Article

Pre-hospital invasive ventilation in patients with septic shock: Is hyperoxemia an unwanted company?

Correspondence / American Journal of Emergency Medicine 37 (2019) 530559 533

to high levels of oxygen. Precise monitoring of Gas exchange is not yet easily feasible in the prehospital setting. As an alternative, pulse oxime- try (SpO2) can help to monitor gas exchanges until hospital arrival. The trend is therefore moving toward a more conservative approach regard- ing oxygenation management. The aim is to maintain a SpO2 target at 95-97%, although the optimal PaO2 level has not yet been defined [13]. Nevertheless, it is important to keep in mind that SpO2 target might also change during the course of patient’s management, and con- secutively re-evaluation appears to be the rule.

Finally, we thank Karim et al. [1] for their letter. Indeed, communica- tion between research teams is a key tool to improve our clinical prac- tices. As clearly summarized, none of the potential methods toward a feasible monitoring of gas exchange are perfect when it comes to the prehospital field. Further well-designed randomized controlled trials in critically ill patients with septic shock may help to provide some de- finitive answers to these questions and uncover the precise characteris- tics of the unwanted company.

Romain Jouffroy, M.D.?,1 Anastasia Saade, M.D., pH.D.1 Laure Castres Saint Martin, M.D.

Pascal Philippe, M.D. Pierre Carli, M.D., pH.D. Benoit Vivien, M.D., pH.D.

Intensive Care Unit, Anesthesiology Department and SAMU of Paris, Hopital Necker – Enfants Malades, Assistance Publique – Hopitaux de Paris, Paris

Descartes University, Paris, France

?Corresponding author at: Department of Anesthesia & Intensive Care Unit, SAMU, Hopital Necker Enfants Malades 149 rue de Sevres 75015

Paris, University Paris, Descartes, France.

E-mail address: [email protected] (R. Jouffroy).

3 July 2018

https://doi.org/10.1016/j.ajem.2018.07.0111

References

  1. Karim et al. Pre-hospital invasive ventilation in patients with septic shock: Is hyperoxemia an unwanted company? Am J Emerg Med 2019;(37):533-4.
  2. Jouffroy R, Saade A, Saint Martin LC, Philippe P, Carli P, Vivien B. Prognosis value of partial arterial oxygen pressure in patients with septic shock subjected to pre-hospi- tal invasive ventilation. Am J Emerg Med, Apr Apr. 24 2018;37(1):56-60.
  3. Stolmeijer R, Bouma HR, Zijlstra JG, Drost-De Klerck AM, ter Maaten JC, Ligtenberg JJM. A systematic review of the effects of Hyperoxia in acutely ill patients: should we aim for less? Biomed Res Int 2018, May;2018.
  4. Damiani E, Donati A, Girardis M. Oxygen in the critically ill: friend or foe? Curr Opin

    Anaesthesiol Apr. 2018;31(2):129-35.

    “Hyperoxia and hypertonic saline in patients with septic Shock (HYPERS2S): a two-by- two factorial, multicentre, randomised, clinical Trial – PubMed – NCBI.” [Online]. Avail- able: https://www.ncbi.nlm.nih.gov/pubmed/28219612. [Accessed: 25-Jun-2018].

  5. Damiani E, et al. Arterial hyperoxia and mortality in critically ill patients: a system- atic review and meta-analysis. Crit Care Lond Engl Dec. 2014;18(6):711.
  6. de Jonge E, et al. Association between administered oxygen, arterial partial oxygen pressure and mortality in mechanically ventilated intensive care unit patients. Crit Care Lond Engl 2008;12(6):R156.
  7. Helmerhorst HJF, et al. “Hyperoxia provokes a time- and dose-dependent inflamma- tory response in mechanically ventilated mice, irrespective of tidal volumes,” Inten- sive Care Med. Exp Dec. 2017;5(1):27.
  8. Li L-F, Liao S-K, Ko Y-S, Lee C-H, Quinn DA. Hyperoxia increases ventilator-induced lung injury via mitogen-activated protein kinases: a prospective, controlled animal experiment. Crit Care 2007;11(1):R25.
  9. Helmerhorst HJF, Schultz MJ, van der Voort PHJ, de Jonge E, van Westerloo DJ. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care 2015;19(1).
  10. Page D, et al. Emergency department hyperoxia is associated with increased mortality in Mechanically ventilated patients: a cohort study. Crit Care, vol Jan. 2018:22.
  11. Dellinger RP, et al. Surviving sepsis campaign: international guidelines for manage- ment of severe sepsis and septic shock: 2012. Crit Care Med Feb. 2013;41(2): 580-637.
  12. Durlinger E, Spoelstra-De Man A, Smit B, de Grooth H, Girbes A, Oudemans-Van Straaten H, Smulders Y. Hyperoxemia: at what level of SpO2 is a patient safe? A study in mechanically ventilated ICU patients. J Crit Care 2017 Jun;39: 199-204.

    Pre-hospital invasive ventilation in patients with septic shock: Is hyperoxemia an unwanted company?

    To the Editor,

    Hyperoxemia presents a dangerous association with short outcome, by complex pathways [1]. In this line, we read with great interest the ar- ticle of Jouffroy R et al. suggesting the association between hyperoxemia in septic shock patients who needed ventilator support in the prehospital setting and short term mortality [2]. The study reiterates the fact that hyperoxia might be dangerous for critically ill patients [1, 3], and also suggests that a PaO2 between 100 and 150 mm Hg might be harmful in these patients. However, in our opinion, the authors open a hot controversial topic in their study which needs some more in- formation of key determinants.

    Firstly, hyperoxemia and its complication are associated with time effect. Although the retrospective studies show a deleterious ef- fect of short term hyperoxemia, this is particularly pronounced dur- ing long-term administration, i.e., beyond 12-24 h [4]. Time period of hyperoxemia is unknown from the study. Moreover, the Ventilator management was left up to the discretion of emergency physician without any protocol driven strategy, which itself has inherent bias which can affect the fraction of oxygen concentrations (FiO2) used and Arterial partial pressure of oxygen (PaO2). The information on the use of noninvasive ventilation and the FiO2 also becomes very pertinent.

    Secondly, the data of Jouffroy R, et al. are hypothesis generating for the time being and it would be useful for the scientific commu- nity to know the information regarding how many patients had conditions associated with ischemia/reperfusion injury, such as post-cardiac arrest or stroke etc. as they all determine the short and short and long term outcome as well as relations with hyperoxemia [5].

    Thirdly, the disease severity at the admission/starting of medical care is also important. Although the data from table 1 of the study with context to blood pressure, need of norepinephrine doses and number of patients required norepinephrine supports were not different; the patients were not similar in terms of Severity of diseases. The patients who survived were having significantly lower sequential organ failure assessment score; p 0.007, and higher PaO2/FiO2; p 0.01 (two tailed p from t-test an- alyzed by Graphpad). This indicates that the patients compared were not similar rather the patients who had hyperoxemia were more severely dis- eased. Therefore, the conclusion of the study will not be much more ac- ceptable after ruling out the contributing factors for patients’ inherent conditions at the time of admission, which can contribute to mortality.

    Finally, monitoring gas exchange by pulse oximetry and capnography is easier and more general approach and even well fea- sible in patients with septic shock. Although pulse oximetry cannot detect hyperoxemia by exact values, it can give an idea of hyperoxemia when SpO2 is N95% [6]. The arterial blood gases (ABG)

    1 Contributed equally to the manuscript.

    Abbreviations: PaO2, arterial partial pressure of oxygen; FiO2, fraction of oxygen

    concentration; ABG, arterial blood gas.

    534 Correspondence / American Journal of Emergency Medicine 37 (2019) 530559

    can give the exact PaO2 value, but is a difficult procedure in prehospital setting; as the authors rightly mention while raising the issue of the need of ABG in pre-hospital care by their study. A tightly managed PaO2 to minimize hyperoxemia is also justified in many of the critically ill situations [7]. But, we feel that the main question is whether we can rigidly control hyperoxemic conditions or not as suggested by Jouffroy R et al. data, or what is the outcome of doing so in such pre-hospital patients requiring mechanical venti- lation? More prospective, randomized study will be required to an- swer this question as well as confirm the findings of the present study.

    Source(s) of support

    Nil.

    Conflicting interest

    Authors declare no conflict of interest.

    Authors’ contributions

    All the authors have contributed in literature search, manuscript preparation and editing.

    Antonio M. Esquinas, MD, PhD

    Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain

    Landoni Giovanni, MD IRCCS San Raffaele Scientific Hospital, Milan, Italy Vita-Salute San Raffaele University, Milan, Italy

    Habib M.R. Karim, MD

    Department of Anaesthesiology and Critical Care, All India Institute of

    Medical Sciences, Raipur PIN-492099, India

    Corresponding author.

    E-mail address: [email protected].

    8 June 2018

    https://doi.org/10.1016/j.ajem.2018.07.015

    References

    de Jonge E, Peelen L, Keijzers PJ, Joore H, de Lange D, van der Voort PH, et al. Associ- ation between administered oxygen, arterial partial oxygen pressure and mortal- ity in mechanically ventilated intensive care unit patients. Crit Care 2008;12(6): R156.

  13. Jouffroy R, Saade A, Saint Martin LC, Philippe P, Carli P, Vivien B. Prognosis value of partial arterial oxygen pressure in patients with septic shock sub- jected to pre-hospital invasive ventilation. Am J Emerg Med 2019;37(1): 56-60.
  14. Chu DK, Kim LH, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018;391 (10131):1693-705.
  15. Hafner S, Beloncle F, Koch A, Radermacher P, Asfar P. Hyperoxia in intensive care, emergency, and peri-operative medicine: Dr. Jekyll or Mr. Hyde? A 2015 update. Ann Intensive Care 2015;5(1):42.
  16. Damiani E, Adrario E, Girardis M, Romano R, Pelaia P, Singer M, et al. Arterial hyperoxia and mortality in critically ill patients: a systematic review and meta- analysis. Crit Care 2014;18:711.
  17. Durlinger EMJ, Spoelstra-de Man AME, Smit B, de Grooth HJ, Girbes ARJ, Oudemans- van Straaten HM, et al. Hyperoxia: at what level of SpO2 is a patient safe? A study in mechanically ventilated ICU patients. J Crit Care 2017;39: 199-204.
  18. Kallet RH, Branson RD. Should oxygen therapy be tightly regulated to minimize hyperoxia in critically ill patients? Respir Care 2016;61:801-17.

    health care utilization following motor vehicle collision is poorly stratified by chronic pain risk: Lessons from the CRASH study?

    Over four million patients present to U.S. Emergency Departments (EDs) annually with acute Musculoskeletal pain (MSP) following a motor vehicle collision [1]. Epidemiologic studies indicate that more than 30% of MVC patients discharged home after ED evaluation still experience significant MSP six weeks post-MVC [2]. Interventions are available to prevent [3-5] and treat [6-8] chronic MSP, including an- algesics, physical rehabilitation, psychotherapy, and multidisciplinary approaches. However, it is unknown if patients utilize health care ser- vices in the weeks following MVC ED visit. Low rates of health utiliza- tion among patients at high risk of chronic MSP, or non-trivial rates among those at low risk of chronic MSP, would suggest a need for im- proved triaging of post-MVC care as stratified approaches to MSP man- agement may improve outcomes and reduce costs [9].

    We evaluated health care utilization in the six weeks following MVC stratified by risk for chronic MSP (health outcomes after six weeks are relatively stable) [10-12]. The data were from a large multi-center pro- spective cohort study of non-Hispanic white adults (18-65 years-old) who presented to an ED within 24 h of a MVC and were subsequently discharged home. This cohort, which was followed for one year post- MVC, is predominantly young (mean = 36-years old; SD = 13), female (61%), and with at least a high school education (76%). Participants were enrolled from eight EDs in four states between February 2009 and October 2011. Health care utilization for MVC-related problems was assessed via self-report survey six weeks after MVC. Data were avail- able from 793 patients. Details of the study methodology are described elsewhere [2, 13]. The study was approved by the Institutional Review Board at each site; all participants provided written informed consent.

    Individual-level risk of chronic MSP was calculated using a previously validated Prediction tool [14] based on 26 risk factors (assessed in the ED) for chronic axial MSP. Chronic MSP was defined as self-reported MVC-related MSP of moderate to severe intensity in at least one body re- gion (neck, shoulders, upper back, and lower back) at the 6 week follow- up and at 6 or 12 month follow-up. Our participants were divided into tertiles of low, medium, or high risk for chronic MSP based on the calcu- lated risk score. Roughly three-quarters (74%) of participants in the high risk tertile ultimately developed chronic MSP (positive predictive value) compared to 40% of medium risk and 20% of low risk participants.

    A larger proportion of participants at high risk for chronic MSP had a visit to at least one provider (69%) compared to medium (52%) and low risk (38%) participants (Table 1). Manual therapy was the most common type of health care utilization by high risk participants (48%), with roughly one-third receiving Physical therapy (33%). Primary care utili- zation was slightly less common (43%) than manual therapy. Visits to primary care providers were the most common utilization among me- dium (37%) and low risk (28%) participants. Very few (3%) low risk par- ticipants utilized medical specialists (i.e., spinal surgeons or neurologist). Only 1 in 20 (6%) high risk participants and 1-2% of me- dium and low risk participants utilized mental health services.

    Several conclusions may be drawn from the above findings. First, the fact that less than half of high risk patients received appropriate MSP health services in the weeks following MVC suggests that there is great opportunity to improve access to care for the secondary pre- vention [3-5] or treatment of chronic MSP [6-8]. This is particularly the case, given the critical need for expert early care to avoid improper early treatment of chronic MSP and/or MSP development in the current opioid epidemic. Second, the very low rates of mental health treatment observed suggest that improving early access to mental health services may provide an opportunity to prevent or improve chronic MSP

    ? Scientific Meeting Presentation: American Pain Society Meeting 2015, Palm Springs, CA.

Leave a Reply

Your email address will not be published. Required fields are marked *