Overt and Occult Hypoxemia in Patients Hospitalized With COVID-19.

Autor: Gadrey SM; University of Virginia School of Medicine, Charlottesville, VA., Mohanty P; Emory University, Atlanta, GA., Haughey SP; University of Virginia School of Medicine, Charlottesville, VA., Jacobsen BA; University of Virginia School of Medicine, Charlottesville, VA., Dubester KJ; University of Virginia School of Medicine, Charlottesville, VA., Webb KM; University of Virginia School of Medicine, Charlottesville, VA., Kowalski RL; University of Virginia School of Medicine, Charlottesville, VA., Dreicer JJ; University of Virginia School of Medicine, Charlottesville, VA., Andris RT; University of Virginia School of Medicine, Charlottesville, VA.; University of Virginia Center for Advanced Medical Analytics., Clark MT; University of Virginia Center for Advanced Medical Analytics.; Nihon Kohden Digital Health Solutions, Inc, Irvine, CA., Moore CC; University of Virginia School of Medicine, Charlottesville, VA.; University of Virginia Center for Advanced Medical Analytics., Holder A; Emory University, Atlanta, GA., Kamaleswaran R; Emory University, Atlanta, GA., Ratcliffe SJ; University of Virginia School of Medicine, Charlottesville, VA.; University of Virginia Center for Advanced Medical Analytics., Moorman JR; University of Virginia School of Medicine, Charlottesville, VA.; University of Virginia Center for Advanced Medical Analytics.
Jazyk: angličtina
Zdroj: Critical care explorations [Crit Care Explor] 2023 Jan 20; Vol. 5 (1), pp. e0825. Date of Electronic Publication: 2023 Jan 20 (Print Publication: 2023).
DOI: 10.1097/CCE.0000000000000825
Abstrakt: Progressive hypoxemia is the predominant mode of deterioration in COVID-19. Among hypoxemia measures, the ratio of the Pao 2 to the Fio 2 (P/F ratio) has optimal construct validity but poor availability because it requires arterial blood sampling. Pulse oximetry reports oxygenation continuously (ratio of the Spo 2 to the Fio 2 [S/F ratio]), but it is affected by skin color and occult hypoxemia can occur in Black patients. Oxygen dissociation curves allow noninvasive estimation of P/F ratios (ePFRs) but remain unproven.
Objectives: Measure overt and occult hypoxemia using ePFR.
Design Setting and Participants: We retrospectively studied COVID-19 hospital encounters ( n = 5,319) at two academic centers (University of Virginia [UVA] and Emory University).
Main Outcomes and Measures: We measured primary outcomes (death or ICU transfer within 24 hr), ePFR, conventional hypoxemia measures, baseline predictors (age, sex, race, comorbidity), and acute predictors (National Early Warning Score [NEWS] and Sequential Organ Failure Assessment [SOFA]). We updated predictors every 15 minutes. We assessed predictive validity using adjusted odds ratios (AORs) and area under the receiver operating characteristic curves (AUROCs). We quantified disparities (Black vs non-Black) in empirical cumulative distributions using the Kolmogorov-Smirnov (K-S) two-sample test.
Results: Overt hypoxemia (low ePFR) predicted bad outcomes (AOR for a 100-point ePFR drop: 2.7 [UVA]; 1.7 [Emory]; p < 0.01) with better discrimination (AUROC: 0.76 [UVA]; 0.71 [Emory]) than NEWS (0.70 [both sites]) or SOFA (0.68 [UVA]; 0.65 [Emory]) and similar to S/F ratio (0.76 [UVA]; 0.70 [Emory]). We found racial differences consistent with occult hypoxemia. Black patients had better apparent oxygenation (K-S distance: 0.17 [both sites]; p < 0.01) but, for comparable ePFRs, worse outcomes than other patients (AOR: 2.2 [UVA]; 1.2 [Emory]; p < 0.01).
Conclusions and Relevance: The ePFR was a valid measure of overt hypoxemia. In COVID-19, it may outperform multi-organ dysfunction models. By accounting for biased oximetry as well as clinicians' real-time responses to it (supplemental oxygen adjustment), ePFRs may reveal racial disparities attributable to occult hypoxemia.
Competing Interests: Dr. Moore is supported by the National Institutes of Health (U01AI150508). Dr. Holder is supported by the National Institutes of Health (K23GM37182), and he has received speaker and consulting fees from Baxter International and Philips, respectively. Dr. Kamaleswaran was supported by the National Institutes of Health (R01GM139967). Dr. Clark is an employee of Nihon Kohden Digital Health Solutions (Irvine, CA). Dr. Moorman has equity in Medical Predictive Science Corporation, Charlottesville, VA, and consults for Nihon Kohden Digital Health Solutions, Irvine, CA, with proceeds donated to the University of Virginia Medical Foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.
(Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)
Databáze: MEDLINE
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