Hyperoxemia during resuscitation of trauma patients and increased intensive care unit length of stay: inverse probability of treatment weighting analysis

Abstract

Background: Information on hyperoxemia among patients with trauma has been limited, other than traumatic brain injuries. This study aimed to elucidate whether hyperoxemia during resuscitation of patients with trauma was associated with unfavorable outcomes.

Methods: A post hoc analysis of a prospective observational study was carried out at 39 tertiary hospitals in 2016-2018 in adult patients with trauma and injury severity score (ISS) of > 15. Hyperoxemia during resuscitation was defined as PaO₂ of ≥ 300 mmHg on hospital arrival and/or 3 h after arrival. Intensive care unit (ICU)-free days were compared between patients with and without hyperoxemia. An inverse probability of treatment weighting (IPW) analysis was conducted to adjust patient characteristics including age, injury mechanism, comorbidities, vital signs on presentation, chest injury severity, and ISS. Analyses were stratified with intubation status at the emergency department (ED). The association between biomarkers and ICU length of stay were then analyzed with multivariate models.

Results: Among 295 severely injured trauma patients registered, 240 were eligible for analysis. Patients in the hyperoxemia group (n = 58) had shorter ICU-free days than those in the non-hyperoxemia group [17 (10-21) vs 23 (16-26), p < 0.001]. IPW analysis revealed the association between hyperoxemia and prolonged ICU stay among patients not intubated at the ED [ICU-free days = 16 (12-22) vs 23 (19-26), p = 0.004], but not among those intubated at the ED [18 (9-20) vs 15 (8-23), p = 0.777]. In the hyperoxemia group, high inflammatory markers such as soluble RAGE and HMGB-1, as well as low lung-protective proteins such as surfactant protein D and Clara cell secretory protein, were associated with prolonged ICU stay.

Conclusions: Hyperoxemia until 3 h after hospital arrival was associated with prolonged ICU stay among severely injured trauma patients not intubated at the ED.

Trial registration: UMIN-CTR, UMIN000019588 . Registered on November 15, 2015.

Keywords: Critically ill; Hyperoxemia; Hyperoxia; ICU length of stay; Mortality; Trauma.

Fig. 1

Patient flow diagram. A total of 295 patients with severe injuries were registered in the JAAM FORECAST TRAUMA study, which enrolled patients (1) aged ≥ 16 years, (2) with injury severity score (ISS) of ≥ 16, and (3) directly transported from the scene. Among them, 244 with available PaO₂ within 3 h after hospital arrival were eligible for this study. Fifty-eight patients exposed to hyperoxemia (PaO₂ ≥ 300 mmHg) within 3 h after arrival were included in the hyperoxemia group, whereas 186 not exposed to hyperoxemia were included in the non-hyperoxemia group

Fig. 2

Effect of inflammatory and lung-related biomarkers on ICU-free days. Biological parameters were evaluated with multivariate regression among patients treated with hyperoxemia. CI, confidence interval; sRAGE, soluble receptor for advanced glycation end-products; HMGB-1, high mobility group box-1; SPD, surfactant protein D; CCSP, Clara cell secretory protein; IL, interleukin