Oxygen supplementation is a cornerstone of supportive medical treatment for critically ill patients. We studied self-reported attitudes towards oxygen therapy and actual clinical practice of ICU... Show moreOxygen supplementation is a cornerstone of supportive medical treatment for critically ill patients. We studied self-reported attitudes towards oxygen therapy and actual clinical practice of ICU clinicians. We found that clinicians are concerned with oxygen induced lung injury and will change mechanical ventilation settings accordingly. However, we performed a large, randomized trial assessing whether a conservative oxygenation strategy resulted in reduced mortality compared to a liberal oxygenation strategy and found there was no significant difference in mortality between the two groups. This thesis has brought to light an important problem of studying ICU patients regarding the consent procedure. We had to exclude patients because no consent had been obtained, losing valuable data and risking selection bias. Afterwards we asked patients how they experienced participating in the trial and most were not aware of their participation but did agree with their participation. This challenges the feasibility of informed consent in critically ill patients. Moreover, we researched disturbances in the homeostasis of sodium and found that an increase in serum sodium was associated with mortality, even in patients with normonatremia and moderate hyponatremia. This challenges the assumption that correcting hyponatremia would lead to lower mortality. Show less
Boeijen, J.A.; Pol, A.C. van de; Uum, R.T. van; Smit, K.; Ahmad, A.; Rijswijk, E. van; ... ; Zwart, D.L.M. 2023
ObjectiveDuring the COVID-19 pandemic new collaborative-care initiatives were developed for treating and monitoring COVID-19 patients with oxygen at home. Aim was to provide a structured overview... Show moreObjectiveDuring the COVID-19 pandemic new collaborative-care initiatives were developed for treating and monitoring COVID-19 patients with oxygen at home. Aim was to provide a structured overview focused on differences and similarities of initiatives of acute home-based management in the Netherlands.MethodsInitiatives were eligible for evaluation if (i) COVID-19 patients received oxygen treatment at home; (ii) patients received structured remote monitoring; (iii) it was not an ‘early hospital discharge’ program; (iv) at least one patient was included. Protocols were screened, and additional information was obtained from involved physicians. Design choices were categorised into: eligible patient group, organization medical care, remote monitoring, nursing care, and devices used.ResultsNine initiatives were screened for eligibility; five were included. Three initiatives included low-risk patients and two were designed specifically for frail patients. Emergency department (ED) visit for an initial diagnostic work-up and evaluation was mandatory in three initiatives before starting home management. Medical responsibility was either assigned to the general practitioner or hospital specialist, most often pulmonologist or internist. Pulse-oximetry was used in all initiatives, with additional monitoring of heart rate and respiratory rate in three initiatives. Remote monitoring staff’s qualification and authority varied, and organization and logistics were covered by persons with various backgrounds. All initiatives offered remote monitoring via an application, two also offered a paper diary option.ConclusionsWe observed differences in the organization of interprofessional collaboration for acute home management of hypoxemic COVID-19 patients. All initiatives used pulse-oximetry and an app for remote monitoring. Our overview may be of help to healthcare providers and organizations to set up and implement similar acute home management initiatives for critical episodes of COVID-19 (or other acute disorders) that would otherwise require hospital care. Show less
For the preterm infant with respiratory insufficiency requiring supplemental oxygen, tight control of oxygen saturation (SpO(2)) is advocated, but difficult to achieve in practice. Automated... Show moreFor the preterm infant with respiratory insufficiency requiring supplemental oxygen, tight control of oxygen saturation (SpO(2)) is advocated, but difficult to achieve in practice. Automated control of oxygen delivery has emerged as a potential solution, with six control algorithms currently embedded in commercially-available respiratory support devices. To date, most clinical evaluations of these algorithms have been short-lived crossover studies, in which a benefit of automated over manual control of oxygen titration has been uniformly noted, along with a reduction in severe SpO(2) deviations and need for manual FiO(2) adjustments. A single non randomised study has examined the effect of implementation of automated oxygen control with the CLiO2 algorithm as standard care for preterm infants; no clear benefits in relation to clinical outcomes were noted, although duration of mechanical ventilation was lessened. The results of randomised controlled trials are awaited. Beyond the gathering of evidence regarding a treatment effect, we contend that there is a need for a better understanding of the function of contemporary control algorithms under a range of clinical conditions, further exploration of techniques of adaptation to individualise algorithm performance, and a concerted effort to apply this technology in low resource settings in which the majority of preterm infants receive care. Attainment of these goals will be paramount in optimisation of oxygen therapy for preterm infants globally. Show less
The side-effects of hyperoxia can be roughly subdivided in cell damage, inflammation, pulmonary complications, neurological symptoms and vascular effects. These features are responsible for the... Show moreThe side-effects of hyperoxia can be roughly subdivided in cell damage, inflammation, pulmonary complications, neurological symptoms and vascular effects. These features are responsible for the large majority of unfavourable effects and increased risk for morbidity and mortality following (prolonged) exposure to hyperoxia. From this thesis, we conclude that careful oxygen titration and monitoring is the best therapeutic strategy aimed at the prevention of potentially dangerous hyperoxia while preserving adequate tissue oxygenation. In this context, conservative oxygenation in the intensive care unit is a promising strategy to achieve better clinical outcomes for critically ill patients. Administering oxygen remains essential to prolong the window of opportunity and provide as much oxygen as necessary in anticipation of or during arterial hypoxia, and to rapidly establish pulmonary vasodilation or systemic vasoconstriction, when other measures are inadequate or fail. At the same time, clinicians should be well aware of the side-effects that are induced by supplying high levels of oxygen, as hyperoxia is also frequently encountered in critically ill patients.In expectation of compelling evidence from future clinical trials, targeting relative normoxia (80-150 mmHg) by avoiding exposure to both subphysiological as well as supraphysiological oxygenation should be considered the most rational choice in most patients. Show less
