Oxygen Toxicity Risks of VA-ECMO
A study notes the possibility of exposure to severe hyperoxia for patients receiving VA-ECMO.
Among adults with cardiogenic shock receiving veno-arterial extracorporeal membrane oxygenation (VA-ECMO), severe hyperoxia at 24 hours is associated with significantly increased in-hospital mortality, driven primarily by direct oxygen toxicity rather than end-organ complications.
“Hyperoxia and End-Organ Complications Among Cardiogenic Shock Patients Supported by Veno-Arterial Extracorporeal Membrane Oxygenation,” in Critical Care Medicine, emphasizes the need for specific strategies to optimize oxygen delivery for this critically ill population.
The multicenter, multinational study analyzed data from 10,541 adults with cardiogenic shock supported by VA-ECMO between 2010 and 2023, using the Extracorporeal Life Support Organization Registry. Patients were stratified by oxygen levels at 24 hours to assess associations with mortality and organ dysfunction.
At the 24-hour mark, patients with severe hyperoxia had the highest in-hospital mortality at 71.7%, compared with mild hyperoxia (63.8%) and normoxia (52.7%). Although hyperoxia was linked to more end-organ complications, 86% of the effect on mortality was due to direct oxygen toxicity, with only 14% attributed to complications such as neurologic, renal, hepatic and bleeding events.
“This analysis highlights the potential dangers of exposure to severe hyperoxia in VA-ECMO patients and suggests that the key mechanisms linking hyperoxia with mortality remain to be elucidated as they appear to exist outside of commonly recognized complications,” the study notes.
More research is needed to validate the findings and identify organs that are most susceptible to hyperoxia. “Knowing which end-organs are more vulnerable to hyperoxia can assist inpatient selection and alert clinicians to which patients may require more judicious use of oxygen,” the study adds.
AACN offers an array of evidence-based resources and continuing education opportunities focused on ECMO therapy, including a microcredential. From foundational knowledge to advanced clinical strategies, these materials help nurses deepen their understanding, stay current with best practices and deliver safe, effective care to patients receiving this complex life-support modality.
Rethinking ABC: Hemorrhage Control in Trauma Care
Evidence supports shifting away from the traditional ABC-first approach.
Prioritizing hemorrhage control over airway and breathing, an approach known as x-ABC, can significantly improve survival in patients with life-threatening bleeding, reinforcing its importance in prehospital and early in-hospital care.
“x-ABC Versus ABC: Shifting Paradigms in Early Trauma Resuscitation,” in Trauma Surgery & Acute Care Open, notes that exsanguination is the leading cause of preventable death after trauma, and evidence supports shifting away from the traditional ABC-first approach (airway, breathing and circulation) in military and civilian practice.
When no significant anatomic injury or severe hypoxia is present, care teams should focus on aggressive bleeding control using tourniquets, hemostatic dressings and blood products, the review adds, followed by immediate transfer to surgery for torso hemorrhage control.
According to the review, battlefield experiences in Iraq and Afghanistan exposed limitations to the ABC approach, which often failed to address life-threatening hemorrhage. Civilian trauma research noted related findings.
Specifically, in Miami-Dade County, Florida, medical examiner data shows that 28.5% of prehospital deaths were potentially survivable, and 54.1% of those were due to hemorrhage, mostly from chest injury. A Pittsburgh study reports that each one-minute delay in early resuscitation increases the odds of 24-hour and 30-day mortality by 2%.
Whether hypotensive trauma patients with GCS <8 should be intubated first — as traditionally taught — remains a point of debate, since altered mental status may be caused by hemorrhagic shock. The review cites studies that link early intubation to increased mortality, while circulation-first strategies, such as early transfusion and vasopressin, may improve blood pressure, reduce cardiac arrest and decrease 24-hour mortality.
“Overall, whether prehospital or in hospital, exsanguinating patients in the civilian center do better if intubation is avoided and resuscitation is prioritized,” the review adds. “One could make the argument that stopping bleeding and resuscitating these patients is the best treatment of airway by restoring circulation and cerebral perfusion.”
Trauma Patients With Delirium and Effect on Quality of Life
For patients with TBI, potentially treatable components of delirium may be under-recognized.
Severely injured adult trauma patients likely experienced delirium during their ICU stays and have reduced quality of life a year after discharge if they did have delirium.
In “Delirium After Major Trauma Critical Care and the Association With Recovery at 12 Months,” a retrospective study in Trauma, follow-up questionnaires indicate that about two-thirds of patients experienced delirium while hospitalized, but only 44% of patients with delirium received psychological support after discharge. “Psychological problems were greater after in-hospital delirium, and longer-term support for these patients appears to be limited,” the study notes.
The study of 285 patients – who received trauma care at one of four critical care units in London for 18 months starting in 2017 – found that 180 (63%) reported delirium. There were 102 patients with traumatic brain injury (TBI), and they accounted for 40% of those reporting delirium but 28% of those who did not; otherwise, there were no notable differences in demographics.
Patients with delirium had a higher incidence of multiple organ dysfunction (67% vs. 52%), longer critical care (12 days vs. 7 days) and longer hospital stays (30 days vs. 22 days). A year post-discharge, patients with delirium reported more days per month with difficulties managing activities (22 vs. 17) and more days where they had to reduce or eliminate activities (7 vs. 4).
The study notes that patients with TBI may have symptoms related to their injury and brain damage that mimic delirium symptoms and make them more difficult to distinguish. “There is a risk that in cases of TBI, functional and potentially treatable components of delirium may be under-recognised and go undertreated,” the study adds.
AACN offers many resources on delirium, including continuing education, journals and nurse stories. Clinicians can refer to these tools to improve their recognition and management of delirium in intensive care patients.
High Blood Pressure Guidelines Include Effective Strategies
Collaborate to implement BP screening and guideline-based recommendations.
Guidelines note that preventing and managing high blood pressure (BP) even well into middle age offers significant benefits for patients.
“2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines,” in Circulation, retires and replaces the 2017 guideline. It includes significant changes in recommendations and emphasizes the range of opportunities to help adult patients manage BP.
“Clinicians should collaborate with community leaders, health systems and practices to implement screening of all adults in their communities and implement guideline-based recommendations regarding prevention and management of high blood pressure to improve rates of blood pressure control,” the report notes.
Additional key take-home messages in the user-friendly report include the need for multidisciplinary team care, healthy eating education, medication therapies, treatment goals for pregnancy and the use of at-home tools. Emphasizing the need to enhance diagnosis worldwide, the report adds, “Current rates of awareness, treatment, and control of hypertension remain far below target levels for all groups and demonstrate important age- and race-based disparities.”
A related study of data from over 2 million people, “Global Effect of Cardiovascular Risk Factors on Lifetime Estimates,” in The New England Journal of Medicine, discusses the five primary risk factors for cardiovascular disease and how BP modifications are one of the significant ways to improve life expectancy. “As compared with no changes in the presence of all risk factors, modification of hypertension at an age of 55 to less than 60 years was associated with the most additional life-years free of cardiovascular disease, and modification of smoking at an age of 55 to less than 60 years was associated with the most additional life-years free of death,” notes the related study.
Hypertonic Saline vs. Mannitol in Pediatric TBI
Future large multicenter randomized clinical trials may validate the study findings.
Administering hypertonic saline (HTS) to control elevated intracranial pressure in children with moderate to severe traumatic brain injury (TBI) does not improve survival or functional outcomes compared with mannitol.
“Clinical Outcomes of Hypertonic Saline vs Mannitol Treatment Among Children With Traumatic Brain Injury,” in JAMA Network Open, noted no statistically significant differences in mortality rates at 7.1% for the HTS group vs. 11.0% for those receiving mannitol. The prospective, multicenter, cohort study involved 445 patients with a median age of 5 years.
The study also observed no differences in neurologic outcomes (PCPC scores at discharge, GOS-E Peds scores at three months) or clinical course measures, including mechanical ventilation time, pediatric ICU stay, hospital stay or seizure occurrence.
The study enrolled children with moderate to severe TBI. They were younger than 18 years with a Glasgow Coma Scale score of ≤13 across 28 pediatric ICUs in Asia, Latin America and Europe between June 2018 and December 2022. Severe injury was noted in 77.3%. Treatment varied with 41.3% receiving hypertonic saline, 18.4% mannitol, 15.5% both and 24.7% receiving neither.
For outcome comparisons, patients were grouped by exposure to 3% HTS, 20% mannitol, both agents or neither. Children who received both were more likely to present with cerebral edema and diffuse axonal injury and had higher mortality and poorer GOS-E Peds scores — patterns the study interprets as markers of greater injury severity rather than treatment effect.
“However, future studies will need to investigate details on clinical severity, the specific dosages of each type of drug, and other TBI management strategies, as well as their association with clinical outcomes,” the study adds.
Limitations include differences between the study’s patient population and prior research, such as inclusion of children with moderate brain injury and inconsistent monitoring of brain pressure. Because treatment practices varied and data on pressure levels was limited, the findings cannot confirm cause-and-effect relationships or be applied to all settings.
Critical Care Pharmacist Interventions Associated With Better Outcomes
The average treatment was positive with increases in the quantity and intensity of interventions.
More high-intensity medication interventions by critical care pharmacists (CCPs) increased the survival rates of critically ill adult patients and decreased their time in intensive care.
“Effect of Comprehensive Medication Management on Mortality in Critically Ill Patients,” in Critical Care Medicine, a study of comprehensive medication management (CMM) that focused on medication regimen complexity (MRC), found benefits across a range of outcomes.
“After applying rigorous causal inference methods to evaluate the impact of CCP delivery of CMM on mortality and length of stay, and controlling for multiple patient factors including severity of illness and ICU MRC, we observed patients who receive more pharmacist medication interventions and interventions with a higher intervention intensity had lower rates of mortality and a reduced length of ICU stay,” the study adds.
The retrospective, observational propensity-matched study at Oregon Health Sciences University involved 10,441 adult ICU patients from June 2020 to June 2023 and used propensity matching to create treatment and control groups. Aside from one subgroup in the study, the average treatment effect was positive with an increase in the quantity and intensity of interventions.
The study observes that CMM can improve patient safety and quality of care as well as generate cost savings through reduced ICU stays. “Our results also highlight that CCP workload should be monitored given high workload may reduce CMM quality and adversely affect patient outcomes.”
Study limitations include the possibility of inaccurate or incompletely recorded pharmacist interventions when reviewed retrospectively, a lack of data on patient outcomes beyond 90 days, and no measurement of the pharmacists’ experience or training levels. The study proposes the possibility of using artificial intelligence models “to cross-verify the causal pathway and the results.”
President’s Column: The Gift of Partnership
In her column, AACN President Rebekah Marsh celebrates how professional nursing organizations partner and align to shape the future of nursing. She explores some recent AACN successes and how consensus-building sparks a source of renewal and inspiration.
Carrying the Torch: A Nurse’s Legacy
For Nick Souza, a former marketing professional turned critical care nurse, nursing is more than a profession – it’s a legacy three generations in the making. Driven by a deep belief in lifelong learning and mentorship, Souza says, “I hope to inspire others to always strive to be better, not only for their patients but for themselves.”