1
|
Robba C, Badenes R, Battaglini D, Ball L, Sanfilippo F, Brunetti I, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Martin A, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Grejs AM, Ebner F, Pelosi P. Oxygen targets and 6-month outcome after out of hospital cardiac arrest: a pre-planned sub-analysis of the targeted hypothermia versus targeted normothermia after Out-of-Hospital Cardiac Arrest (TTM2) trial. Crit Care 2022; 26:323. [PMID: 36271410 PMCID: PMC9585831 DOI: 10.1186/s13054-022-04186-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Optimal oxygen targets in patients resuscitated after cardiac arrest are uncertain. The primary aim of this study was to describe the values of partial pressure of oxygen values (PaO2) and the episodes of hypoxemia and hyperoxemia occurring within the first 72 h of mechanical ventilation in out of hospital cardiac arrest (OHCA) patients. The secondary aim was to evaluate the association of PaO2 with patients' outcome. METHODS Preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after OHCA (TTM2) trial. Arterial blood gases values were collected from randomization every 4 h for the first 32 h, and then, every 8 h until day 3. Hypoxemia was defined as PaO2 < 60 mmHg and severe hyperoxemia as PaO2 > 300 mmHg. Mortality and poor neurological outcome (defined according to modified Rankin scale) were collected at 6 months. RESULTS 1418 patients were included in the analysis. The mean age was 64 ± 14 years, and 292 patients (20.6%) were female. 24.9% of patients had at least one episode of hypoxemia, and 7.6% of patients had at least one episode of severe hyperoxemia. Both hypoxemia and hyperoxemia were independently associated with 6-month mortality, but not with poor neurological outcome. The best cutoff point associated with 6-month mortality for hypoxemia was 69 mmHg (Risk Ratio, RR = 1.009, 95% CI 0.93-1.09), and for hyperoxemia was 195 mmHg (RR = 1.006, 95% CI 0.95-1.06). The time exposure, i.e., the area under the curve (PaO2-AUC), for hyperoxemia was significantly associated with mortality (p = 0.003). CONCLUSIONS In OHCA patients, both hypoxemia and hyperoxemia are associated with 6-months mortality, with an effect mediated by the timing exposure to high values of oxygen. Precise titration of oxygen levels should be considered in this group of patients. TRIAL REGISTRATION clinicaltrials.gov NCT02908308 , Registered September 20, 2016.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain
- Department of Surgery, University of Valencia, Valencia, Spain
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Lorenzo Ball
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. "Policlinico-San Marco", Catania, Italy
| | - Iole Brunetti
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Malmö, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Pedro David Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - 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
| | - Glenn Eastwood
- 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 Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Unden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Lund University, Halland, Sweden
| | - Matthew Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | | | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Centre for Resuscitation Science, Karolinska Institutet, Solna, Sweden
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Manoj Saxena
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Annborn Martin
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic
- Department of Internal Medicine - Cardioangiology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Brussels, Belgium
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Anders Morten Grejs
- Department of Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Florian Ebner
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Helsingborg Hospital, Lund University, 251 87, Helsingborg, Sweden
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| |
Collapse
|
3
|
Robba C, Badenes R, Battaglini D, Ball L, Brunetti I, Jakobsen JC, Lilja G, Friberg H, Wendel-Garcia PD, Young PJ, Eastwood G, Chew MS, Unden J, Thomas M, Joannidis M, Nichol A, Lundin A, Hollenberg J, Hammond N, Saxena M, Annborn M, Solar M, Taccone FS, Dankiewicz J, Nielsen N, Pelosi P. Ventilatory settings in the initial 72 h and their association with outcome in out-of-hospital cardiac arrest patients: a preplanned secondary analysis of the targeted hypothermia versus targeted normothermia after out-of-hospital cardiac arrest (TTM2) trial. Intensive Care Med 2022; 48:1024-1038. [PMID: 35780195 PMCID: PMC9304050 DOI: 10.1007/s00134-022-06756-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/24/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The optimal ventilatory settings in patients after cardiac arrest and their association with outcome remain unclear. The aim of this study was to describe the ventilatory settings applied in the first 72 h of mechanical ventilation in patients after out-of-hospital cardiac arrest and their association with 6-month outcomes. METHODS Preplanned sub-analysis of the Target Temperature Management-2 trial. Clinical outcomes were mortality and functional status (assessed by the Modified Rankin Scale) 6 months after randomization. RESULTS A total of 1848 patients were included (mean age 64 [Standard Deviation, SD = 14] years). At 6 months, 950 (51%) patients were alive and 898 (49%) were dead. Median tidal volume (VT) was 7 (Interquartile range, IQR = 6.2-8.5) mL per Predicted Body Weight (PBW), positive end expiratory pressure (PEEP) was 7 (IQR = 5-9) cmH20, plateau pressure was 20 cmH20 (IQR = 17-23), driving pressure was 12 cmH20 (IQR = 10-15), mechanical power 16.2 J/min (IQR = 12.1-21.8), ventilatory ratio was 1.27 (IQR = 1.04-1.6), and respiratory rate was 17 breaths/minute (IQR = 14-20). Median partial pressure of oxygen was 87 mmHg (IQR = 75-105), and partial pressure of carbon dioxide was 40.5 mmHg (IQR = 36-45.7). Respiratory rate, driving pressure, and mechanical power were independently associated with 6-month mortality (omnibus p-values for their non-linear trajectories: p < 0.0001, p = 0.026, and p = 0.029, respectively). Respiratory rate and driving pressure were also independently associated with poor neurological outcome (odds ratio, OR = 1.035, 95% confidence interval, CI = 1.003-1.068, p = 0.030, and OR = 1.005, 95% CI = 1.001-1.036, p = 0.048). A composite formula calculated as [(4*driving pressure) + respiratory rate] was independently associated with mortality and poor neurological outcome. CONCLUSIONS Protective ventilation strategies are commonly applied in patients after cardiac arrest. Ventilator settings in the first 72 h after hospital admission, in particular driving pressure and respiratory rate, may influence 6-month outcomes.
Collapse
Affiliation(s)
- Chiara Robba
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clínic Universitari de Valencia, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain
| | - Denise Battaglini
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Lorenzo Ball
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Iole Brunetti
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Skåne University Hospital, Lund University, Getingevägen 4, 222 41, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences Lund, Anesthesia and Intensive Care, Lund University, Lund, Sweden
| | - Pedro D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100, 8091, Zurich, Switzerland
| | - 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
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Johan Unden
- Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.,Department of Operation and Intensive Care, Lund University, Hallands Hospital Halmstad, Halland, Sweden
| | - Matthew Thomas
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | | | - Andreas Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 423 45, Gothenburg, Sweden
| | - Jacob Hollenberg
- Department of Medicine, Centre for Resuscitation Science, Karolinska Institutet, Södersjukhuset Sjukhusbacken 10, Solna, 118 83, Stockholm, Sweden
| | - Naomi Hammond
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Critical Care Division, The George Institute for Global Health, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Manoj Saxena
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - Martin Annborn
- Department of Clinical Medicine, Anaesthesiology and Intensive Care, Lund University, Lund, Sweden
| | - Miroslav Solar
- Department of Internal Medicine, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czech Republic.,Department of Internal Medicine-Cardioangiology, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Fabio S Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Brussels, Belgium
| | - Josef Dankiewicz
- Department of Clinical Sciences Lund, Cardiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Niklas Nielsen
- Department of Clinical Sciences Lund, Anaesthesia and Intensive Care and Clinical Sciences Helsingborg, Helsingborg Hospital, Lund University, Lund, Sweden
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | | |
Collapse
|