First, do no oxygen

Stephen Bernard MD FACEM FCICM FCCM ASM

First, a story……..

Warren Zapol

Conclusion

A critical care physician can get an arterial line in any artery ……

http://d2npw7jqx38emt.cloudfront.net/content/cardiovascres/61/3/471/F2.large.jpg?width=800&height=600&carousel=1

Dion Stub, Karen Smith, Stephen Bernard, Ziad Nehme, Michael Stephenson, Janet E. Bray, Peter Cameron, Bill Barger, Andris H. Ellims, Andrew J. Taylor, Ian T. Meredith, David M. Kaye for the

AVOID Investigators.

Circulation 2015; 131:2143-50

AVOID StudyAVOID StudyAAir ir VVersus ersus OOxygen xygen IIn ST-elevation n ST-elevation

MyocarMyocarDDial Infarctionial Infarction

Trial DesignParamedics Assess Patient

Symptoms of STEMI <12 hours, O2 Sats ≥ 94%ST-elevation ≥2 contiguous ECG leads

Intended for primary PCI

Stub et al. AHJ 2012;163;3;339-345Clinicaltrials.gov NCT01272713

Exclusion Criteria Oxygen saturation <94% measured on pulse oximeter

Oxygen administration prior to randomizationAltered conscious state

Planned transport to a non-participating hospital

CharacteristicOxygen Arm

N=218No Oxygen Arm

N=223

Status on arrival at the catheterization laboratory  

Oxygen being administered, %† 95.9 7.7

Oxygen dose, median (IQR)† 8.0 (8.0, 8.0) 4.0 (2.0, 8.0)

Pain score, median (IQR) 2.0 (0.0-4.0) 2.0 (0.5-3.5)

Time from Paramedic on scene to hospital arrival, median (IQR)

55.0 (46.0, 69.0) 56.5 (48.0, 68.8)

Cardiac arrest, % 4.6 3.6

Cardiogenic Shock, % 5.0 5.4† P for difference <0.05

SpO2 in patients with STEMI

P trend <0.05

Resuscitation. 2012 Apr;83(4):417-22

Animal studies

Multicenter retrospective cohort study 120 US hospitals 2001-2005 Non-traumatic cardiac arrest within 24 hours

of ICU admission Association between PaO2 of 1st ABG in ICU

and in-hospital mortality-Hyperoxia mortality rate 63%-Hypoxia mortality rate 57%-Normoxia mortality rate 45%

The EXACT pilot study

Reduction of oxygen after cardiac arrest

Phase 2 study

Post VF arrest with pulse oximeter >94%

Paramedics randomise O2 to 2L/min or

>10L/min

Increase to >10L/min if desaturation / re-arrest

The EXACT pilot study

Reduction of oxygen after cardiac arrest

34 patients

5/18 allocated to 2L/min desaturated <94%

0/16 allocated to 10L/min desaturated <94%

The EXACT Phase 3 study

NHMRC funded for 2016-2019

3 States in Australia

1,360 patients post cardiac arrest

Sample size based on 35% to 44% survival

increase

Paramedic randomisation to 4L/min then 2L/min

with target O2 sat 90-94%

Continue allocation through to ICU

Thanks!

@AmbVicMedic

s.bernard@alfred.org.au