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

Aidan Burrell; Michael J. Bailey; Rinaldo Bellomo; Hergen Buscher; Glenn Eastwood; Paul Forrest; John F. Fraser; Bentley Fulcher; David Gattas; Alisa M. Higgins; Carol L. Hodgson; Edward Litton; Emma Leah Martin; Priya Nair; Sze J. Ng; Neil Orford; Kelly Ottosen; Eldho Paul; Vincent Pellegrino; Liadain Reid; Kiran Shekar; Richard J. Totaro; Tony Trapani; Andrew Udy; Marc Ziegenfuss; David Pilcher; The BLENDER Trial Investigators, EXCEL Registry, ECMONet and the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group and Centre for Outcomes and Resource Evaluation; Joanne McIntyre; Shailesh Bihari; Fiona McDonald; Andrew Thomas

doi:10.1007/s00134-024-07564-8

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

Aidan Burrell, Michael J. Bailey, Rinaldo Bellomo, Hergen Buscher, Glenn Eastwood, Paul Forrest, John F. Fraser, Bentley Fulcher, David Gattas, Alisa M. Higgins, Carol L. Hodgson, Edward Litton, Emma Leah Martin, Priya Nair, Sze J. Ng, Neil Orford, Kelly Ottosen, Eldho Paul, Vincent Pellegrino, Liadain ReidKiran Shekar, Richard J. Totaro, Tony Trapani, Andrew Udy, Marc Ziegenfuss, David Pilcher, The BLENDER Trial Investigators, EXCEL Registry, ECMONet and the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group and Centre for Outcomes and Resource Evaluation, Joanne McIntyre, Shailesh Bihari, Fiona McDonald, Andrew Thomas

Research output: Contribution to journal › Article › peer-review

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Abstract

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 SaO₂ 92–96%) or to a liberal oxygen strategy (target SaO₂ 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 0–13.7], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/159 [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.

Original language	English
Pages (from-to)	1470–1483
Number of pages	14
Journal	Intensive Care Medicine
Volume	50
Issue number	9
Early online date	20 Aug 2024
DOIs	https://doi.org/10.1007/s00134-024-07564-8
Publication status	Published - Sept 2024
Externally published	Yes

Keywords

ECMO
Extracorporeal membrane oxygenation
Hyperoxaemia
Hyperoxia
Oxygen target

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10.1007/s00134-024-07564-8Licence: CC BY-NC

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Burrell, A., Bailey, M. J., Bellomo, R., Buscher, H., Eastwood, G., Forrest, P., Fraser, J. F., Fulcher, B., Gattas, D., Higgins, A. M., Hodgson, C. L., Litton, E., Martin, E. L., Nair, P., Ng, S. J., Orford, N., Ottosen, K., Paul, E., Pellegrino, V., ... Thomas, A. (2024). Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation. Intensive Care Medicine, 50(9), 1470–1483. https://doi.org/10.1007/s00134-024-07564-8

@article{357c9a84f8d841429bf6ab1f1d266997,

title = "Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation",

abstract = "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 SaO2 92–96%) or to a liberal oxygen strategy (target SaO2 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 0–13.7], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/159 [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.",

keywords = "ECMO, Extracorporeal membrane oxygenation, Hyperoxaemia, Hyperoxia, Oxygen target",

author = "Aidan Burrell and Bailey, {Michael J.} and Rinaldo Bellomo and Hergen Buscher and Glenn Eastwood and Paul Forrest and Fraser, {John F.} and Bentley Fulcher and David Gattas and Higgins, {Alisa M.} and Hodgson, {Carol L.} and Edward Litton and Martin, {Emma Leah} and Priya Nair and Ng, {Sze J.} and Neil Orford and Kelly Ottosen and Eldho Paul and Vincent Pellegrino and Liadain Reid and Kiran Shekar and Totaro, {Richard J.} and Tony Trapani and Andrew Udy and Marc Ziegenfuss and David Pilcher and {The BLENDER Trial Investigators, EXCEL Registry, ECMONet and the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group and Centre for Outcomes and Resource Evaluation} and Amanda Corley and Andrew Hilton and Meredith Young and Jasmin Board and Annalie Jones and Phoebe McCracken and Alastair Brown and Helen Young and Leah Peck and Andrew Hilton and John Dyett and Stephanie Hunter and Cheelim Liew and Kym Gellie and Nicole Robertson and Palermo, {Anne Marie} and Chris Allen and Ubbo Wiersema and Joanne McIntyre and Shailesh Bihari and Joe McCaffrey and Matthew Maiden and Nima Kakho and Allison Bone and Tania Salerno and Michelle Horton and Jemma Trickey and Samantha Breguet and Lucy Range and Meg Gallagher and James Winearls and Mandy Tallott and Maimoonbe Gough and Julie Pitman and James McCullough and Maree Houbert and Lewis McLean and Poulter, {Amber Louise} and Sarah Dalton and Jorge Brieva and Lucas Webb and {de Wit}, Daniel and James Walsham and Jason Meyer and Meg Harward and Anand Krishnan and Cassie Jones and Josephine Mackay and Benjamin Reddi and Stephanie O{\textquoteright}Connor and Kathleen Glasby and Nerissa Brown and Sarah Doherty and Justine Rivett and Fiona McDonald and Sophie Dohnt and Mahni Foster and Heidi Buhr and Jennifer Coles and Ruaidhri Carey and Sally Newman and Claire Reynolds and Andrew Thomas and Rachel Bushell and Dawn Lockwood and Oystein Tronstad and Jiville Latu and India Pearse and Ferguson, {Niall D.} and Lehana Thabane and Matthieu Schmidt",

year = "2024",

month = sep,

doi = "10.1007/s00134-024-07564-8",

language = "English",

volume = "50",

pages = "1470–1483",

journal = "Intensive Care Medicine",

issn = "0342-4642",

publisher = "Springer Verlag",

number = "9",

}

Burrell, A, Bailey, MJ, Bellomo, R, Buscher, H, Eastwood, G, Forrest, P, Fraser, JF, Fulcher, B, Gattas, D, Higgins, AM, Hodgson, CL, Litton, E, Martin, EL, Nair, P, Ng, SJ, Orford, N, Ottosen, K, Paul, E, Pellegrino, V, Reid, L, Shekar, K, Totaro, RJ, Trapani, T, Udy, A, Ziegenfuss, M, Pilcher, D, The BLENDER Trial Investigators, EXCEL Registry, ECMONet and the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group and Centre for Outcomes and Resource Evaluation, McIntyre, J, Bihari, S, McDonald, F & Thomas, A 2024, 'Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation', Intensive Care Medicine, vol. 50, no. 9, pp. 1470–1483. https://doi.org/10.1007/s00134-024-07564-8

TY - JOUR

T1 - Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation

AU - Burrell, Aidan

AU - Bailey, Michael J.

AU - Bellomo, Rinaldo

AU - Buscher, Hergen

AU - Eastwood, Glenn

AU - Forrest, Paul

AU - Fraser, John F.

AU - Fulcher, Bentley

AU - Gattas, David

AU - Higgins, Alisa M.

AU - Hodgson, Carol L.

AU - Litton, Edward

AU - Martin, Emma Leah

AU - Nair, Priya

AU - Ng, Sze J.

AU - Orford, Neil

AU - Ottosen, Kelly

AU - Paul, Eldho

AU - Pellegrino, Vincent

AU - Reid, Liadain

AU - Shekar, Kiran

AU - Totaro, Richard J.

AU - Trapani, Tony

AU - Udy, Andrew

AU - Ziegenfuss, Marc

AU - Pilcher, David

AU - The BLENDER Trial Investigators, EXCEL Registry, ECMONet and the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group and Centre for Outcomes and Resource Evaluation

AU - Corley, Amanda

AU - Hilton, Andrew

AU - Young, Meredith

AU - Board, Jasmin

AU - Jones, Annalie

AU - McCracken, Phoebe

AU - Brown, Alastair

AU - Young, Helen

AU - Peck, Leah

AU - Hilton, Andrew

AU - Dyett, John

AU - Hunter, Stephanie

AU - Liew, Cheelim

AU - Gellie, Kym

AU - Robertson, Nicole

AU - Palermo, Anne Marie

AU - Allen, Chris

AU - Wiersema, Ubbo

AU - McIntyre, Joanne

AU - Bihari, Shailesh

AU - McCaffrey, Joe

AU - Maiden, Matthew

AU - Kakho, Nima

AU - Bone, Allison

AU - Salerno, Tania

AU - Horton, Michelle

AU - Trickey, Jemma

AU - Breguet, Samantha

AU - Range, Lucy

AU - Gallagher, Meg

AU - Winearls, James

AU - Tallott, Mandy

AU - Gough, Maimoonbe

AU - Pitman, Julie

AU - McCullough, James

AU - Houbert, Maree

AU - McLean, Lewis

AU - Poulter, Amber Louise

AU - Dalton, Sarah

AU - Brieva, Jorge

AU - Webb, Lucas

AU - de Wit, Daniel

AU - Walsham, James

AU - Meyer, Jason

AU - Harward, Meg

AU - Krishnan, Anand

AU - Jones, Cassie

AU - Mackay, Josephine

AU - Reddi, Benjamin

AU - O’Connor, Stephanie

AU - Glasby, Kathleen

AU - Brown, Nerissa

AU - Doherty, Sarah

AU - Rivett, Justine

AU - McDonald, Fiona

AU - Dohnt, Sophie

AU - Foster, Mahni

AU - Buhr, Heidi

AU - Coles, Jennifer

AU - Carey, Ruaidhri

AU - Newman, Sally

AU - Reynolds, Claire

AU - Thomas, Andrew

AU - Bushell, Rachel

AU - Lockwood, Dawn

AU - Tronstad, Oystein

AU - Latu, Jiville

AU - Pearse, India

AU - Ferguson, Niall D.

AU - Thabane, Lehana

AU - Schmidt, Matthieu

PY - 2024/9

Y1 - 2024/9

N2 - 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 SaO2 92–96%) or to a liberal oxygen strategy (target SaO2 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 0–13.7], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/159 [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.

AB - 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 SaO2 92–96%) or to a liberal oxygen strategy (target SaO2 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 0–13.7], median treatment effect: 0 days [95% confidence interval (CI) – 3.1 to 3.1]). Mortality at day 28 (59/159 [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.

KW - ECMO

KW - Extracorporeal membrane oxygenation

KW - Hyperoxaemia

KW - Hyperoxia

KW - Oxygen target

UR - http://www.scopus.com/inward/record.url?scp=85202464070&partnerID=8YFLogxK

U2 - 10.1007/s00134-024-07564-8

DO - 10.1007/s00134-024-07564-8

M3 - Article

C2 - 39162827

AN - SCOPUS:85202464070

SN - 0342-4642

VL - 50

SP - 1470

EP - 1483

JO - Intensive Care Medicine

JF - Intensive Care Medicine

IS - 9

ER -

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

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Correction: Conservative or liberal oxygen targets in patients on venoarterial extracorporeal membrane oxygenation (Intensive Care Medicine, (2024), 50, 9, (1470-1483), 10.1007/s00134-024-07564-8)

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