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EP.069
Too much of a good thing? Auditing the prescription and titration of Oxygen on a general intensive care unit at a university teaching hospital

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Too much of a good thing? Auditing the prescription and titration of Oxygen on a general ITU at a university teaching hospital

Christopher Hebbes1, Rebecca Perry2, Nathan Sloane2, Andrew Wilkinson2, Alex Keeshan3

Specialty trainee1, Foundation doctor2, and Consultant3 in Anaesthesia and Critical Care

Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust

 

Background

Oxygen is a commonly used drug in hospital.  The complications of inadequate titration and monitoring  can affect multiple organ systems and cause poor outcomes in medical and surgical patients

The British Thoracic Society audit in 2015 found that, despite its high usage, prescription and monitoring of targets for Oxygenation in hospital was poor1.

42.5% of patients had no valid Oxygen prescription

69.0% of patients on Oxygen had an SpO2 target outside of the prescribed range

There is increasing evidence that acute exposure to high concentrations of Oxygen can worsen outcomes in myocardial infarction, traumatic brain injury, surgery, and post cardiac arrest.

WHO recommends supplemental Oxygen to reduce Surgical Site Infection2

Hyperoxia may worse outcomes in Myocardial Infarction3

 

Hyperoxia may worsen mortality in Traumatic Brain Injury4

The recent OXYGEN-ICU1 trial demonstrated a significant reduction in ICU mortality where a SpO2 target of  94-98% (conservative) was used compared to usual treatment 97-100%

Whilst the threshold at which hyperoxia in critical illness becomes deleterious is unknown, this baseline audit aims to evaluate current practice and compliance with the BTS guidelines in target setting and titration of Oxygen therapy in emergency care1.  As a secondary aim, we will quantify hyperoxia on a mixed general ITU.

 

Methods

Retrospective audit of all admissions to the intensive care unit at the Leicester Royal Infirmary during March 2017

Reason and time of admission, any risk of hypercapnic respiratory failure, hourly Oxygen saturations were extracted from the notes.  Arterial blood gases were downloaded from the blood gas analyser.

Data were coded and analysed using SPSS for Windows and R for Linux.  Time to normoxia was analysed using survival curves .

 

Standards

95% of all patients on Oxygen should have an saturation target specified in the ITU medical notes

95% of patients should have an appropriate saturation target documented

 

Results – Target setting

107 patients admitted to intensive care during March 2017

6726 patient hours audited

5291 on Oxygen, 1435 on room air


44.9% Of all patients had a saturation target specified in the ITU medical notes

24.0% Of all patients with a saturation target had appropriate targets with upper and lower limits at any time during admission

26.5% Of patients not at risk of hypercapnic respiratory failure had a saturation target of 94-98% at any time during admission

60.0% Of patients at risk of hypercapnic respiratory failure had a saturation target of 88-92% at any time during admission

 

Results - Oxygen titration

Median time to first normoxic ABG 4.8 hours

No difference between medical and surgical patients

 

Conclusions and action points

Few patients had Oxygen saturation targets specified, and of those, many were not consistent with BTS guidelines

There is a significant time to normoxia for patients which may be improved by Oxygen titration and targeting. Initial hyperoxia is a significant issue

There is increasing evidence that exposure to hyperoxia may cause harm and worsen outcomes in intensive care

Designing and developing training for nurses and junior staff to aid target setting, and titration of Oxygen

Establishing consultant consensus on acceptable default targets for Oxygenation to aid junior staff in target setting setting and prescribing

Troubleshooting guide and flowchart to aid titration of Oxygen added to existing ventilation care bundle

 

References

1.British Thoracic Society Emergency Oxygen Audit Report, 2015
2.World Health Organisation, Global guidelines on the prevention of SSI.  2016
3.Stub, D.  Air Versus Oxygen in ST-Segment–Elevation Myocardial Infarction. Circulation. 2015;131:2143–2150
4.S. R. Asher, Survival advantage and PaO2 threshold in severe traumatic brain injury, Journal of Neurosurgical Anesthesiology, 2013: 25(2),: 68–173
5.Wetterslev J, The effects of high perioperative inspiratory oxygen fraction for adult surgical patients. Cochrane Database Syst Rev. 2015:CD00888
6.Girardis, M. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016;316(15):1583-1589


 

 

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