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Reducing Hyperoxia Exposure in Infants Requiring Veno-Arterial Extracorporeal Membrane Oxygenation after Cardiac
Nathaniel R Sznycer-Taub1, Ray Lowery2, Sunkyung Yu2
1Division of Pediatric Cardiology, C.S. Mott Children's Hospital, University of Michigan, 1540 East Hospital Drive, Ann Arbor, MI, 48109-4204, USA. nsznycer@med.umich.edu.
Insights
Reducing inspired oxygen (FiO2) in veno-arterial extracorporeal membrane oxygenation (VA-ECMO) did not alter mortality but may reduce hyperoxia-related risks. Further research is needed to optimize protocols for avoiding hyperoxia in pediatric cardiac surgery patients on VA-ECMO.
Area of Science:
- Pediatric Cardiac Surgery
- Extracorporeal Membrane Oxygenation
- Critical Care Medicine
Background:
- Hyperoxia during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is linked to adverse outcomes.
- The impact of reducing inspired oxygen (FiO2) of sweep gas on hyperoxia exposure and patient outcomes in pediatric VA-ECMO is not well-established.
Purpose of the Study:
- To investigate the effect of adjusting the FiO2 of sweep gas to reduce hyperoxia exposure in pediatric patients on VA-ECMO after cardiac surgery.
- To assess the association between reduced hyperoxia and 30-day mortality or end-organ injury.
Main Methods:
- Retrospective review of 143 pediatric patients (<1 year) on VA-ECMO post-cardiac surgery (2007-2018).
- Comparison of outcomes between patients with FiO2 < 100% (n=64) and FiO2 = 100% (n=79).
- Analysis of average and individual PaO2 values within the first 48 hours of support.
Main Results:
- Patients with FiO2 < 100% had significantly lower average PaO2 (210 mm Hg) compared to those with FiO2 = 100% (405 mm Hg).
- No significant difference in 30-day mortality or end-organ injury markers between the groups.
- A trend suggested reduced 30-day mortality risk (OR=0.45) with at least one PaO2 < 200 mm Hg in the first 24 hours for the FiO2 < 100% group.
- Only 47% of patients in the FiO2 < 100% group achieved an average PaO2 < 200 mm Hg, indicating incomplete hyperoxia reduction.
Conclusions:
- Adjusting sweep gas FiO2 in pediatric VA-ECMO did not significantly impact 30-day mortality or end-organ injury.
- Lowering FiO2 may offer a potential survival benefit, but the intervention was not consistently effective in preventing hyperoxia.
- Further research and clinical protocols are necessary to effectively manage hyperoxia and understand its injury mechanisms in VA-ECMO patients.
Abstract:
Recent studies have suggested worse outcomes in patients exposed to hyperoxia while supported on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). However, there are no data regarding the effect of reducing hyperoxia exposure in this population by adjusting the fraction of inspired oxygen (FiO2) of the sweep gas of the ECMO circuit. A retrospective review of 143 patients less than 1 year of age requiring VA-ECMO following cardiac surgery from 2007 to 2018 was completed. 64 patients had a FiO2 of the sweep gas < 100% with an average PaO2 of 210 mm Hg in the first 48 h of support [vs 405 mm Hg in the group with a FiO2 = 100% (p < 0.0001)]. There was no difference in mortality at 30 days after surgery or other markers of end-organ injury with respect to whether the FiO2 was adjusted. At least one PaO2 value < 200 mm Hg in the first 24 h on ECMO in patients with a FiO2 < 100% trended toward a significant association (OR = 0.45, 95% CI = 0.21-1.01) with decreased risk of 30-day mortality when compared to those patients with a FiO2 = 100% and all PaO2 values > 200 mm Hg. Only 47% of patients with a FiO2 < 100% had an average PaO2 less than 200 mm Hg which indicates that the intervention of reducing the FiO2 of the sweep gas was not entirely effective at reducing hyperoxia exposure. Future research is needed for developing clinical protocols to avoid hyperoxia and to identify mechanisms for hyperoxia-induced injury on VA-ECMO.
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