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. 2023 Apr;16(4):e010328.
doi: 10.1161/CIRCHEARTFAILURE.122.010328. Epub 2023 Mar 5.

Exposure to Arterial Hyperoxia During Extracorporeal Membrane Oxygenator Support and Mortality in Patients With Cardiogenic Shock

Jacob C Jentzer  1 , P Elliott Miller  2 , Carlos Alviar  3 , Suraj Yalamuri  4 , J Kyle Bohman  4 , Joseph E Tonna  5
Affiliations

Exposure to Arterial Hyperoxia During Extracorporeal Membrane Oxygenator Support and Mortality in Patients With Cardiogenic Shock

Jacob C Jentzer et al. Circ Heart Fail. 2023 Apr.

Abstract

Background: Exposure to hyperoxia, a high arterial partial pressure of oxygen (PaO2), may be associated with worse outcomes in patients receiving extracorporeal membrane oxygenator (ECMO) support. We examined hyperoxia in the Extracorporeal Life Support Organization Registry among patients receiving venoarterial ECMO for cardiogenic shock.

Methods: We included Extracorporeal Life Support Organization Registry patients from 2010 to 2020 who received venoarterial ECMO for cardiogenic shock, excluding extracorporeal CPR. Patients were grouped based on PaO2 after 24 hours of ECMO: normoxia (PaO2 60-150 mmHg), mild hyperoxia (PaO2 151-300 mmHg), and severe hyperoxia (PaO2 >300 mmHg). In-hospital mortality was evaluated using multivariable logistic regression.

Results: Among 9959 patients, 3005 (30.2%) patients had mild hyperoxia and 1972 (19.8%) had severe hyperoxia. In-hospital mortality increased across groups: normoxia, 47.8%; mild hyperoxia, 55.6% (adjusted odds ratio, 1.37 [95% CI, 1.23-1.53]; P<0.001); severe hyperoxia, 65.4% (adjusted odds ratio, 2.20 [95% CI, 1.92-2.52]; P<0.001). A higher PaO2 was incrementally associated with increased in-hospital mortality (adjusted odds ratio, 1.14 per 50 mmHg higher [95% CI, 1.12-1.16]; P<0.001). Patients with a higher PaO2 had increased in-hospital mortality in each subgroup and when stratified by ventilator settings, airway pressures, acid-base status, and other clinical variables. In the random forest model, PaO2 was the second strongest predictor of in-hospital mortality, after older age.

Conclusions: Exposure to hyperoxia during venoarterial ECMO support for cardiogenic shock is strongly associated with increased in-hospital mortality, independent from hemodynamic and ventilatory status. Until clinical trial data are available, we suggest targeting a normal PaO2 and avoiding hyperoxia in CS patients receiving venoarterial ECMO.

Keywords: extracorporeal circulation; extracorporeal membrane oxygenation; oxygen; oxygen inhalation therapy; oxygenators, membrane; shock; shock, cardiogenic.

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Conflict of interest statement

Disclosures: The authors have no relevant financial disclosures or conflicts of interest.

Figures

Figure 1AB:
Figure 1AB:
Histogram of PaO2 after 24 hours on ECMO (A) in the population (p <0.001 for comparison of hospital survivors versus in-hospital deaths) and prevalence of hyperoxia by year of ECMO initiation (B). Abbreviations: ECMO, extracorporeal membrane oxygenation; PaO2, partial pressure of arterial oxygen (arterial oxygen tension)
Figure 1AB:
Figure 1AB:
Histogram of PaO2 after 24 hours on ECMO (A) in the population (p <0.001 for comparison of hospital survivors versus in-hospital deaths) and prevalence of hyperoxia by year of ECMO initiation (B). Abbreviations: ECMO, extracorporeal membrane oxygenation; PaO2, partial pressure of arterial oxygen (arterial oxygen tension)
Figure 2:
Figure 2:
Locally estimated scatterplot smoother (LOESS) curve showing in-hospital mortality as a function of the PaO2 at 24 hours after ECMO initiation. Abbreviations: ECMO, extracorporeal membrane oxygenation; PaO2, partial pressure of arterial oxygen (arterial oxygen tension)
Figure 3:
Figure 3:
In-hospital mortality in patients with normoxia, mild hyperoxia, and severe hyperoxia in selected subgroups. All between groups differences were significant (p <0.05) in each subgroup.
Figure 4:
Figure 4:
In-hospital mortality in patients with normoxia, mild hyperoxia, and severe hyperoxia according to SCAI Shock Stage at the time of ECMO initiation. Abbreviations: PaO2, partial pressure of arterial oxygen (arterial oxygen tension); SCAI, Society for Cardiovascular Angiography and Interventions
Figure 5:
Figure 5:
Kaplan-Meier curves demonstrating 30-day in-hospital mortality between hyperoxia groups; p value is for log-rank test.
Figure 6AB:
Figure 6AB:
In-hospital mortality in patients as a function of PaO2 quartile versus quartile of ventilator FiO2 (A) and ECMO flow (B) after 24 hours on ECMO. Abbreviations: ECMO, extracorporeal membrane oxygenation; FiO2, fraction of inspired oxygen; PaO2, partial pressure of arterial oxygen (arterial oxygen tension)
Figure 6AB:
Figure 6AB:
In-hospital mortality in patients as a function of PaO2 quartile versus quartile of ventilator FiO2 (A) and ECMO flow (B) after 24 hours on ECMO. Abbreviations: ECMO, extracorporeal membrane oxygenation; FiO2, fraction of inspired oxygen; PaO2, partial pressure of arterial oxygen (arterial oxygen tension)
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