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A Model to Simulate Clinically Relevant Hypoxia in Humans
Published on: December 22, 2016
A quasiexperimental study of targeted normoxia in critically ill trauma patients
Layne Dylla1, Erin L Anderson, David J Douin
1From the Department of Emergency Medicine (L.D., E.L.A., R.T.N., C.V.S.B., A.A.G.), University of Colorado School of Medicine; Department of Anesthesiology (D.J.D.), University of Colorado School of Medicine; Department of Biostatistics and Informatics (C.L.J., J.D.R.), Colorado School of Public Health, Aurora, Colorado; US Army Institute of Surgical Research (S.G.S.), Houston; US Air Force 59th Medical Wing (S.G.S., C.V.S.B.), Office of the Chief Scientist, Lackland; Department of Emergency Medicine (S.G.S.), Brooke Army Medical Center, San Antonio, Texas; and Department of Surgery (F.L.W.) and Center for COMBAT Research, Department of Emergency Medicine (C.V.S.B., A.A.G.), University of Colorado School of Medicine, Aurora, Colorado.
Background:
Avoidance of hypoxia and hyperoxia may reduce morbidity and mortality in critically ill civilian and military trauma patients. The objective of this study was to determine if a multimodal quality improvement intervention increases adherence to a consensus-based, targeted normoxia strategy. We hypothesized that this intervention would safely improve compliance with targeted normoxia.
Methods:
This is a pre/postquasiexperimental pilot study to improve adherence to normoxia, defined as a pulse oximetry (SpO2) of 90% to 96% or an arterial partial pressure oxygen (PaO2) of 60 to 100 mm Hg. We used a multimodal informatics and educational intervention guiding clinicians to safely titrate supplemental oxygen to normoxia based on SpO2 monitoring in critically ill trauma patients admitted to the surgical-trauma or neurosurgical intensive care unit within 24 hours of emergency department arrival. The primary outcome was effectiveness in delivering targeted normoxia (i.e., an increase in the probability of being in the targeted normoxia range and/or a reduction in the probability of being on a higher fraction-inspired oxygen concentration [FiO2]).
Results:
Analysis included 371 preintervention subjects and 201 postintervention subjects. Preintervention and postintervention subjects were of similar age, race/ethnicity, and sex and had similar comorbidities and Acute Physiologic and Chronic Health Evaluation II scores. Overall, the adjusted probability of being hyperoxic while on supplemental oxygen was reduced during the postintervention period (adjusted odds ratio, 0.74; 95% confidence interval, 0.57-0.97). There was a higher probability of being on room air (FiO2, 0.21) in the postintervention period (adjusted odds ratio, 1.38; 95% confidence interval, 0.83-2.30). In addition, there was a decreased amount of patient time spent on higher levels of FiO2 (FiO2, >40%) without a concomitant increase in hypoxia.
Conclusion:
A multimodal intervention targeting normoxia in critically ill trauma patients increased normoxia and lowered the use of supplemental oxygen. A large clinical trial is needed to validate the impact of this protocol on patient-centered clinical outcomes.
Level Of Evidence:
Therapeutic/care management, level II.
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