Li T, Peng L, Wang P, Xiao Y, Fang F. Lower versus higher oxygen targets for out-of-hospital cardiac arrest: a systematic review and meta-analysis. Crit Care 2023; 27:401. [PMID: 37858246 PMCID: PMC10588244 DOI: 10.1186/s13054-023-04684-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/11/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Supplemental oxygen is commonly administered to patients after out-of-hospital cardiac arrest. However, the findings from studies on oxygen targeting for out-of-hospital cardiac arrest are inconclusive. Thus, we conducted a systematic review and meta-analysis to evaluate the impact of lower oxygen target compared with higher oxygen target on patients after out-of-hospital cardiac arrest. METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, from inception to February 6, 2023, for randomized controlled trials comparing lower and higher oxygen target in adults (aged ≥ 18 years) after out-of-hospital cardiac arrest. We screened studies and extracted data independently. The primary outcome was mortality at 90 days after cardiac arrest. We assessed quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study was registered with PROSPERO, number CRD42023409368. RESULTS The analysis included 7 randomized controlled trials with a total of 1451 participants. Compared with lower oxygen target, the use of a higher oxygen target was not associated with a higher mortality rate (relative risk 0.97, 95% confidence intervals 0.82 to 1.14; I2 = 25%). Findings were robust to trial sequential, subgroup, and sensitivity analysis. CONCLUSION Lower oxygen target did not reduce the mortality compared with higher oxygen target in patients after out-of-hospital cardiac arrest.
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Affiliation(s)
- Xin Cheng
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yu Zhang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Haidong Deng
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yuning Feng
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Weelic Chong
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Yang Hai
- Thomas Jefferson University, Philadelphia, PA, USA
| | - Pengfei Hao
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Jialing He
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Tiangui Li
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Liyuan Peng
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Peng Wang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yangchun Xiao
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Fang Fang
- West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu, 610041, Sichuan, China.
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18
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Jiang X, Qiu D. Effects of Conservative Oxygen Therapy versus Conventional Oxygen Therapy on the Mortality in ICU Patients: A Meta-Analysis. Can Respir J 2023; 2023:7023712. [PMID: 37868784 PMCID: PMC10590270 DOI: 10.1155/2023/7023712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 09/10/2023] [Accepted: 09/27/2023] [Indexed: 10/24/2023] Open
Abstract
Objective To compare the effects of conservative oxygen therapy and conventional oxygen therapy on the mortality of critically ill patients in ICU. Methods Searching for randomized controlled clinical trials (RCT) on the effect of conservative oxygen therapy and conventional oxygen therapy on the mortality of critically ill patients in computer databases, including PubMed, Embase, Cochrane Library, CNKI, VIP, and Wanfang, with postdate before August 2022. We have two researchers evaluating the quality of the literature included and extracting data as per the inclusion and exclusion criteria and then analyzed it with RevMan 5.4 statistical software. Primary outcome included short-term mortality (28-day mortality or ICU mortality); secondary outcome included 90-day mortality, ICU length of stay, hospital length of stay, incidence of new organ dysfunction in ICU, incidence of new infection in ICU, and incidence of ICUAW. Results A total of 5779 subjects were included in 10 articles, including 2886 in the conservative oxygen therapy group and 2893 in the conventional oxygen therapy group. The meta-analysis showed that conservative oxygen therapy had an advantage over conventional oxygen therapy in terms of short-term mortality (P=0.03). Subgroup analysis based on different conservative oxygen targets showed that this advantage was statistically significant when the target is set above 90% (RR = 0.76, 95% CI = 0.62∼0.94, P=0.01), while there was no significant difference between conservative oxygen therapy and conventional oxygen therapy when the target is set below 90% (RR = 0.95, 95% CI = 0.79∼1.16, P=0.63). In addition, in terms of the incidence of new infections in the ICU (P=0.03) and the incidence of ICUAW (P=0.03), conservative oxygen therapy also had advantages over conventional oxygen therapy, and the difference was statistically significant. But in terms of 90-day mortality (P=0.61), ICU length of stay (P=0.96), hospital length of stay (P=0.47), and incidence of new organ dysfunction in ICU (P=0.61), there was no significant difference between conservative oxygen therapy and conventional oxygen therapy. Conclusion Compared with conventional oxygen therapy, conservative oxygen therapy can reduce the short-term mortality of severe patients, especially when the conservative oxygen therapy target is set above 90%. And it can also reduce the incidence of ICU new infections and ICUAW, while having no effect on 90-day mortality, ICU length of stay, and hospital length of stay.
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Affiliation(s)
- Xinyu Jiang
- The First Affiliated Hospital of Soochow University, Suzhou 215006, China
| | - Dong Qiu
- The First Affiliated Hospital of Soochow University, Suzhou 215006, China
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19
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Daniels E, Lamb GC, Beckius A. Reducing inappropriate oxygen use in hospitalized medicine patients. Hosp Pract (1995) 2023; 51:205-210. [PMID: 37496308 DOI: 10.1080/21548331.2023.2241341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 03/21/2023] [Accepted: 07/24/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Evidence suggests inappropriate oxygenation may be harmful to patients. To improve oxygen use in our hospital, we initiated a quality improvement project with a goal to reduce the percentage of inappropriate utilization of oxygen by 50% within a year. METHODS Nasal cannula (NC) oxygen use data for medicine inpatients was abstracted weekly for chart review. A multidisciplinary team developed a guideline for use. Initiation of NC O2 with a baseline SPO2 > 92% was deemed inappropriate and 3+ consecutive SPO2 > 96% was defined as over-supplementation. Formal interventions included an oxygen use guideline, updated EMR order, unit-specific feedback, and magnetic placards. Progress was tracked by control charts. RESULTS Baseline data revealed 40% of patients were inappropriately placed on oxygen and 55% of patients had one instance of excessive supplementation. Only half of all improper uses of oxygen had charted medical reasoning, and 30% had a corresponding order. Instances of proper oxygen use had orders 48% of the time. Run charts revealed inappropriate initiation was significantly reduced to 27.1% (p < 0.0001) and excessive oxygenation decreased significantly to 34.4% (p < 0.0001) following interventions with no effect on other variables. CONCLUSIONS Our interventions significantly decreased improper oxygen initiation and excessive supplementation.
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Affiliation(s)
| | - Geoffrey C Lamb
- Section of Hospital Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anna Beckius
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
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20
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Burrell A, Ng S, Ottosen K, Bailey M, Buscher H, Fraser J, Udy A, Gattas D, Totaro R, Bellomo R, Forrest P, Martin E, Reid L, Ziegenfuss M, Eastwood G, Higgins A, Hodgson C, Litton E, Nair P, Orford N, Pellegrino V, Shekar K, Trapani T, Pilcher D. Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial: Study Protocol and Statistical Analysis Plan. CRIT CARE RESUSC 2023; 25:118-125. [PMID: 37876374 PMCID: PMC10581278 DOI: 10.1016/j.ccrj.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Introduction Critically ill patients supported with venoarterial extracorporeal membrane oxygenation (VA ECMO) are at risk of developing severe arterial hyperoxia, which has been associated with increased mortality. Lower saturation targets in this population may lead to deleterious episodes of severe hypoxia. This manuscript describes the protocol and statistical analysis plan for the Blend to Limit OxygEN in ECMO: A RanDomised ControllEd Registry (BLENDER) Trial. Design The BLENDER trial is a pragmatic, multicentre, registry-embedded, randomised clinical trial., registered at ClinicalTrials.gov (NCT03841084) and approved by The Alfred Hospital Ethics Committee project ID HREC/50486/Alfred-2019. Participants and setting Patients supported by VA ECMO for cardiogenic shock or cardiac arrest who are enrolled in the Australian national ECMO registry. Intervention The study compares a conservative oxygenation strategy (target arterial saturations 92-96%) with a liberal oxygenation strategy (target 97-100%). Main Outcome Measures The primary outcome is the number of intensive care unit (ICU)-free days for patients alive at day 60. Secondary outcomes include duration of mechanical ventilation, ICU and hospital mortality, the number of hypoxic episodes, neurocognitive outcomes, and health economic analyses. The 300-patient sample size enables us to detect a 3-day difference in ICU-free days at day 60, assuming a mean ICU-free days of 11 days, with a risk of type 1 error of 5% and power of 80%. Data will be analysed according to a predefined analysis plan. Findings will be disseminated in peer-reviewed publications. Conclusions This paper details the protocol and statistical analysis plan for the BLENDER trial, a registry-embedded, multicentre interventional trial comparing liberal and conservative oxygenation strategies in VA ECMO.
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Affiliation(s)
- Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sze Ng
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Kelly Ottosen
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, VIC, Australia
| | - Hergen Buscher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- St. Vincent's Hospital Sydney, University of New South Wales, Darlinghurst, NSW, Australia
| | - John Fraser
- Critical Care Research Group, Brisbane, QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - David Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Richard Totaro
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, VIC, Australia
| | - Paul Forrest
- Sydney Medical School, University of Sydney, Sydney, NSW, Australia
- Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Emma Martin
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Liadain Reid
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Marc Ziegenfuss
- Critical Care Research Group, Brisbane, QLD, Australia
- Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Alisa Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, VIC, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Priya Nair
- Intensive Care Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Neil Orford
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
- School of Medicine, Deakin University, Waurn Ponds, VIC, Australia
| | - Vince Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Kiran Shekar
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Adult Intensive Care Unit, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
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21
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Abdelbaky AM, Elmasry WG, Awad AH. Lower Versus Higher Oxygenation Targets for Critically Ill Patients: A Systematic Review. Cureus 2023; 15:e41330. [PMID: 37408938 PMCID: PMC10318567 DOI: 10.7759/cureus.41330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2023] [Indexed: 07/07/2023] Open
Abstract
Supplemental oxygen is a standard therapeutic intervention for critically ill patients such as patients suffering from cardiac arrest, myocardial ischemia, traumatic brain injury, and stroke. However, the optimal oxygenation targets remain elusive owing to the paucity and inconsistencies in the relevant literature. A comprehensive analysis of the available scientific evidence was performed to establish the relative efficacy of the lower and higher oxygenation targets. A systematic literature search was conducted in PubMed, MEDLINE, and Scopus databases from 2010 to 2023. Further, Google Scholar was also searched. Studies evaluating the efficacy of oxygenation targets and the associated clinical outcomes were included. Studies that included participants with hyperbaric oxygen therapy, chronic respiratory diseases, or extracorporeal life support were excluded. The literature search was performed by two blinded reviewers. A total of 19 studies were included in this systemic review, including 72,176 participants. A total of 14 randomized control trials were included. A total of 12 studies investigated the efficacy of lower and higher oxygenation targets in ICU-admitted patients, and seven were assessed in patients with acute myocardial infarction and stroke. For ICU patients, the evidence was conflicting, with some studies showing the efficacy of conservative oxygen therapy while others reported no difference. Overall, nine studies concluded that lower oxygen targets are favorable. However, most studies (n=4) in stroke and myocardial infarction patients showed no difference in lower or higher oxygenation targets whereas only two supported lower oxygenation targets. Available evidence suggests that lower oxygenation targets result in either improved or equivalent clinical outcomes compared with higher oxygenation targets.
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Affiliation(s)
- Ahmed M Abdelbaky
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Wael G Elmasry
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
| | - Ahmed H Awad
- Intensive Care Unit, Dubai Academic Health Corporation - Rashid Hospital, Dubai, ARE
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22
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Blanchet MA, Mercier G, Delobel A, Nayet E, Bouchard PA, Simard S, L'Her E, Branson RD, Lellouche F. Accuracy of Multiple Pulse Oximeters in Stable Critically Ill Patients. Respir Care 2023; 68:565-574. [PMID: 36596654 PMCID: PMC10171338 DOI: 10.4187/respcare.10582] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND An accurate SpO2 value is critical in order to optimally titrate oxygen delivery to patients and to follow oxygenation guidelines. Limited prospective data exist on real-world performance of pulse oximeters in critically ill patients. The objective of this study was to assess accuracy and bias of the SpO2 values measured by several oximeters in hospitalized subjects. METHODS We included stable adults in the ICU with an arterial catheter in place. Main exclusion criteria were poor SpO2 signal and SpO2 > 96%. In each subject, we simultaneously evaluated 4 oximeters: Nonin (Plymouth, Minnesota) embedded in the FreeO2 device (OxyNov, Québec City, Québec, Canada), Masimo (Radical-7, Masimo, Irvine, California), Philips (FAST, Philips, Amsterdam, the Netherlands), and Nellcor (N-600, Medtronic, Minneapolis, Minnesota). Arterial blood gases were drawn and simultaneously each oximeters' SpO2 values were collected. SpO2 values were compared to the reference (arterial oxygen saturation [SaO2 ] value) to determine bias and accuracy. The ability for oximeters to detect hypoxemia and the impact of oximeters on oxygen titration were evaluated. RESULTS We included 193 subjects (153 male, mean age 66 y) in whom 211 sets of measurements were performed. The skin pigmentation evaluated by Fitzpatrick scale showed 96.2% of subjects were light skin (types 1 and 2). One oximeter overestimated SaO2 (Philips, +0.9%), whereas the 3 others underestimated SaO2 (Nonin -3.1%, Nellcor -0.3%, Masimo -0.2%). SaO2 was underestimated with Nonin oximeter in 91.3% of the cases, whereas it was overestimated in 55.2% of the cases with Philips oximeter. Moderate hypoxemia (SaO2 86-90% or PaO2 55-60 mm Hg) was detected in 92, 33, 42, and 11% of the cases with Nonin, Nellcor, Masimo, and Philips, respectively. CONCLUSIONS We found significant bias and moderate accuracy between the tested oximeters and the arterial blood gases in the studied population. These discrepancies may have important clinical impact on the detection of hypoxemia and management of oxygen therapy.
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Affiliation(s)
- Marie-Anne Blanchet
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Gabriel Mercier
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Antoine Delobel
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Emi Nayet
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Pierre-Alexandre Bouchard
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Serge Simard
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada
| | - Erwan L'Her
- Medical Intensive Care Unit, CHRU Brest, La Cavale Blanche, Brest, France
| | - Richard D Branson
- Department of Surgery, Division of Trauma and Critical Care, University Cincinnati, Cincinnati, Ohio
| | - François Lellouche
- Department of Medicine, Centre de recherche, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Canada.
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23
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Minkove S, Dhamapurkar R, Cui X, Li Y, Sun J, Cooper D, Eichacker PQ, Torabi-Parizi P. Effect of low-to-moderate hyperoxia on lung injury in preclinical animal models: a systematic review and meta-analysis. Intensive Care Med Exp 2023; 11:22. [PMID: 37088856 PMCID: PMC10122981 DOI: 10.1186/s40635-023-00501-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/13/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Extensive animal investigation informed clinical practice regarding the harmful effects of high fractional inspired oxygen concentrations (FiO2s > 0.60). Since questions persist whether lower but still supraphysiologic FiO2 ≤ 0.60 and > 0.21 (FiO2 ≤ 0.60/ > 0.21) are also harmful with inflammatory lung injury in patients, we performed a systematic review examining this question in animal models. METHODS Studies retrieved from systematic literature searches of three databases, that compared the effects of exposure to FiO2 ≤ 0.60/ > 0.21 vs. FiO2 = 0.21 for ≥ 24 h in adult in vivo animal models including an inflammatory challenge or not were analyzed. Survival, body weight and/or lung injury measures were included in meta-analysis if reported in ≥ 3 studies. RESULTS More than 600 retrieved reports investigated only FiO2s > 0.60 and were not analyzed. Ten studies with an inflammatory challenge (6 infectious and 4 noninfectious) and 14 studies without, investigated FiO2s ≤ 0.60/ > 0.21 and were analyzed separately. In seven studies with an inflammatory challenge, compared to FiO2 = 0.21, FiO2 ≤ 0.60/ > 0.21 had consistent effects across animal types on the overall odds ratio of survival (95%CI) that was on the side of harm but not significant [0.68 (0.38,1.23), p = 0.21; I2 = 0%, p = 0.57]. However, oxygen exposure times were only 1d in 4 studies and 2-4d in another. In a trend approaching significance, FiO2 ≤ 0.60/ > 0.21 with an inflammatory challenge consistently increased the standardized mean difference (95%CI) (SMD) in lung weights [0.47 (- 0.07,1.00), p = 0.09; I2 = 0%, p = 0.50; n = 4 studies] but had inconsistent effects on lung lavage protein concentrations (n = 3), lung pathology scores (n = 4) and/or arterial oxygenation (n = 4) (I2 ≥ 43%, p ≤ 0.17). Studies without an inflammatory challenge had consistent effects on lung lavage protein concentration (n = 3) SMDs on the side of being increased that was not significant [0.43 (- 0.23,1.09), p = 0.20; I2 = 0%, p = 0.40] but had inconsistent effects on body and lung weights (n = 6 and 8 studies, respectively) (I2 ≥ 71%, p < 0.01). Quality of evidence for studies was weak. INTERPRETATION Limited animal studies have investigated FiO2 ≤ 0.60/ > 0.21 with clinically relevant models and endpoints but suggest even these lower FiO2s may be injurious. Given the influence animal studies examining FiO2 > 0.60 have had on clinical practice, additional ones investigating FiO2 ≤ 0.60/ > 0.21 appear warranted, particularly in pneumonia models.
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Affiliation(s)
- Samuel Minkove
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Rhea Dhamapurkar
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Xizhong Cui
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Yan Li
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Junfeng Sun
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Diane Cooper
- NIH Library, Clinical Center, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Peter Q Eichacker
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA
| | - Parizad Torabi-Parizi
- Critical Care Medicine Department, National Institutes of Health, Building 10, Room 2C145, 9000 Rockville Pike, Bethesda, MD, 20892, USA.
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24
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Desalu OO, Ojuawo OB, Adeoti AO, Oyedepo OO, Aladesanmi AO, Afolayan OJ, Ibraheem RM, Suleiman ZA, Opeyemi CM. Doctors' and Nurses' Knowledge and Perceived Barriers Regarding Acute Oxygen Therapy in a Tertiary Care Hospital in Nigeria. ADVANCES IN MEDICAL EDUCATION AND PRACTICE 2022; 13:1535-1545. [PMID: 36568879 PMCID: PMC9783829 DOI: 10.2147/amep.s378533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/16/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE Oxygen may cause serious consequences when administered wrongly. This study aimed to assess doctors' and nurses' knowledge of acute oxygen therapy and perceived delivery barriers. PARTICIPANTS AND METHODS We conducted a cross sectional study among 202 healthcare providers (134 doctors and 68 nurses) in a Nigerian hospital. The validated Acute Oxygen Therapy Questionnaire (AOTQ), which consisted of 21 knowledge assessment questions, was self administered by participants. Provider's knowledge was classified as good if the score was≥80% and poor if < 60%. RESULTS Overall, 26.7% (37.3% doctors and 5.9% nurses) had good knowledge of acute oxygen therapy (AOT), 35.9% were aware, and 19.3% used the AOT guidelines. The commonest source of knowledge on oxygen therapy was medical /nursing school (75.2%). The participants' mean knowledge score was 14.75 ± 2.83(possible score of 0-21). Doctors in postgraduate (PG) training obtained the highest score (15.96±2.48) among the participants (F=12.45, df=4, p<0.001). Most doctors (62%) and 23.5% of nurses considered oxygen as a drug. More doctors (52.2%) than nurses (14.7%) believed that a doctor's order was mandatory before oxygen administration, contrary to guidelines recommendations. Most nurses did not know that breathlessness does not always signify hypoxemia and that asymptomatic anemia was not an indication for oxygen. Concerning oxygen prescription, 39.7% of nurses and 64.2% of doctors knew that it should be prescribed to achieve a target saturation range rather than a fixed dose. In acute oxygen delivery in COPD, doctors and nurses exhibited poor knowledge of the appropriate device and flow rate. The reported barriers to oxygen delivery were: a shortage of oxygen supply, inadequate delivery devices, power outages and out of pocket costs. CONCLUSION A significant proportion of doctors and nurses had poor knowledge of acute oxygen therapy, poor awareness and infrequently used AOT guidelines, and reported pertinent delivery barriers that warrant educational and administrative interventions.
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Affiliation(s)
- Olufemi O Desalu
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Olutobi B Ojuawo
- Department of Medicine, University of Ilorin Teaching Hospital, Ilorin, Nigeria
| | - Adekunle O Adeoti
- Department of Medicine, Ekiti State University Teaching Hospital, Ado Ekiti, Nigeria
| | | | | | | | - Rasheedah M Ibraheem
- Department of Child Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria
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25
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McIlroy DR, Shotwell MS, Lopez MG, Vaughn MT, Olsen JS, Hennessy C, Wanderer JP, Semler MS, Rice TW, Kheterpal S, Billings FT. Oxygen administration during surgery and postoperative organ injury: observational cohort study. BMJ 2022; 379:e070941. [PMID: 36450405 PMCID: PMC9710248 DOI: 10.1136/bmj-2022-070941] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To examine whether supraphysiological oxygen administration during surgery is associated with lower or higher postoperative kidney, heart, and lung injury. DESIGN Observational cohort study. SETTING 42 medical centers across the United States participating in the Multicenter Perioperative Outcomes Group data registry. PARTICIPANTS Adult patients undergoing surgical procedures ≥120 minutes' duration with general anesthesia and endotracheal intubation who were admitted to hospital after surgery between January 2016 and November 2018. INTERVENTION Supraphysiological oxygen administration, defined as the area under the curve of the fraction of inspired oxygen above air (21%) during minutes when the hemoglobin oxygen saturation was greater than 92%. MAIN OUTCOMES Primary endpoints were acute kidney injury defined using Kidney Disease Improving Global Outcomes criteria, myocardial injury defined as serum troponin >0.04 ng/mL within 72 hours of surgery, and lung injury defined using international classification of diseases hospital discharge diagnosis codes. RESULTS The cohort comprised 350 647 patients with median age 59 years (interquartile range 46-69 years), 180 546 women (51.5%), and median duration of surgery 205 minutes (interquartile range 158-279 minutes). Acute kidney injury was diagnosed in 19 207 of 297 554 patients (6.5%), myocardial injury in 8972 of 320 527 (2.8%), and lung injury in 13 789 of 312 161 (4.4%). The median fraction of inspired oxygen was 54.0% (interquartile range 47.5%-60.0%), and the area under the curve of supraphysiological inspired oxygen was 7951% min (5870-11 107% min), equivalent to an 80% fraction of inspired oxygen throughout a 135 minute procedure, for example. After accounting for baseline covariates and other potential confounding variables, increased oxygen exposure was associated with a higher risk of acute kidney injury, myocardial injury, and lung injury. Patients at the 75th centile for the area under the curve of the fraction of inspired oxygen had 26% greater odds of acute kidney injury (95% confidence interval 22% to 30%), 12% greater odds of myocardial injury (7% to 17%), and 14% greater odds of lung injury (12% to 16%) compared with patients at the 25th centile. Sensitivity analyses evaluating alternative definitions of the exposure, restricting the cohort, and conducting an instrumental variable analysis confirmed these observations. CONCLUSIONS Increased supraphysiological oxygen administration during surgery was associated with a higher incidence of kidney, myocardial, and lung injury. Residual confounding of these associations cannot be excluded. TRIAL REGISTRATION Open Science Framework osf.io/cfd2m.
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Affiliation(s)
- David R McIlroy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marcos G Lopez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michelle T Vaughn
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Joanna S Olsen
- Department of Anesthesiology, Oregon Health and Science University, Portland, OR, USA
| | - Cassandra Hennessy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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26
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Sarkar M, Madabhavi I, Kadakol N. Oxygen-induced hypercapnia: physiological mechanisms and clinical implications. Monaldi Arch Chest Dis 2022. [DOI: 10.4081/monaldi.2022.2399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. The risk of hypercapnia is not restricted to COPD only; it has also been reported in patients with morbid obesity, asthma, cystic fibrosis, chest wall skeletal deformities, bronchiectasis, chest wall deformities, or neuromuscular disorders. However, the risk of hypercapnia should not be a deterrent to oxygen therapy in hypoxemic patients with chronic lung diseases, as hypoxemia may lead to life-threatening cardiovascular complications. Various mechanisms leading to the development of oxygen-induced hypercapnia are the abolition of ‘hypoxic drive’, loss of hypoxic vasoconstriction and absorption atelectasis leading to an increase in dead-space ventilation and Haldane effect. The international guideline recommends a target oxygen saturation of 88% to 92% in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and other chronic lung diseases at risk of hypercapnia. Oxygen should be administered only when oxygen saturation is below 88%. We searched PubMed, EMBASE, and the CINAHL from inception to June 2022. We used the following search terms: “Hypercapnia”, “Oxygen therapy in COPD”, “Oxygen-associated hypercapnia”, “oxygen therapy”, and “Hypoxic drive”. All types of study are selected. This review will focus on the physiological mechanisms of oxygen-induced hypercapnia and its clinical implications.
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27
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Semler MW, Casey JD, Lloyd BD, Hastings PG, Hays MA, Stollings JL, Buell KG, Brems JH, Qian ET, Seitz KP, Wang L, Lindsell CJ, Freundlich RE, Wanderer JP, Han JH, Bernard GR, Self WH, Rice TW. Oxygen-Saturation Targets for Critically Ill Adults Receiving Mechanical Ventilation. N Engl J Med 2022; 387:1759-1769. [PMID: 36278971 PMCID: PMC9724830 DOI: 10.1056/nejmoa2208415] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Invasive mechanical ventilation in critically ill adults involves adjusting the fraction of inspired oxygen to maintain arterial oxygen saturation. The oxygen-saturation target that will optimize clinical outcomes in this patient population remains unknown. METHODS In a pragmatic, cluster-randomized, cluster-crossover trial conducted in the emergency department and medical intensive care unit at an academic center, we assigned adults who were receiving mechanical ventilation to a lower target for oxygen saturation as measured by pulse oximetry (Spo2) (90%; goal range, 88 to 92%), an intermediate target (94%; goal range, 92 to 96%), or a higher target (98%; goal range, 96 to 100%). The primary outcome was the number of days alive and free of mechanical ventilation (ventilator-free days) through day 28. The secondary outcome was death by day 28, with data censored at hospital discharge. RESULTS A total of 2541 patients were included in the primary analysis. The median number of ventilator-free days was 20 (interquartile range, 0 to 25) in the lower-target group, 21 (interquartile range, 0 to 25) in the intermediate-target group, and 21 (interquartile range, 0 to 26) in the higher-target group (P = 0.81). In-hospital death by day 28 occurred in 281 of the 808 patients (34.8%) in the lower-target group, 292 of the 859 patients (34.0%) in the intermediate-target group, and 290 of the 874 patients (33.2%) in the higher-target group. The incidences of cardiac arrest, arrhythmia, myocardial infarction, stroke, and pneumothorax were similar in the three groups. CONCLUSIONS Among critically ill adults receiving invasive mechanical ventilation, the number of ventilator-free days did not differ among groups in which a lower, intermediate, or higher Spo2 target was used. (Supported by the National Heart, Lung, and Blood Institute and others; PILOT ClinicalTrials.gov number, NCT03537937.).
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Affiliation(s)
- Matthew W Semler
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Jonathan D Casey
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Bradley D Lloyd
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Pamela G Hastings
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Margaret A Hays
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Joanna L Stollings
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Kevin G Buell
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - John H Brems
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Edward T Qian
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Kevin P Seitz
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Li Wang
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Christopher J Lindsell
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Robert E Freundlich
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Jonathan P Wanderer
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Jin H Han
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Gordon R Bernard
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Wesley H Self
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
| | - Todd W Rice
- From the Divisions of Allergy, Pulmonary, and Critical Care Medicine (M.W.S., J.D.C., M.A.H., E.T.Q., K.P.S., G.R.B., T.W.R.) and Respiratory Care (B.D.L., P.G.H.), the Departments of Pharmaceutical Services (J.L.S.), Medicine (K.G.B., J.H.B.), Biostatistics (L.W., C.J.L.), Anesthesiology (R.E.F., J.P.W.), Biomedical Informatics (R.E.F., J.P.W.), and Emergency Medicine (J.H.H., W.H.S.), and the Vanderbilt Institute for Clinical and Translational Research (G.R.B., W.H.S., T.W.R.), Vanderbilt University Medical Center, and the Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System (J.H.H.) - all in Nashville
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Mart MF, Semler MW, Bernard G, Casey JD, Ely EW, Freundlich R, Jackson JC, Kiehl A, Jenkins C, Wang G, Lindsell C, Bryant P, Rice TW, Self WH, Stollings J, Wanderer JP, Wang L, Han JH. Cognitive Outcomes in the Pragmatic Investigation of optima L Oxygen Targets (CO-PILOT) trial: protocol and statistical analysis plan. BMJ Open 2022; 12:e064517. [PMID: 36319061 PMCID: PMC9628689 DOI: 10.1136/bmjopen-2022-064517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 10/17/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Long-term cognitive impairment is one of the most common complications of critical illness among survivors who receive mechanical ventilation. Recommended oxygen targets during mechanical ventilation vary among international guidelines. Different oxygen targets during mechanical ventilation have the potential to alter long-term cognitive function due to cerebral hypoxemia or hyperoxemia. Whether higher, intermediate or lower SpO2 targets are associated with better cognitive function at 12-month follow-up is unknown. METHODS AND ANALYSIS The Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial is an ongoing pragmatic, cluster-randomised, cluster-crossover trial comparing the effect of a higher SpO2 target (target 98%, goal range 96%-100%), an intermediate SpO2 target (target 94%, goal range 92%-96%) and a lower SpO2 target (target 90%, goal range 88%-92%) on clinical outcomes in mechanically ventilated patients admitted to the medical intensive care unit at a single centre in the USA. For this ancillary study of long-term Cognitive Outcomes (CO-PILOT), survivors of critical illness who are in the PILOT trial and who do not meet exclusion criteria for CO-PILOT are approached for consent. The anticipated number of patients for whom assessment of long-term cognition will be performed in CO-PILOT is 612 patients over 36 months of enrolment. Cognitive, functional and quality of life assessments are assessed via telephone interview at approximately 12 months after enrolment in PILOT. The primary outcome of CO-PILOT is the telephone version of the Montreal Cognitive Assessment. A subset of patients will also complete a comprehensive neuropsychological telephone battery to better characterise the cognitive domains affected. ETHICS AND DISSEMINATION The CO-PILOT ancillary study was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.
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Affiliation(s)
- Matthew F Mart
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon Bernard
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - E Wesley Ely
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Robert Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James C Jackson
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Amy Kiehl
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Cathy Jenkins
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Guanchao Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christopher Lindsell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Patsy Bryant
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wesley H Self
- Vanderbilt Institute for Clinical and Translational Research (VICTR), Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joanna Stollings
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jin Ho Han
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center (GRECC), Veterans Affairs Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Joean O, Klooster MPV, Kayser MZ, Valtin C, Ewen R, Golpon H, Fühner T, Gottlieb J. Eine Querschnittsuntersuchung zur Qualität der Sauerstofftherapie in drei deutschen Krankenhäusern. Pneumologie 2022; 76:697-704. [DOI: 10.1055/a-1916-1505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Zusammenfassung
Einleitung Sauerstoff (O2) ist eines der am häufigsten angewendeten Arzneimittel in deutschen Krankenhäusern und im Rettungswesen. Sowohl eine Hypoxämie als auch eine Hyperoxämie sind mit Komplikationen vergesellschaftet. In Deutschland fehlen bislang belastbare Daten zur Anwendung, Dokumentation und Überwachung der O2-Therapie.
Methoden Eine Querschnittsstudie zur Sauerstoff-Anwendung wurde in 3 Krankenhäusern der maximalen bzw. supramaximalen Versorgung in Hannover im Herbst 2020 durchgeführt.
Ergebnisse Von 343 erfassten Patienten erhielten 20 % eine O2-Therapie. Bei 29 % der Patienten mit O2-Therapie bestand ein Hyperkapnie-Risiko. Lediglich bei 68 % Patienten mit einer O2-Therapie lag eine SOP zur O2-Anwendung auf den jeweiligen Stationen vor und nur bei 22 % entsprach die gegebene O2-Therapie dem tatsächlichen Bedarf des Patienten. Nur bei 30 % des Gesamtkollektivs und 41 % der Patienten mit O2-Therapie erfolgte eine vollständige Dokumentation der Vitalparameter. Eine Überwachung der O2-Therapie mittels arterieller oder kapillärer Blutgasanalyse (BGA) erfolgte bei 76 % der O2-Patienten. Hier zeigte sich bei 64 % der Patienten eine Normoxämie, bei 17 % eine Hyperoxämie und bei 19 % eine Hypoxämie. Der einzige identifizierbare Prediktor für eine adäquate O2-Therapie war eine vorangegangene Beatmungstherapie.
Diskussion Insgesamt zeigt sich eine suboptimale Indikationsstellung, Anwendung und Kontrolle der Sauerstofftherapie. Schulungen des pflegerischen und ärztlichen Personals zur Verbesserung der Anwendung der O2-Therapie und resultierend auch der Patientensicherheit sind dringend notwendig.
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Affiliation(s)
- Oana Joean
- Klinik für Pneumologie, Medizinische Hochschule Hannover
| | | | | | | | - Raphael Ewen
- Klinik für Pneumologie, Medizinische Hochschule Hannover
| | - Heiko Golpon
- Klinik für Pneumologie, Medizinische Hochschule Hannover
- Deutsches Zentrum für Lungenforschung (DZL), Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover
| | - Thomas Fühner
- Klinik für Pneumologie und Beatmungsmedizin, Krankenhaus Siloah, Klinikum Region Hannover
| | - Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover
- Deutsches Zentrum für Lungenforschung (DZL), Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover
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Mart MF, Sendagire C, Ely EW, Riviello ED, Twagirumugabe T. Oxygen as an Essential Medicine. Crit Care Clin 2022; 38:795-808. [PMID: 36162911 PMCID: PMC9417445 DOI: 10.1016/j.ccc.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental oxygen is an essential medication in critical care. The optimal oxygen dose delivery system remains unclear, however. The "dose" and "delivery" of oxygen carry significant importance for resource-limited settings, such as low- and middle-income countries (LMICs). Regrettably, LMICS often experience significant inequities in oxygen supply and demand, with major impacts on preventable mortality. These inequities have become particularly prominent during the global COVID-19 pandemic, highlighting the need for additional investment and research into the best methods to utilize supplemental oxygen and ensure stable access to medical oxygen.
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Affiliation(s)
- Matthew F Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21(st) Avenue South, Nashville, TN 37232, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4(th) Floor, Nashville, TN 37203, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, 1310 24(th) Avenue South, Nashville, TN 37212, USA
| | - Cornelius Sendagire
- Anesthesia and Critical Care, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda
| | - Eugene Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, 1161 21(st) Avenue South, Nashville, TN 37232, USA; Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, 2525 West End Avenue, Suite 450, 4(th) Floor, Nashville, TN 37203, USA; Geriatric Research, Education, and Clinical Center (GRECC), Tennessee Valley Healthcare System, 1310 24(th) Avenue South, Nashville, TN 37212, USA
| | - Elisabeth D Riviello
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
| | - Theogene Twagirumugabe
- Department of Anesthesiology, Kigali University Teaching Hospital, University of Rwanda, College of Medicine and Health Sciences, School of Medicine and Pharmacy, P.O. Box 3286 Kigali, Rwanda
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Bizuneh YB, Getahun YA, Melesse DY, Chekol WB. Assessment of knowledge, attitude, and factors associated with oxygen therapy for critically ill patients among nurses at the University of Gondar Comprehensive Specialized Hospital Northwest, Ethiopia, 2021. Ann Med Surg (Lond) 2022; 80:104334. [PMID: 35992207 PMCID: PMC9389197 DOI: 10.1016/j.amsu.2022.104334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/28/2022] [Accepted: 07/31/2022] [Indexed: 11/26/2022] Open
Abstract
Background Administering oxygen therapy has an essential role in preventing and managing hypoxemia in both acute and chronic conditions. The aim of this study was to assess knowledge, attitude and factors associated with oxygen therapy for critically ill patients among nurses. Methods An institutional-based cross-sectional study was conducted from May 23 to June 07 at the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia, in 2021. A self-administered, structured and validated questionnaire was used. It has socio-demographic characteristics, multiple choice questions, items that measure the possible associated factors and items that were used to assess the level of knowledge and attitude. Epi Data (“The EpiData Association” Odense, Denmark) version 4.6 was used to enter data, and SPSS (IBM) version 20 was used to analyze it. Both bivariate and multivariate logistic regression analyses were used to identify associated factors. Variables with a p value < 0.05 were considered statistically significant. Results The overall proportion of critically ill patients with good knowledge and a positive attitude toward oxygen therapy was 33% (95% CI: 25.8–37.8) and 53.8% (95% CI: 49–59), respectively. Age (AOR; 1.738, 95% CI: 1.034–2.921), level of education (AOR; 7.731, 95% CI: 2.507–23.846) and guideline (AOR; 4.338, 95% CI: 2.233–8.428) and good level of practice (AOR; 1.885, 95% CI: 1.173–3.030) were discovered to be significant factors associated with good knowledge towards oxygen therapy and the reading guideline was found to be a significant factor associated with a positive attitude toward oxygen therapy (AOR; 1.396, 95% CI: 0.830–2.348). Conclusions and recommendations: The level of knowledge was low, whereas the attitude of nurses was positive towards oxygen therapy. Reading guidelines, older aged nurses, master holder nurses, and good practice were significant factors associated with good knowledge of oxygen therapy, and reading guidelines was statistically associated with a positive attitude toward oxygen therapy. Thus, nurses need to be aware and skillful regarding the updated oxygen therapy guidelines. They should improve their level of education. To assess the level of knowledge and attitude of nurses on oxygen therapy in critically ill patients. An institutional-based cross-sectional survey study was conducted. The overall proportions of good knowledge and a positive attitude toward oxygen therapy were 33% and 53.8%, respectively. The level of knowledge was low, whereas the attitude of nurses was positive towards oxygen therapy.
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Seiler C, Kristiansson L, Klingberg C, Sundh J, Braman Eriksson A, Lundeqvist D, Nilsson KF, Hårdstedt M. Swimming-Induced Pulmonary Edema: Evaluation of Prehospital Treatment With CPAP or Positive Expiratory Pressure Device. Chest 2022; 162:410-420. [PMID: 35288117 PMCID: PMC9424325 DOI: 10.1016/j.chest.2022.02.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Swimming-induced pulmonary edema (SIPE) occasionally occurs during swimming in cold open water. Although optimal treatment for SIPE is unknown, non-invasive positive pressure ventilation (NPPV) is an option for prehospital treatment. RESEARCH QUESTION Is NPPV a feasible and safe prehospital treatment for SIPE, and which outcome measures reflect recovery after treatment? STUDY DESIGN AND METHODS A prospective observational study was conducted at Vansbrosimningen, Sweden's largest open water swimming event, from 2017 through 2019. Swimmers with a diagnosis of SIPE and with peripheral oxygen saturation (Spo2) of ≤ 95%, persistent respiratory symptoms, or both were eligible for the study. NPPV was administered on site as CPAP by facial mask or as positive expiratory pressure (PEP) by a PEP device. Discharge criteria were Spo2 of > 95% and clinical recovery. Four outcome measures were evaluated: Spo2, crackles on pulmonary auscultation, pulmonary edema on lung ultrasound (LUS), and patient-reported respiratory symptoms. RESULTS Of 119 treated individuals, 94 received CPAP, 24 received treatment with a PEP device, and one required tracheal intubation. In total, 108 individuals (91%) were discharged after NPPV for a median of 10 to 20 min and 11 individuals (9%) required hospital transfer. NPPV resulted in increased Spo2 from a median of 91% to 97% (P < .0001) together with improvement of six patient-reported respiratory symptoms (median numerical rating scales, 1-7 to 0-1; P < .0001). No significant decrease in auscultation of crackles (93% vs 87%; P = .508) or pulmonary edema on LUS (100% vs 97%; P = .500) was seen during NPPV treatment. INTERPRETATION NPPV administered as CPAP or via a PEP device proved feasible and safe as prehospital treatment for SIPE with a vast majority of patients discharged on site. Spo2 and patient-reported respiratory symptoms reflected recovery after treatment, whereas pulmonary auscultation or LUS findings did not.
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Affiliation(s)
- Claudia Seiler
- Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Sweden; Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Linda Kristiansson
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Sandviken North Primary Health Care Center, Sandviken, Sweden; Center for Research and Development, Uppsala University/Region Gävleborg, Gävle, Sweden
| | - Cecilia Klingberg
- Department of Anesthesiology and Intensive Care, Falun Hospital, Falun, Sweden
| | - Josefin Sundh
- Department of Respiratory Medicine, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | | | | | - Kristofer F Nilsson
- Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Maria Hårdstedt
- Center for Clinical Research Dalarna-Uppsala University, Falun, Sweden; School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden; Vansbro Primary Health Care Center, Vansbro, Sweden
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Joean O, vanʼt Klooster MP, Kayser MZ, Valtin C, Ewen R, Golpon H, Fühner T, Gottlieb J. [A cross-sectional study in three German hospitals regarding oxygen therapy characteristics]. Dtsch Med Wochenschr 2022; 147:62-69. [PMID: 35868312 PMCID: PMC9307294 DOI: 10.1055/a-1821-5994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Oxygen (O2) therapy is one of the most commonly applied medications in German hospitals and rescue services. Both hypoxemia and hyperoxemia can be associated with complications. There is currently a lack of reliable data on the use, documentation and surveillance of O2-therapy in German hospitals. METHODS We conducted a cross-sectional study on the use of O2 in three hospitals in Hannover, Germany. RESULTS Of 343 patients included in this study, 20 % received O2 therapy. Twenty-nine percent of patients receiving O2 were at increased risk for hypercapnia. A standard operating procedure (SOP) for O2 therapy was available in only 68 % of patients. In 22 % patients the applied O2-therapy was appropriate in the context of the documented vital parameters. A complete documentation of vital parameters was conducted in only 30 % of all patients and 41 % of patients receiving O2-therapy. A surveillance of O2-therapy using capillary or arterial blood gas analysis was performed in 76 % of patients. Here, 64 % of patients showed normoxemia, 17 % showed hyperoxemia and 19 % of patients showed hypoxemia. The only identifiable predictor for an adequate O2-therapy was a previous invasive ventilation. DISCUSSION Our data point towards and inadequate prescription, application and documentation of O2 therapy. The recently released German S3-guideline should be used to increase awareness among physicians and nursing staff regarding the use of O2-therapy to improve O2 therapy and consequently patient safety.
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Affiliation(s)
- Oana Joean
- Klinik für Pneumologie, Medizinische Hochschule Hannover
| | | | | | | | - Raphael Ewen
- Klinik für Pneumologie, Medizinische Hochschule Hannover
| | - Heiko Golpon
- Klinik für Pneumologie, Medizinische Hochschule Hannover
- Deutsches Zentrum für Lungenforschung (DZL), Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover
| | - Thomas Fühner
- Klinik für Pneumologie und Beatmungsmedizin, Krankenhaus Siloah, Klinikum Region Hannover
| | - Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover
- Deutsches Zentrum für Lungenforschung (DZL), Biomedical Research in End-Stage and Obstructive Lung Disease (BREATH), Hannover
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Lockstone J, Parry S, Denehy L, Robertson I, Story D, Boden I. Non-Invasive Positive airway Pressure thErapy to Reduce Postoperative Lung complications following Upper abdominal Surgery (NIPPER PLUS): a pilot randomised control trial. Physiotherapy 2022; 117:25-34. [DOI: 10.1016/j.physio.2022.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 05/18/2022] [Accepted: 06/07/2022] [Indexed: 12/11/2022]
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Hassanzad M, Ghaffaripour H, Rekabi M, Mirzendehdel M, Sadati E, Elahimehr N, Derakhshanfar H. Nurses' Knowledge Regarding Oxygen Therapy; a Cross-Sectional Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e38. [PMID: 35765611 PMCID: PMC9187132 DOI: 10.22037/aaem.v10i1.1553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction Oxygen therapy, if done correctly, can save patients' life promptly. However, improper use will be just as dangerous. The present study aimed to investigate the level of nurses' knowledge on properly using oxygen. Method This was a cross-sectional study with a minimum sample size of 72 nurses who were randomly selected from various wards of Masih Daneshvari Hospital, Tehran, Iran. To determine the level of knowledge about oxygen therapy, a questionnaire was used to collect data. This questionnaire consists of seven items, each of which is designed to determine the level of the individual's knowledge about the various details of oxygen therapy. Results Seventy-eight nurses with the mean age of 35.80±7.42 years participated in the study (87% female). The mean knowledge score of nurses regarding oxygen therapy was 8.89 ± 2.79 out of 16 points. 84.6% of the nurses were able to differentiate various types of oxygen masks. Accordingly, 94.9% of nurses had good knowledge on oxygen humidification. Also, 50% of the nurses had sufficient knowledge about the amount of oxygen flow produced by different masks. 10.3% of the nurses could choose the most appropriate mask for different clinical conditions. 6.4% of the nurses had knowledge of working with flowmeters, and 15.4% of the nurses had sufficient information about the maximum level of oxygen required for the patient. 17.9% of the nurses were familiar with measuring the appropriate amount of oxygen for patients. There was no statistically significant relationship between age (p = 0.57), gender (p = 0.09), employment status (p = 0.38), workplace (p = 0.86), current position (p = 0.11), degree (p = 0.27), and graduation time (p = 0.58) of nurses with good knowledge of using oxygen. However, a statistically significant relationship was reported between nurses' related work experience and their knowledge of the proper use of oxygen (p = 0.03). Conclusion In general, the nurses' knowledge at Masih Daneshvari Hospital on how to properly use oxygen is at a moderate level. Nurses' knowledge in some areas, such as working with the flowmeter, choosing the suitable mask for specific clinical conditions, and the maximum oxygen required for patients, is meager and requires training intervention.
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Affiliation(s)
- Maryam Hassanzad
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hosseinali Ghaffaripour
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Rekabi
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Mirzendehdel
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Sadati
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasrin Elahimehr
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hojjat Derakhshanfar
- Pediatric Respiratory Disease Research Center, NRITLD, Masih Daneshvari Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. ,Corresponding author: Hojjat Derakhshanfar; Mofid Children’s Hospital, Shariati Ave, Tehran, Iran. Mahsa Mirzendehdel. Tel: +982122227033, ORCID: 0000-0002-9114-7491
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Li T, Zhou D, Zhao D, Lin Q, Wang D, Wang C, Zhang R. Impact of Oxygen Saturation on Mortality in Obese and Non-obese Critically Ill Patients With Mechanical Ventilation: A Retrospective Observational Study. Front Med (Lausanne) 2022; 9:839787. [PMID: 35492310 PMCID: PMC9051400 DOI: 10.3389/fmed.2022.839787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The main aim of this study was to evaluate the effect of oxygen saturation on mortality in critically ill patients with mechanical ventilation according to obesity status. Methods We conducted an observational study in mechanically ventilated patients admitted to the ICU retrospectively. Demographic, arterial blood gas, ventilator setting, interventions, and peripheral oxygen saturation (Spo2) during the first 24 h were recorded and analyzed between non-obese and obese patients. The main exposure included Spo2, time-weighted mean Spo2 (TWM-Spo2), and proportion of time spent in different Spo2 (PTS-Spo2) levels. The primary outcome was hospital mortality. We used multivariable logistic regression models to assess the relationship between Spo2 and mortality, as well as the interaction between PTS-Spo2 and obesity status. Results A total of 25,100 patients were included, of which 10,564 (42%) were obese patients. After adjusting for confounders, compared with TWM-Spo2 of 94–98%, TWM-Spo2 of < =88% (OR 3.572; CI [2.343, 5.455]; p < 0.001) and of 89–93% (OR 1.514; CI [1.343, 1.706]; p < 0.001) were both associated with higher risk of mortality. PTS-Spo2 of 99–100% was associated with increased risk of mortality for obese patients (OR 1.028; 95% CI 1.010–1.046; p = 0.002; Pinteraction = 0.001), while PTS-Spo2 of 89–93% was associated with increased risk of mortality (OR 1.089; 95% CI 1.051–1.128; p < 0.001; Pinteraction = 0.001) for non-obese patients. Conclusions For obese and non-obese critically ill patients with mechanical ventilation, the impact of oxygen saturation on hospital mortality is different.
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Coker RK, Armstrong A, Church AC, Holmes S, Naylor J, Pike K, Saunders P, Spurling KJ, Vaughn P. BTS Clinical Statement on air travel for passengers with respiratory disease. Thorax 2022; 77:329-350. [PMID: 35228307 PMCID: PMC8938676 DOI: 10.1136/thoraxjnl-2021-218110] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Robina Kate Coker
- Respiratory Medicine, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Alison Armstrong
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | | | - Katharine Pike
- Department of Paediatric Respiratory Medicine, Bristol Royal Hospital for Children, Bristol, UK
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Getahun YA, Bizuneh YB, Melesse DY, Chekol WB. Assessment of practice and barriers of oxygen therapy in critically ill patients among nurses: A survey from University of Gondar Comprehensive Specialized Hospital Northwest, Ethiopia, 2021. Ann Med Surg (Lond) 2022; 76:103481. [PMID: 35313541 PMCID: PMC8933666 DOI: 10.1016/j.amsu.2022.103481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/02/2022] [Accepted: 03/06/2022] [Indexed: 11/29/2022] Open
Affiliation(s)
- Yayeh Adamu Getahun
- Department of Anesthesia, College of Medicine and Health Sciences, Dilla University, Ethiopia
| | - Yosef Belay Bizuneh
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Ethiopia
- Corresponding author.
| | - Debas Yaregal Melesse
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Ethiopia
| | - Wubie Birlie Chekol
- Department of Anesthesia, College of Medicine and Health Sciences, University of Gondar, Ethiopia
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Abstract
Opioid-induced ventilatory impairment is the primary mechanism of harm from opioid use. Opioids suppress the activity of the central respiratory centres and are sedating, leading to impairment of alveolar ventilation.Respiratory physiological changes induced with acute opioid use include depression of the hypercapnic ventilatory response and hypoxic ventilatory response. In chronic opioid use a compensatory increase in hypoxic ventilatory response maintains ventilation and contributes to the onset of sleep-disordered breathing patterns of central sleep apnoea and ataxic breathing. Supplemental oxygen use in those at risk of opioid-induced ventilatory impairment requires careful consideration by the clinician to prevent failure to detect hypoventilation, if oximetry is being relied on, and the overriding of hypoxic ventilatory drive. Obstructive sleep apnoea and opioid-induced ventilatory impairment are frequently associated, with this interrelationship being complex and often unpredictable. Monitoring the patient for opioid-induced ventilatory impairment poses challenges in the areas of reliability, avoidance of alarm fatigue, cost, and personnel demands. Many situations remain in which patients cannot be provided effective analgesia without opioids, and for these the clinician requires a comprehensive knowledge of opioid-induced ventilatory impairment.
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Affiliation(s)
- Gavin G Pattullo
- Department of Anaesthesia and Pain Management, Royal North Shore Hospital, St Leonards, Australia
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40
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Abstract
Misuse of prescription opioids forced an inevitable response from authorities to intervene with consequences felt by all.In the Australian community one person will die for approximately every 3600 adults prescribed opioids, while in the hospital setting a postoperative patient managed primarily with opioids, as opposed to epidural analgesia, has an additional risk of death as high as between one in 56 to 477.Opioids maintain a valid role in acute pain management when use is reasoned and with full awareness of the harms and how they are to be avoided, such as in those at risk of ongoing use, the opioid naïve, and when opioid-induced ventilatory impairment may occur.Clinicians managing acute pain can focus on assessing pain versus nociception, strategically apply antinociceptive medications and neural blockade when indicated, assess pain with an emphasis on the degree of bothersomeness and functional impairment and, finally, optimise the use of framing and placebo-enhancing communication to minimise reliance on medications.
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Affiliation(s)
- Gavin G Pattullo
- Department of Anaesthesia and Pain Management, Royal North Shore Hospital, St Leonards, Australia
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Crescioli E, Uldal Krejberg K, Lass Klitgaard T, Mølgaard Nielsen F, Barbateskovic M, Skrubbeltrang C, Hylander Møller M, Lilleholt Schjørring O, Steen Rasmussen B. The long-term effects of lower versus higher oxygenation levels in adult ICU patients - protocol for a systematic review. Acta Anaesthesiol Scand 2022; 66:145-151. [PMID: 34570915 PMCID: PMC8652878 DOI: 10.1111/aas.13984] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 09/20/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Many organs can remain impaired after discharge from the intensive care unit (ICU) leading to temporal or permanent dysfunctions. Long-term impairments may be affected by supplemental oxygen, a common treatment in ICU, having both potential beneficial and harmful long-lasting effects. This systematic review aims to assess the long-term outcomes of lower versus higher oxygen supplementation and/or oxygenation levels in adults admitted to ICU. METHODS We will include trials differentiating between a lower and a higher oxygen supplementation or a lower and a higher oxygenation strategy in adults admitted to the ICU. We will search major electronic databases and trial registers for randomised clinical trials. Two authors will independently screen and select references for inclusion using Covidence and predefined data will be extracted. The methodological quality and risk of bias of included trials will be evaluated using the Cochrane Risk of Bias tool 2. Meta-analysis will be performed if two or more trials with comparable outcome measures will be included. Otherwise, a narrative description of the trials' results will be presented instead. To assess the certainty of evidence, we will create a 'Summary of findings' table containing all prespecified outcomes using the GRADE system. The protocol is submitted on the PROSPERO database (ID 223630). CONCLUSION No systematic reviews on the impact of oxygen treatment in the ICU on long-term outcomes, other than mortality and quality of life, have been reported yet. This systematic review will provide an overview of the current evidence and will help future research in the field.
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Affiliation(s)
- Elena Crescioli
- Department of Anaesthesia and Intensive CareAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Collaboration for Research in Intensive CareCopenhagenDenmark
| | | | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive CareAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive CareAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Marija Barbateskovic
- Copenhagen Trial UnitCentre for Clinical Intervention ResearchCapital Region of DenmarkDenmark
| | | | - Morten Hylander Møller
- Collaboration for Research in Intensive CareCopenhagenDenmark
- Department of Intensive Care, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive CareAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Collaboration for Research in Intensive CareCopenhagenDenmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive CareAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Collaboration for Research in Intensive CareCopenhagenDenmark
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Doan V, Liu Y, Teeter EG, Smeltz AM, Vavalle JP, Kumar PA, Kolarczyk LM. Propofol Versus Remifentanil Sedation for Transcatheter Aortic Valve Replacement: A Single Academic Center Experience. J Cardiothorac Vasc Anesth 2022; 36:103-108. [PMID: 34074554 PMCID: PMC8563487 DOI: 10.1053/j.jvca.2021.04.038] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/23/2021] [Accepted: 04/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Comparison of remifentanil versus propofol for sedation during transcatheter aortic valve replacement (TAVR) procedures to analyze the risk of sedation-related hypoxemia and hypotension. Secondary outcomes included the rate of conversion to general anesthesia, procedure length, rate of intensive care unit (ICU) admission, ICU and hospital lengths of stay, and 30-day mortality. DESIGN Retrospective cohort study. SETTING A single tertiary teaching hospital. PARTICIPANTS Two hundred fifty-nine patients who had propofol or remifentanil sedation for TAVR between March 2017 and March 2020. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS There were 130 patients (50.2%) in the propofol cohort and 129 patients (49.8%) in the remifentanil cohort. The primary outcomes were oxygen saturation nadir values and vasopressor infusion use. Remifentanil was associated with a lower oxygen saturation nadir, as compared to propofol (91.3% v . 95.4%, p < 0.001). Risk factors associated with hypoxemia (defined as <92%) were body mass index (p = 0.0004), obstructive sleep apnea (p = 0.004), and remifentanil maintenance (p < 0.001). Vasopressor infusion use was significantly higher with propofol (64.9% v . 8.5%, p < 0.001). Propofol maintenance and angiotensin-converting enzyme inhibitor/angiotensin II receptor-blocker use were the only variables identified as risk factors for vasopressor use (p < 0.001 and p = 0.009). CONCLUSIONS For patients undergoing TAVR with conscious sedation, remifentanil was associated with more hypoxemia while propofol was associated with a higher rate of vasopressor use.
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Affiliation(s)
- Vivian Doan
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - Yutong Liu
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599
| | - Emily G. Teeter
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - Alan M. Smeltz
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - John P. Vavalle
- Division of Cardiology, Department of Medicine, University of North Carolina Hospitals, Chapel Hill, NC 27599
| | - Priya A. Kumar
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599,Outcomes Research Consortium, Cleveland, OH 44103
| | - Lavinia M. Kolarczyk
- Department of Anesthesiology, University of North Carolina Hospitals, Chapel Hill, NC 27599
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Imtiaz MS, Bandoian CV, Santoro TJ. Hypoxia driven opioid targeted automated device for overdose rescue. Sci Rep 2021; 11:24513. [PMID: 34972818 PMCID: PMC8720093 DOI: 10.1038/s41598-021-04094-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 12/13/2021] [Indexed: 11/27/2022] Open
Abstract
Opioid use disorder has been designated a worsening epidemic with over 100,000 deaths due to opioid overdoses recorded in 2021 alone. Unintentional deaths due to opioid overdoses have continued to rise inexorably. While opioid overdose antidotes such as naloxone, and nalmefene are available, these must be administered within a critical time window to be effective. Unfortunately, opioid-overdoses may occur in the absence of antidote, or may be unwitnessed, and the rapid onset of cognitive impairment and unconsciousness, which frequently accompany an overdose may render self-administration of an antidote impossible. Thus, many lives are lost because: (1) an opioid overdose is not anticipated (i.e., monitored/detected), and (2) antidote is either not present, and/or not administered within the critical frame of effectiveness. Currently lacking is a non-invasive means of automatically detecting, reporting, and treating such overdoses. To address this problem, we have designed a wearable, on-demand system that comprises a safe, compact, non-invasive device which can monitor, and effectively deliver an antidote without human intervention, and report the opioid overdose event. A novel feature of our device is a needle-stow chamber that stores needles in a sterile state and inserts needles into tissue only when drug delivery is needed. The system uses a microcontroller which continuously monitors respiratory status as assessed by reflex pulse oximetry. When the oximeter detects the wearer’s percentage of hemoglobin saturated with oxygen to be less than or equal to 90%, which is an indication of impending respiratory failure in otherwise healthy individuals, the microcontroller initiates a sequence of events that simultaneously results in the subcutaneous administration of opioid antidote, nalmefene, and transmission of a GPS-trackable 911 alert. The device is compact (4 × 3 × 3 cm), adhesively attaches to the skin, and can be conveniently worn on the arm. Furthermore, this device permits a centralized remotely accessible system for effective institutional, large-scale intervention. Most importantly, this device has the potential for saving lives that are currently being lost to an alarmingly increasing epidemic.
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Semler MW, Casey JD, Lloyd BD, Hastings PG, Hays M, Roth M, Stollings J, Brems J, Buell KG, Wang L, Lindsell CJ, Freundlich RE, Wanderer JP, Bernard GR, Self WH, Rice TW. Protocol and statistical analysis plan for the Pragmatic Investigation of optimaL Oxygen Targets (PILOT) clinical trial. BMJ Open 2021; 11:e052013. [PMID: 34711597 PMCID: PMC8557284 DOI: 10.1136/bmjopen-2021-052013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 10/12/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Mechanical ventilation of intensive care unit (ICU) patients universally involves titration of the fraction of inspired oxygen to maintain arterial oxygen saturation (SpO2). However, the optimal SpO2 target remains unknown. METHODS AND ANALYSIS The Pragmatic Investigation of optimaL Oxygen Targets (PILOT) trial is a prospective, unblinded, pragmatic, cluster-crossover trial being conducted in the emergency department (ED) and medical ICU at Vanderbilt University Medical Center in Nashville, Tennessee, USA. PILOT compares use of a lower SpO2 target (target 90% and goal range: 88%-92%), an intermediate SpO2 target (target 94% and goal range: 92%-96%) and a higher SpO2 target (target 98% and goal range: 96%-100%). The study units are assigned to a single SpO2 target (cluster-level allocation) for each 2-month study block, and the assigned SpO2 target switches every 2 months in a randomly generated sequence (cluster-level crossover). The primary outcome is ventilator-free days (VFDs) to study day 28, defined as the number of days alive and free of invasive mechanical ventilation from the final receipt of invasive mechanical ventilation through 28 days after enrolment. ETHICS AND DISSEMINATION The trial was approved by the Vanderbilt Institutional Review Board. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBER The trial protocol was registered with ClinicalTrials.gov on 25 May 2018 prior to initiation of patient enrolment (ClinicalTrials.gov identifier: NCT03537937).
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Affiliation(s)
- Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Bradley D Lloyd
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pamela G Hastings
- Division of Respiratory Care, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Margaret Hays
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Megan Roth
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Joanna Stollings
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - John Brems
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kevin George Buell
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Schoool of Medicine, Nashville, TN, USA
| | - Christopher J Lindsell
- Department of Biostatistics, Vanderbilt University Schoool of Medicine, Nashville, TN, USA
| | - Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gordon R Bernard
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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45
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Harper JCP, Semprini R, Kearns NA, Hatter L, Bird GE, Braithwaite I, Eathorne A, Weatherall M, Beasley R. Determination of oxygen saturation compared to a prescribed target range using continuous pulse oximetry in acutely unwell medical patients. BMC Pulm Med 2021; 21:332. [PMID: 34702236 PMCID: PMC8546386 DOI: 10.1186/s12890-021-01700-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 10/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Both inadequate and excessive administration of oxygen to acutely unwell patients results in risk of harm. Guidelines recommend titration of oxygen to achieve a target oxygen saturation (SpO2) range. Information regarding whether this is being achieved is limited. METHODS In this two-centre non-interventional study we used continuous pulse oximetry in acutely unwell medical patients over a 24-h period to determine the proportion of time spent with SpO2 within the prescribed target range and whether this is influenced by the target range, age, care in a high-dependency area and the number of oxygen adjustments. RESULTS Eighty participants were included in the analysis. The mean (SD) proportion of time spent in target range was 55.6% (23.6), this was lower in those with a reduced hypercapnic target range (88-92% or below) compared to those with a range of 92-96%; difference - 13.1% (95% CI - 3.0 to - 23.2), P = 0.012. The proportion of time spent above range was 16.2% (22.9); this was higher in those with a reduced hypercapnic range; difference 21.6% (31.4 to 12), P < 0.001. The proportion of time below range was 28.4% (25.2); there was no difference between target ranges. The proportion of time spent in range was higher for those in a high dependency area in the multivariate model; difference 15.5% (95% CI 2.3 to 28.7), P = 0.02. CONCLUSIONS Medical patients receiving oxygen in a ward setting spend significant periods of time with SpO2 both above and below the prescribed target range while receiving oxygen therapy.
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Affiliation(s)
- James C P Harper
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand.
- Victoria University, Wellington, New Zealand.
- Capital & Coast District Health Board, Wellington, New Zealand.
| | - Ruth Semprini
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
- Hutt Valley District Health Board, Wellington, New Zealand
| | - Nethmi A Kearns
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Lee Hatter
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Grace E Bird
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
- Victoria University, Wellington, New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Irene Braithwaite
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | - Allie Eathorne
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
| | | | - Richard Beasley
- Medical Research Institute of New Zealand, Private Bag 7902, Newtown, Wellington, 6242, New Zealand
- Victoria University, Wellington, New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
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46
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Yu C, Miller BR. Oxygen therapy target ranges: finding the balance. Eur Respir J 2021; 58:58/3/2101023. [PMID: 34598975 DOI: 10.1183/13993003.01023-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 05/17/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Christiaan Yu
- Dept of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | - Belinda R Miller
- Dept of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia .,Dept of Medicine, Central and Eastern Clinical School, Monash University, Melbourne, Australia
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47
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Liu L, Tian Y. Liberal or conservative oxygen therapy for ventilated patients in the ICU: a meta-analysis of randomized controlled trials. J Cardiothorac Surg 2021; 16:261. [PMID: 34526060 PMCID: PMC8441241 DOI: 10.1186/s13019-021-01634-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/29/2021] [Indexed: 02/08/2023] Open
Abstract
Background The acknowledgment that conservative oxygen therapy (COT) was related to better prognosis in the intensive care unit (ICU) was challenged recently. We conducted an updated meta-analysis aimed to determine whether liberal oxygen therapy (LOT) or COT is associated with better improve clinical outcomes. Methods We systematically searched the electronic databases (PubMed, Web of Science and Embase) up to May 2021 for randomized controlled trials (RCTs). The primary outcome was the mortality of the final follow-up time and secondary outcomes were ICU mortality, the ICU length of stay and the number of ventilator-free days. Results A total of 7 RCTs were included, with 2166 patients admitted to the ICU. There was no significant difference in the primary outcome between the LOT and COT. Additionally, LOT could not significantly increase ICU mortality and the ICU length of stay compared with COT. Conclusions The present study showed that COT was not significantly superior to LOT in clinical outcomes. Therefore, additional high-quality studies with novel designs are required to further elucidate this controversy.
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Affiliation(s)
- Lu Liu
- Department of Anesthesiology, West China Hospital/West China School of Nursing, Sichuan University, Chengdu, 610041, China
| | - Yali Tian
- West China School of Nursing, Sichuan University/West China Hospital, Sichuan University, Chengdu, 610041, China.
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48
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Young PJ, Frei D. Oxygen therapy for critically Ill and post-operative patients. J Anesth 2021; 35:928-938. [PMID: 34490494 PMCID: PMC8420843 DOI: 10.1007/s00540-021-02996-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/28/2021] [Indexed: 11/02/2022]
Abstract
Nearly all patients receiving treatment in a peri-operative or intensive care setting receive supplemental oxygen therapy. It is biologically plausible that the dose of oxygen used might affect important patient outcomes. Most peri-operative research has focussed on oxygen regimens that target higher than normal blood oxygen levels. Whereas, intensive care research has mostly focussed on conservative oxygen regimens which assiduously avoid exposure to higher than normal blood oxygen levels. While such conservative oxygen therapy is preferred for spontaneously breathing patients with chronic obstructive pulmonary disease, the optimal oxygen regimen in other patient groups is not clear. Some data suggest that conservative oxygen therapy might be preferred for patients with hypoxic ischaemic encephalopathy. However, unless oxygen supplies are constrained, routinely aggressively down-titrating oxygen in either the peri-operative or intensive care setting is not necessary based on available data. Targeting higher than normal levels of oxygen might reduce surgical site infections in the perioperative setting and/or improve outcomes for intensive care patients with sepsis but further research is required and available data are not sufficiently strong to warrant routine implementation of such oxygen strategies.
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Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand. .,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand. .,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
| | - Daniel Frei
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.,Department of Anaesthesia, Wellington Regional Hospital, Wellington, New Zealand
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49
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Cajanding R. Oxygen use and saturation targets in patients with COVID-19: Are we giving too much or aiming too low? Nurs Crit Care 2021; 27:282-285. [PMID: 34476873 PMCID: PMC8661992 DOI: 10.1111/nicc.12709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 08/14/2021] [Indexed: 01/15/2023]
Affiliation(s)
- Ruff Cajanding
- Adult Critical Care Unit, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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50
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, König M, Markewitz A, Nothacker M, Roiter S, Unverzagt S, Veit W, Volk T, Witt C, Wildenauer R, Worth H, Fühner T. [German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]. Pneumologie 2021; 76:159-216. [PMID: 34474487 DOI: 10.1055/a-1554-2625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
| | - Philipp Capetian
- Klinik für Neurologie, Neurologische Intensivstation, Universitätsklinikum Würzburg
| | - Uwe Hamsen
- Fachbereich für Unfallchirurgie und Orthopädie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | - Uwe Janssens
- Innere Medizin und internistische Intensivmedizin, Sankt Antonius Hospital GmbH, Eschweiler
| | - Christian Karagiannidis
- Abteilung für Pneumologie und Beatmungsmedizin, ARDS/ECMO Zentrum, Lungenklinik Köln-Merheim
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg
| | - Marco König
- Deutscher Berufsverband Rettungsdienst e. V., Lübeck
| | - Andreas Markewitz
- ehem. Klinik für Herz- und Gefäßchirurgie Bundeswehrzentralkrankenhaus Koblenz
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg
| | | | | | - Wolfgang Veit
- Bundesverband der Organtransplantierten e. V., Marne
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Witt
- Seniorprofessor Innere Medizin und Pneumologie, Charité Berlin
| | | | | | - Thomas Fühner
- Krankenhaus Siloah, Klinik für Pneumologie und Beatmungsmedizin, Klinikum Region Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
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