Prognostic classification based on P/F and PEEP in invasively ventilated ICU patients with hypoxemia-insights from the MARS study

Fabienne D Simonis, Laura R A Schouten, Olaf L Cremer, David S Y Ong, Gabriele Amoruso, Gilda Cinella, Marcus J Schultz, Lieuwe D Bos, MARS consortium, F M de Beer, L D Bos, G J Glas, J Horn, A J Hoogendijk, R T van Hooijdonk, M A Huson, T van der Poll, B Scicluna, L R Schouten, M J Schultz, M Straat, L A van Vught, L Wieske, M A Wiewel, E Witteveen, M J Bonten, O L Cremer, J F Frencken, K van de Groep, P M Klein Klouwenberg, M E Koster-Brouwer, D S Ong, D M Verboom, Fabienne D Simonis, Laura R A Schouten, Olaf L Cremer, David S Y Ong, Gabriele Amoruso, Gilda Cinella, Marcus J Schultz, Lieuwe D Bos, MARS consortium, F M de Beer, L D Bos, G J Glas, J Horn, A J Hoogendijk, R T van Hooijdonk, M A Huson, T van der Poll, B Scicluna, L R Schouten, M J Schultz, M Straat, L A van Vught, L Wieske, M A Wiewel, E Witteveen, M J Bonten, O L Cremer, J F Frencken, K van de Groep, P M Klein Klouwenberg, M E Koster-Brouwer, D S Ong, D M Verboom

Abstract

Background: Outcome prediction in patients with acute respiratory distress syndrome (ARDS) greatly improves when patients are reclassified based on predefined arterial oxygen partial pressure to fractional inspired oxygen ratios (PaO2/FiO2) and positive end-expiratory pressure (PEEP) cutoffs 24 h after the initial ARDS diagnosis. The aim of this study was to test whether outcome prediction improves when patients are reclassified based on predefined PaO2/FiO2 and PEEP cutoffs 24 h after development of mild hypoxemia while not having ARDS.

Methods: Post hoc analysis of a large prospective, multicenter, observational study that ran in the ICUs of two academic hospitals in the Netherlands between January 2011 and December 2013. Patients were classified into four groups using predefined cutoffs for PaO2/FiO2 (250 mmHg) and PEEP (5 cm H2O), both at onset of hypoxemia and after 24 h: PaO2/FiO2 ≥ 250 mmHg and PEEP < 6 cm H2O (group I), PaO2/FiO2 ≥ 250 mmHg and PEEP ≥ 6 cm H2O (group II), PaO2/FiO2 < 250 mmHg and PEEP < 6 cm H2O (group III), and PaO2/FiO2 < 250 mmHg and PEEP ≥ 6 cm H2O (group IV), to look for trend association with all-cause in-hospital mortality, the primary outcome. Secondary outcome were ICU- and 90-day mortality, and the number of ventilator-free days or ICU-free days and alive at day 28.

Results: The analysis included 689 consecutive patients. All-cause in-hospital mortality was 35%. There was minimal variation in mortality between the four groups at onset of hypoxemia (33, 36, 38, and 34% in groups I to IV, respectively; P = 0.65). Reclassification after 24 h resulted in a strong trend with increasing mortality from group I to group IV (31, 31, 37, and 48% in groups I to IV, respectively; P < 0.01). Similar trends were found for the secondary endpoints.

Conclusions: Reclassification using PaO2/FiO2 and PEEP cutoffs after 24 h improved classification for outcome in invasively ventilated ICU patients with hypoxemia not explained by ARDS, compared to classification at onset of hypoxemia.

Trial registration: ClinicalTrials.gov identifier: NCT01905033. Registered on July 11, 2013. Retrospectively registered.

Keywords: Hypoxemia; ICU-free days; Intensive care unit; Invasive ventilation; Mortality; P/F; PEEP; PaO2/FiO2; Positive end–expiratory pressure; Prognostication; Ventilator-free days.

Conflict of interest statement

None

Figures

Fig. 1
Fig. 1
Patient flow and evolution of patient classification; patients were classified at onset of hypoxemia (green boxes) and after 24 h of standard care (yellow boxes); numbers represent the number of patients per group with the fraction of patients

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