Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation

• Published in: Intensive care medicine Vol. 50; no. 9; pp. 1470 - 1483
• Main Authors: Burrell, Aidan, Bailey, Michael J., Bellomo, Rinaldo, Buscher, Hergen, Eastwood, Glenn, Forrest, Paul, Fraser, John F., Fulcher, Bentley, Gattas, David, Higgins, Alisa M., Hodgson, Carol L., Litton, Edward, Martin, Emma-Leah, Nair, Priya, Ng, Sze J., Orford, Neil, Ottosen, Kelly, Paul, Eldho, Pellegrino, Vincent, Reid, Liadain, Shekar, Kiran, Totaro, Richard J., Trapani, Tony, Udy, Andrew, Ziegenfuss, Marc, Pilcher, David
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01-09-2024; Springer Nature B.V
• Subjects: Adult; Aged; Anesthesiology; Critical Care Medicine; Emergency Medicine; Extracorporeal membrane oxygenation; Extracorporeal Membrane Oxygenation - adverse effects; Extracorporeal Membrane Oxygenation - methods; Female; Heart Arrest - mortality; Heart Arrest - therapy; Humans; Intensive; Intensive Care Units - statistics & numerical data; Male; Medicine; Medicine & Public Health; Membranes; Middle Aged; Mortality; Original; Oxygen; Oxygen content; Oxygen Saturation - physiology; Oxygenation; Pain Medicine; Patients; Pediatrics; Pneumology/Respiratory System; Registries - statistics & numerical data; Shock, Cardiogenic - mortality; Shock, Cardiogenic - therapy; ECMO; Oxygen target; Hyperoxaemia; Extracorporeal membrane oxygenation; Hyperoxia
• ISSN: 0342-4642; 1432-1238; 1432-1238
• DOI: 10.1007/s00134-024-07564-8

Purpose
Patients receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) frequently develop arterial hyperoxaemia, which may be harmful. However, lower oxygen saturation targets may also lead to harmful episodes of hypoxaemia.
Methods
In this registry-embedded, multicentre trial, we randomly assigned adult patients receiving VA-ECMO in an intensive care unit (ICU) to either a conservative (target SaO
2
92–96%) or to a liberal oxygen strategy (target SaO
2
97–100%) through controlled oxygen administration via the ventilator and ECMO gas blender. The primary outcome was the number of ICU-free days to day 28. Secondary outcomes included ICU-free days to day 60, mortality, ECMO and ventilation duration, ICU and hospital lengths of stay, and functional outcomes at 6 months.
Results
From September 2019 through June 2023, 934 patients who received VA-ECMO were reported to the EXCEL registry, of whom 300 (192 cardiogenic shock, 108 refractory cardiac arrest) were recruited. We randomised 149 to a conservative and 151 to a liberal oxygen strategy. The median number of ICU-free days to day 28 was similar in both groups (conservative: 0 days [interquartile range (IQR) 0–13.7] versus liberal: 0 days [IQR 0–13.3], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/149 [39.6%] vs 59/151 [39.1%]) and at day 60 (64/149 [43%] vs 62/151 [41.1%] were similar in conservative and liberal groups, as were all other secondary outcomes and adverse events. The conservative group experienced 44 (29.5%) major protocol deviations compared to 2 (1.3%) in the liberal oxygen group (
P
 < 0.001).
Conclusions
In adults receiving VA-ECMO in ICU, a conservative compared to a liberal oxygen strategy, did not affect the number of ICU-free days to day 28.