UMEM Educational Pearls

 

Hyperoxia has been repeatedly demonstrated to be detrimental in a variety of patients, including those with myocardial infarction, cardiac arrest, stroke, traumatic brain injury, and requiring mechanical ventilation,^1-4 and the data that hyperoxia is harmful continues to mount:

• Systematic review and meta-analysis of 16,000 patients admitted to hospital with sepsis, trauma, MI, stroke, emergency surgery, cardiac arrest: liberal oxygenation strategy (supplemental O2 for average SpO2 96%, range 94-100%) associated with increased in-hospital and 30-day mortality compared to conservative strategy.⁵

• ED patients requiring mechanical ventilation admitted to ICU: hyperoxia defined as PaO@ >120mmHg. Patients with hyperoxia in the ED had higher mortality than not only normoxic but hypoxic patients (30% v 19% v 13% respectively), and longer vent days and ICU/hospital LOS.⁶

• ICU patients, majority respiratory failure, 60% requiring mechanical ventilation; hyperoxia defined as PaO2 >100mmHg. Just ONE episode of hyperoxia an independent risk factor for ICU mortality (OR 3.80, 95% CI 1.08-16.01, p=0.047).⁷

 

Bottom Line: Avoid hyperoxia in your ED patients, both relatively stable and critically ill. Remove or turn down supplemental O2 added by well-meaning pre-hospital providers and nurses, and wean down ventilator settings (often FiO2). A target SpO2 of >92% (>88% in COPD patients) or PaO2 >55-60 is reasonable in the majority of patients.⁸

References

1. Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment elevation myocardial infarction. Circulation. 2015;131(24):2143-50. 
2. Kilgannon JH, Jones AE, Parrillo JE, et al. Relationship between supranormal oxygen tension and outcome after resuscitation from cardiac arrest. Circulation. 2011; 123(23):2717-22. 
3. Rincon F, Kang J, Maltenfort M, et al. Association between hyperoxia and mortality after stroke: a multicenter cohort study. Crit Care Med.2014;42(2):387-96.
4. Brenner M, Stein D, Hu P, et al. Association between early hyperoxia and worse outcomes after traumatic brain injury. Arch Surg. 2012;147(11):1042-6. 
5. Chu DK, Kim LHY, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018;391(10131):1693-1705.
6. Page D, Ablordeppey E, Wessman BT, et al. Emergency department hyperoxia is associate with increased mortality in mechanically ventilated patients: a cohort study. Crit Care. 2018;22(1):9. doi:10.1186/s13054-017-1926-4.
7. Ruggiu M, Aissaoui N, Nael J, et al. Hyperoxia effects on intensive care unit mortality: a retrospective pragmatic cohort study. Crit Care. 2018;22: 218.
8. Panwar R, Hardie M, Bellomo R, et al. Conservative versus liberal oxygenation targets for mechanically ventilated patients. A pilot multicenter randomized controlled trial. Am J Respir Crit Care Med. 2016;193(1):43-51.