Hyperoxemia and long-term outcome after traumatic brain injury

Rahul Raj, Stepani Bendel, Matti Reinikainen, Riku Kivisaari, Jari Siironen, Maarit Lång, Markus Skrifvars, Rahul Raj, Stepani Bendel, Matti Reinikainen, Riku Kivisaari, Jari Siironen, Maarit Lång, Markus Skrifvars

Abstract

Introduction: The relationship between hyperoxemia and outcome in patients with traumatic brain injury (TBI) is controversial. We sought to investigate the independent relationship between hyperoxemia and long-term mortality in patients with moderate-to-severe traumatic brain injury.

Methods: The Finnish Intensive Care Consortium database was screened for mechanically ventilated patients with a moderate-to-severe TBI. Patients were categorized, according to the highest measured alveolar-arterial O₂ gradient or the lowest measured PaO₂ value during the first 24 hours of ICU admission, to hypoxemia (<10.0 kPa), normoxemia (10.0 to 13.3 kPa) and hyperoxemia (>13.3 kPa). We adjusted for markers of illness severity to evaluate the independent relationship between hyperoxemia and 6-month mortality.

Results: A total of 1,116 patients were included in the study, of which 16% (n = 174) were hypoxemic, 51% (n = 567) normoxemic and 33% (n = 375) hyperoxemic. The total 6-month mortality was 39% (n = 435). A significant association between hyperoxemia and a decreased risk of mortality was found in univariate analysis (P = 0.012). However, after adjusting for markers of illness severity in a multivariate logistic regression model hyperoxemia showed no independent relationship with 6-month mortality (hyperoxemia vs. normoxemia OR 0.88, 95% CI 0. 63 to 1.22, P = 0.43; hyperoxemia vs. hypoxemia OR 0.97, 95% CI 0.63 to 1.50, P = 0.90).

Conclusion: Hyperoxemia in the first 24 hours of ICU admission after a moderate-to-severe TBI is not predictive of 6-month mortality.

Figures

Figure 1
Figure 1
Study population. TBI, traumatic brain injury; FICC, Finnish Intensive Care Consortium; GCS, Glasgow coma scale; ABG, arterial blood gas analysis.
Figure 2
Figure 2
Locally weighted scatterplot smoothing (lowess) curve showing the relationship between arterial oxygen value (PaO2) and predicted 6-month mortality. Predicted risk of death showed good performance in predicting actual mortality with an area under the curve (AUC) of 0.869 and RL2 of 0.422. A clear association between increased risk of death and low (approximately <11 kPa) PaO2 or values very high (approximately >42 kPa) PaO2 values was noted. The predicted probability of death is calculated using the following variables: acute physiology and chronic health evaluation II (APACHE II) index independent of oxygenation (AP2no-ox), admission year (before or after 2007), emergency operation, intracranial pressure monitoring, controlled hypothermia and platelet count.
Figure 3
Figure 3
Observed and mean predicted in-hospital mortality differences between arterial oxygen tension (PaO2) groups. The difference in mean predicted risk of death was significantly different among the groups (P <0.001), it being highest in the hypoxemia group and lowest in the hyperoxemia group. Predicted risk of death matched observed mortality very well within the quartiles with RL2 values between 0.097 and 0.746. The predicted probability of death was calculated using the following variables: acute physiology and chronic health evaluation II (APACHE II) index independent of oxygenation (AP2no-ox), admission year (before or after 2007), emergency operation, intracranial pressure monitoring, controlled hypothermia and platelet count.
Figure 4
Figure 4
Observed and mean predicted 6-month mortality differences between PaO2 groups. The difference in mean predicted risk of death is significantly different among the groups (p < 0.001), being highest in the hypoxemia group and lowest in the hyperoxemia group. Predicted risk of death matched observed mortality very well within the quartiles with RL2 values between 0.519 and 0.603.
Figure 5
Figure 5
Observed and predicted 6-month mortality by deciles of arterial oxygen tension (PaO2). PaO2 was divided by deciles. Predicted risk of death matched observed mortality very well within deciles with RL2 values between 0.088 and 0.987. The predicted probability of death was calculated using the following variables: acute physiology and chronic health evaluation II (APACHE II) index independent on oxygenation (AP2no-ox), admission year (before or after 2007), emergency operation, intracranial pressure monitoring, controlled hypothermia and platelet count.

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