Jeffrey Wang, Apoorva Gangavelli, Joseph E Tonna, J Trent Magruder, Akram M Zaaqoq, Suraj Yalamuri, P Elliott Miller, Jacob C Jentzer
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End-organ complications were analyzed using multivariate logistic regression models, and causal mediation analysis was performed to estimate the direct and indirect effects of hyperoxia on mortality.</p><p><strong>Setting: </strong>Multicenter, multinational prospective cohort study.</p><p><strong>Patients: </strong>Adults with CS supported on VA-ECMO.</p><p><strong>Interventions: </strong>Partial pressure of oxygen at 24 hours after VA-ECMO cannulation.</p><p><strong>Measurements/main results: </strong>A total of 10,541 patients were included (normoxia: 48.4%, mild hyperoxia: 30.0%, severe hyperoxia: 21.5%). There was higher in-hospital mortality in patients with severe hyperoxia (71.7%, adjusted OR [aOR]: 2.17; 95% CI, 1.19-2.50) and mild hyperoxia (63.8%, aOR: 1.34; 95% CI, 1.19-1.50) compared normoxia (52.7%; referent group). Severe hyperoxia was associated with more end-organ complications, which incrementally predicted higher mortality (aOR: 1.42; 95% CI, 1.25-1.61). Mediation analysis demonstrated that hyperoxia primary exerted a direct effect on mortality (86%), with contributions from neurologic (3.1%), hepatic (3.9%), renal (3.5%), and bleeding (2.3%) complications.</p><p><strong>Conclusions: </strong>Severe hyperoxia in patients with CS receiving VA-ECMO is associated with increased mortality and more end-organ complications. However, most of the effect of severe hyperoxia on mortality occurs via direct effects, independent of end-organ complications. 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引用次数: 0
摘要
目的：探讨在静脉-动脉体外膜氧合（VA-ECMO）支持的心源性休克（CS）患者中，严重高氧是否易发生终末器官并发症，以及这些并发症是否会导致住院死亡率。设计：2010年至2023年间体外生命支持组织注册的成年CS患者根据24小时的Pao2分为常氧（Pao2 60-150 mm Hg）、轻度高氧（Pao2 151-300 mm Hg）和重度高氧（Pao2 bb0 300 mm Hg）。主要终点是住院死亡率。采用多变量logistic回归模型分析终末器官并发症，并进行因果中介分析以估计高氧对死亡率的直接和间接影响。背景：多中心、多国前瞻性队列研究。患者：成人CS支持VA-ECMO。干预措施：VA-ECMO插管后24小时的氧分压。测量/主要结果：共纳入10541例患者（常氧：48.4%，轻度高氧：30.0%，重度高氧：21.5%）。重度高氧患者住院死亡率较高(71.7%，调整OR [aOR]: 2.17；95% CI, 1.19-2.50)和轻度高氧(63.8%,aOR: 1.34；95% CI, 1.19-1.50)，与正常缺氧相比(52.7%；参照组)。严重高氧与更多的终末器官并发症相关，并逐渐预测更高的死亡率(aOR: 1.42；95% ci, 1.25-1.61)。中介分析表明，高氧主要对死亡率有直接影响（86%），神经系统（3.1%）、肝脏（3.9%）、肾脏（3.5%）和出血（2.3%）并发症也有影响。结论：接受VA-ECMO的CS患者的严重高氧与死亡率增加和终末器官并发症相关。然而，严重高氧对死亡率的大部分影响是通过直接影响发生的，与终末器官并发症无关。这些发现强调了高氧的潜在直接毒性，并强调了在这一危重疾病人群中优化氧气输送策略的必要性。
Hyperoxia and End-Organ Complications Among Cardiogenic Shock Patients Supported by Veno-Arterial Extracorporeal Membrane Oxygenation.
Objectives: To investigate whether severe hyperoxia predisposes to end-organ complications and whether these complications contribute to in-hospital mortality among cardiogenic shock (CS) patients supported in veno-arterial extracorporeal membrane oxygenation (VA-ECMO).
Design: Adult patients with CS from the Extracorporeal Life Support Organization Registry between 2010 and 2023 were categorized into normoxia (Pa o2 60-150 mm Hg), mild hyperoxia (Pa o2 151-300 mm Hg), and severe hyperoxia (Pa o2 > 300 mm Hg) based on their Pa o2 at 24 hours. The primary outcome was in-hospital mortality. End-organ complications were analyzed using multivariate logistic regression models, and causal mediation analysis was performed to estimate the direct and indirect effects of hyperoxia on mortality.
Interventions: Partial pressure of oxygen at 24 hours after VA-ECMO cannulation.
Measurements/main results: A total of 10,541 patients were included (normoxia: 48.4%, mild hyperoxia: 30.0%, severe hyperoxia: 21.5%). There was higher in-hospital mortality in patients with severe hyperoxia (71.7%, adjusted OR [aOR]: 2.17; 95% CI, 1.19-2.50) and mild hyperoxia (63.8%, aOR: 1.34; 95% CI, 1.19-1.50) compared normoxia (52.7%; referent group). Severe hyperoxia was associated with more end-organ complications, which incrementally predicted higher mortality (aOR: 1.42; 95% CI, 1.25-1.61). Mediation analysis demonstrated that hyperoxia primary exerted a direct effect on mortality (86%), with contributions from neurologic (3.1%), hepatic (3.9%), renal (3.5%), and bleeding (2.3%) complications.
Conclusions: Severe hyperoxia in patients with CS receiving VA-ECMO is associated with increased mortality and more end-organ complications. However, most of the effect of severe hyperoxia on mortality occurs via direct effects, independent of end-organ complications. These findings highlight the potential direct toxicity of hyperoxia and underscore the need for strategies to optimize oxygen delivery in this critically ill population.
期刊介绍：
Critical Care Medicine is the premier peer-reviewed, scientific publication in critical care medicine. Directed to those specialists who treat patients in the ICU and CCU, including chest physicians, surgeons, pediatricians, pharmacists/pharmacologists, anesthesiologists, critical care nurses, and other healthcare professionals, Critical Care Medicine covers all aspects of acute and emergency care for the critically ill or injured patient.
Each issue presents critical care practitioners with clinical breakthroughs that lead to better patient care, the latest news on promising research, and advances in equipment and techniques.
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