Effect of maximizing oxygen delivery on morbidity and mortality rates in critically ill patients: A prospective, randomized, controlled study

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Abstract

Objective.

To determine the effects of optimizing oxygen delivery (Do2) to “supranormal” levels on morbidity and mortality in patients with sepsis, septic shock, and adult respiratory distress syndrome.

Design.

A prospective, randomized, controlled trial.

Setting.

A 16-bed surgical intensive care unit (ICU) and 14-bed mixed medical/surgical ICU in two separate hospitals in the University of Hawaii Surgical and Internal Medicine Residency programs.

Patients.

During a 1-yr period, 67 patients who had pulmonary artery catheters and who met the criteria for sepsis or septic shock, adult respiratory distress syndrome, or hypovolemic shock were enrolled in the study. Patients admitted to the ICU who were <18 yrs old, or with a do-not-resuscitate order, or those patients who faced imminent death (<24 hrs), such as those patients with uncontrollable hemorrhage or brain death, were excluded from the study.

Interventions.

Patients were randomized into treatment and control groups. The treatment group was assigned a therapeutic Do2 indexed (Do2I) goal of >600 mL/min/m2. Interventions to attain this goal included fluid boluses, administration of blood products, and the use of ino-tropes. The control group was not assigned to a specific therapeutic goal other than “normal” values of Do2I of 450 to 550 mL/min/m2. Every attempt was made to reach the therapeutic goals within the first 24 hrs after entry into the study.

Interventions.

Hemodynamic measurements were obtained on study patients every 4 hrs until the end of die study. The severity of illness was evaluated using the Therapeutic Intervention Scoring System, and the Acute Physiology and Chronic Health Evaluation II scoring system.

Measurements and Main Results.

There were 32 patients in the control group and 35 patients in the treatment group. The groups were similar in age, sex, number of organ dysfunctions, Acute Physiology and Chronic Health Evaluation II and Therapeutic Intervention scores. There woe no statistical differences between the two groups in mortality, development of organ failure, ICU days, and hospital days. Upon analysis, it became apparent that the patients comprised clinically distinct subgroups, including: a) a treatment group who achieved supranormal Do2I; b) a control group with normal Do2I; c) a treatment group who failed to reach target Do2I; d) a control group who self-generated to high Do2I; values; and e) a small number of patients who could not even reach a normal Do2I of 450 mL/ min/m2. These subgroups were found to be similar and matched. The mortality rate was significantly lower for patients in groups who reached supranormal values of Do2I whether treated or self-generated as compared with patients who reached normal Do2I values (14% vs. 56%, .01).

Conclusions.

Although there was no stat cally significant difference in the contr treatment groups, subgroup analysis strated a strong, significant difference patients with supranormal values of transport vs. patients with normal levels Supranormal values of Do2I, whether self ated or as a result of treatment, results statistically significant decrease in rate. This study adds to the weight of

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