Reducing oxygen levels in critically ill children on mechanical ventilators in ICU may improve survival: Lancet

"A conservative oxygenation target among invasively ventilated children admitted as an emergency to a PICU receiving supplemental oxygen, resulted in a small, but significant, greater probability of better outcomes with regards to the duration of organ support at 30 days or death when compared with a liberal oxygenation target," the researchers reported.

There is no information on the optical target for systemic oxygenation in critically ill children. Liberal oxygenation is practised widely but is shown to harm pediatric patients. Prof Mark J Peters, Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK, and colleagues aimed to evaluate whether conservative oxygenation would reduce the duration of organ support or incidence of death compared to standard care.

The researchers conducted a multicentre, pragmatic, multicentre, randomized controlled trial (Oxy-PICU) across 15 UK PICUs. Eligible participants were children older than 38 weeks of corrected gestational age and younger than 16 years of age who had been accepted for admission to a participating PICU as an emergency and were receiving invasive mechanical ventilation with supplemental oxygen.

1,872 children (55% girls; median age 2.6 years) were randomly allocated in a ratio of 1:1 to conservative peripheral oxygen saturations ([SpO2] 88-92%; 939 children) or liberal (SpO2 >94%; 933 children) targets. The primary outcome was the duration of organ support at 30 days after random allocation, a rank-based endpoint with death either on or before day 30 as the worst outcome, with survivors assigned a score between 1 and 30 depending on the number of calendar days of organ support received.

The study led to the following findings:

• Duration of organ support or death in the first 30 days was significantly lower in the conservative oxygenation group (probabilistic index 0·53, Wilcoxon rank-sum test, adjusted odds ratio 0·84).
• Compared with a liberal oxygenation peripheral oxygen saturation (SpO2) target above 94%, a conservative target of 88-92%, therefore, provided a "small, but significant, greater probability for a better outcome" for invasively ventilated children (adjusted OR 0.84).
• Adverse events were similar between the treatment groups, reaching 3% of conservative oxygenation patients and 4% of liberal oxygenation patients. Events included cardiac ischaemia, lactic acidosis, seizures, acute kidney injury, and critical hypotension and hypoxia.

"The findings suggest that widespread adoption of a conservative oxygenation saturation target (SpO2 88-92%) could help reduce costs and improve outcomes for the sickest children admitted to PICUs," the researchers concluded.

Reference:

Peters MJ, Gould DW, Ray S, Thomas K, Chang I, Orzol M, O'Neill L, Agbeko R, Au C, Draper E, Elliot-Major L, Giallongo E, Jones GAL, Lampro L, Lillie J, Pappachan J, Peters S, Ramnarayan P, Sadique Z, Rowan KM, Harrison DA, Mouncey PR; Oxy-PICU Investigators of the Paediatric Critical Care Society Study Group (PCCS-SG). Conservative versus liberal oxygenation targets in critically ill children (Oxy-PICU): a UK multicentre, open, parallel-group, randomised clinical trial. Lancet. 2023 Dec 1:S0140-6736(23)01968-2. doi: 10.1016/S0140-6736(23)01968-2. Epub ahead of print. PMID: 38048787.