This is not the most recent version of the article. View current version (17 MAR 2014)

Intervention Review

You have free access to this content

Pulse oximetry for perioperative monitoring

  1. Tom Pedersen1,*,
  2. Karen Hovhannisyan2,
  3. Ann Merete Møller3

Editorial Group: Cochrane Anaesthesia Group

Published Online: 7 OCT 2009

Assessed as up-to-date: 30 APR 2009

DOI: 10.1002/14651858.CD002013.pub2


How to Cite

Pedersen T, Hovhannisyan K, Møller AM. Pulse oximetry for perioperative monitoring. Cochrane Database of Systematic Reviews 2009, Issue 4. Art. No.: CD002013. DOI: 10.1002/14651858.CD002013.pub2.

Author Information

  1. 1

    Rigshospitalet, Head and Orthopaedic Center, Copenhagen Ø, Denmark

  2. 2

    Rigshospitalet, The Cochrane Anaesthesia Review Group, Copenhagen, Denmark

  3. 3

    Herlev University Hospital, The Cochrane Anaesthesia Review Group, Rigshospitalet & Department of Anaesthesiology, Herlev, Denmark

*Tom Pedersen, Head and Orthopaedic Center, Rigshospitalet, HOC 2101, Rigshospitalet, University of Copenhagen,Blegdamsvej 9, Copenhagen Ø, DK-2100, Denmark. doctp@yahoo.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 7 OCT 2009

SEARCH

This is not the most recent version of the article. View current version (17 MAR 2014)

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

The introduction of the pulse oximeter, a clinical monitor of oxygen saturation and pulsation levels, has made it possible to monitor perioperative hypoxaemia with a non-invasive continuous measuring technique (Severinghaus 1992).

The greatest value of pulse oximetry is its ability to provide an early warning of hypoxaemia. Hypoxaemia is one of the most feared adverse events during anaesthesia and in the recovery period. For the individual patient, it is unpredictable at which level of hypoxaemia the brain, heart, and other organs suffer from hypoxaemia and to what extent irreversible damage may arise. Many factors, such as cardiac output, haemoglobin concentration, and oxygen demand, affect the lowest tolerable value of oxyhaemoglobin saturation (Bendixen 1963). The occurrence and possible pathogenesis of perioperative hypoxaemia were described many years ago (Laver 1964; Nunn 1965).

Monitoring with pulse oximetry might improve patient outcomes by enabling an early diagnosis and, consequently, correction of perioperative events that might cause postoperative complications or even death (Cooper 1984). An operational definition of such an event is an undesirable incident that required intervention and did, or possibly could, cause complications or death. Such events may be attributed to pathophysiologic processes, malfunction of the gas supply or equipment, or human error, for example oesophageal intubation or anaesthetic mismanagement. For many of these events, hypoxaemia is possibly the most common mechanism responsible for the eventual adverse outcomes (Cooper 1987).

Recent studies have suggested that hypoxaemia is common in the operating theatre and recovery room. Monitoring with pulse oximetry permits early diagnosis and treatment of hypoxaemia, thus reducing the incidence and severity of this condition (Canet 1991; Cote 1991). Only a few randomized clinical trials of pulse oximetry have been performed during anaesthesia and in the recovery room that describe perioperative hypoxaemic events, postoperative cardiopulmonary complications, and cognitive dysfunction (Cote 1988; Cote 1991; Moller 1998; Møller 1994). It was recently hypothesized that continuous pulse oximetry would reduce unplanned respiratory and total admissions to the intensive care unit (ICU) for cardiothoracic postoperative patients in the general surgical care area, and decrease length of ICU readmission (Ochroch 2006).

Many departments and societies of anaesthesiology have adopted standards for perioperative patient monitoring, including the use of pulse oximetry, in order to improve anaesthesia care in accordance with the hypothesis that this may reduce perioperative complications.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

To study the use of perioperative monitoring with pulse oximetry to clearly identify the adverse outcomes that might be prevented or improved by its use.

The following hypotheses were tested.

  1. The use of pulse oximetry is associated with an improvement in the detection and treatment of hypoxaemia.
  2. Early detection and treatment of hypoxaemia reduces morbidity and mortality in the perioperative period.
  3. The use of pulse oximetry per se reduces morbidity as well as mortality in the perioperative period.
  4. The use of pulse oximetry reduces unplanned respiratory admissions to the ICU and decreases length of ICU readmission, or both.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included all randomized and quasi-randomized controlled trials dealing with the use of pulse oximetry or no pulse oximetry during the perioperative period, including in the operating and recovery rooms. We included trials irrespective of blinding, number of patients randomized, or language of the article.

 

Types of participants

We included patients,18 years of age or older, undergoing surgery with anaesthesia.

 

Types of interventions

We included the following interventions: pulse oximetry or no pulse oximetry during the anaesthesia and recovery period.

 

Types of outcome measures

 

Primary outcomes

The primary outcome measures were postoperative complications and mortality from all causes, assessed at the end of the follow-up period scheduled for each trial.

  1. Any serious complications that occurred during anaesthesia or in the postoperative period: admittance to postoperative intensive care due to: respiratory insufficiency, circulatory insufficiency, or infections; respiratory insufficiency due to pneumonia (fever, chest x-ray, or positive culture), atelectasis (chest x-ray), pneumothorax (diagnosed on chest x-ray), or requiring intervention; cardiovascular insufficiency (cardiac arrest, cardiac failure, myocardial infarction); renal and hepatic insufficiency; neurologic and cognitive dysfunction (measuring memory function with the Weschler memory scale); serious infection requiring antibiotics.
  2. Intra- or postoperative mortality.

 

Secondary outcomes

  1. Events detectable by pulse oximetry:
    1. hypoxaemia (pulse oximetry estimate of arterial oxyhaemoglobin saturation (SpO2) less than 90%, corresponding to an arterial oxygen tension less than 7.9 kPa).
  2. Causes of events:
    1. patient respiratory causes of hypoxaemia (pneumothorax, bronchospasm, air embolus, respiratory depression, apnoea, airway obstruction, pneumonia, ventilatory failure, and pulmonary emboli;
    2. patient mechanical causes of hypoxaemia (oesophageal or main stem intubation, mucus plug, kinked endotracheal tube);
    3. delivery system causes of hypoxaemia (anaesthesia machine, and gas supply problems).
  3. Interventions that may prevent, attenuate, or shorten these events:
    1. airway support;
    2. endotracheal intubation;
    3. manual or mechanical ventilation;
    4. oxygen treatment;
    5. pressors and inotropes;
    6. fluid treatment.

 

Search methods for identification of studies

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2009), see Appendix 1; MEDLINE via OvidSP (1966 to May 2009), see Appendix 2; EMBASE via OvidSP (1980 to May 2009), see Appendix 3; CINAHL via EBSCO host (1982 to May 2009), see Appendix 4; ISI Web of Science (1956 to May 2009), see Appendix 5; and LILACS via the BIREME interface (1982 to May 2009), see Appendix 6. We searched the following databases of ongoing trials with the free text terms: oximetry, oxymetry or pulse oximetry.

  1. Current Controlled Trials including the UK Clinical Trials Gateway and The Wellcome Trust

We handsearched the bibliography of each article for relevant references.

We did not impose any language restriction.

 

Data collection and analysis

 

Trial identification

We selected trials to be included in the systematic review based on the results of the search strategy. One author (KH) scanned the titles and abstracts of reports identified by electronic searching to produce a list of possibly relevant reports. Two authors (TP, AM) independently assessed all studies for inclusion. We retrieved all eligible studies in full text.

 

Quality assessment

We considered the methods and adequacy of randomization, blinding, and description of withdrawals in the quality assessment. We defined a clear account of a successful randomization as that where: adequate measures were taken to conceal allocation (for example central randomization; serially numbered, opaque, sealed envelopes; or another description that contained elements convincing of adequate concealment). The randomization and allocation concealment method was assessed for each study and defined as A (centralized randomization by telephone; numbered or coded identical containers administered sequentially; on-site computer system which could only be accessed after entering the characteristics of an enrolled participant; sequentially numbered, sealed, opaque envelopes); B (sealed envelopes but not sequentially numbered or opaque; list of random numbers read by someone entering patient into trial; a trial in which the description suggested adequate concealment but other features were suspicious, for example markedly unequal control and trial intervention groups; stated random but unable to obtain further details); C (any allocation procedure that was transparent before assignment, for example an open list of random numbers, alteration, date of birth, day of week, case record number); or D (not described).

 

Data extraction

We extracted the following data on the randomization and blinding procedures:

  1. number of randomized patients;
  2. number of patients not randomized and the reasons for this;
  3. exclusion after randomization;
  4. drop-outs;
  5. blinding of patients and observers.

We extracted data on perioperative complications and deaths.

 

Statistics

We used the statistical package MetaView in Review Manager (RevMan 5.0) provided by The Cochrane Collaboration.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

In this new update we re-ran our searches for the period from 2002 to May 2009. In our original review we found six studies (Pedersen 2003a) however two studies were ineligible for analysis, so four studies with 21,773 participants were included. In our updated search we found one new study with 1219 participants (Ochroch 2006).

See the tables 'Characteristics of included studies' and 'Characteristics of excluded studies' for more information. The results of our latest search are in Figure 1.

 FigureFigure 1. Search results

 

Risk of bias in included studies

This section lists only the type of trial and methods of allocation concealment used. The identified reports of studies had other flaws which might affect the validity of the study findings. These are further described under 'Results'.

Bierman 1992
Randomized trial, single-blinded outcome assessment. Method of randomization unknown.

Moller 1992a
Randomized trial. Method of randomization unknown.

Moller 1993b
Quasi-randomized trial, blinded comparison. Patients were allocated to an operating theatre after pulse oximeters were allocated randomly to 50% of those theatres. Allocation concealment was by use of coded, sealed envelopes.

Moller 1993c
Quasi-randomized study. Elective patients admitted for an operation were allocated to an operating theatre after pulse oximeters were allocated randomly to 50% of those theatres. Allocation concealment was by use of coded, sealed envelopes. For emergency operations, a numbered envelope containing the random assignment for each patient was drawn from a stack.

Ochroch 2006
Randomized trial. Patients were allocated using sequential, sealed envelopes containing randomly-generated group assignments.

 

Effects of interventions

Searching yielded five reports. All outcome measures in the included studies were extracted and are detailed in the table 'Characteristics of included studies'. The types of outcome measures were separated into events detectable by pulse oximetry that could result in complications, and perioperative complications. This is considered in the same way below.

Studies used a number of different ways of assessing the postoperative outcome.

  1. Events with hypoxaemia measured either with blood gas analysers or pulse oximetry (two trials).
  2. Tests of cognitive function: Wechsler memory scale, continuous reaction time, and subjective perception of cognitive dysfunction (test of memory) (one trial).
  3. Clinical outcome: respiratory, cardiovascular, and neurologic complications following anaesthesia (one trial).
  4. Unplanned respiratory admissions to the ICU, decreased length of ICU readmission, or both (one trial).

 

Studies using blood gas analysis and pulse oximetry to assess hypoxaemia

In the study of Bierman 1992 the staff were instructed to use the pulse oximetry data in lieu of arterial blood gas analysis, whenever possible, in group one. The desaturation alarm on the oximeters was set to sound at values less than or equal to 93%. For patients in group two, blood gas analyses were obtained every hour or more frequently as clinically indicated; these patients were monitored with a modified pulse oximeter from which the SpO2 was recorded continuously at a distant site but not displayed at the bedside. The alarms for desaturation and pulse rate were deactivated in the bedside unit. Utilization of pulse oximetry allowed a significant reduction in the use of arterial blood gas measurement without adverse events. Clinically unapparent desaturations were detected in 7 of 15 patients in the group without pulse oximetry compared to none in the pulse oximetry group. The number of changes in ventilatory support per postoperative intensive care unit (ICU) stay was not different between the groups, whereas the dose of supplemental oxygen was adjusted more frequently in the group without pulse oximetry. There was no evidence of a significant difference between groups regarding the duration of postoperative mechanical ventilation or ICU stay.

Moller 1992a found that hypoxaemia was reduced in the pulse oximetry group, both in the operating theatre and in the recovery room. During observation in the recovery room the incidence of hypoxaemia in the pulse oximetry group was 1.5 to 3 times less, and no patient experienced extreme or severe hypoxaemia. In the pulse oximetry group the lowest recorded SpO2 value in the recovery room (mean 89.4%) was greater than the value in the group without pulse oximetry (mean 87.2%).

As a consequence of pulse oximetry monitoring, changes were made in the recovery room for several interventions: the patients in the oximeter group received an increased fraction of inspired oxygen (FiO2), more patients received naloxone, and the patients had a longer stay (Moller 1993c). The number of patients discharged from the recovery room with an order for supplemental oxygen was 13.3% in the oximeter group and 3.5% in the control group. The higher rate of patients treated with naloxone in the oximetry group may be an example of how the oximeter readings pointed to a problem to which the staff reacted. Indeed, the study authors found that the extent of hypoxaemia may be reduced by pulse oximeter monitoring but, even with the information provided, patients still developed hypoxaemia. No results were given regarding postoperative complications in the two groups.

 

Study using tests of cognitive dysfunction

Moller 1993b demonstrated that the postoperative cognitive function, as measured by the Wechsler memory scale and continuous reaction time, was independent of perioperative monitoring with pulse oximetry. The postoperative subjective reports (by questionnaire) of cognitive deficits revealed no statistically significant difference: 7% in the pulse oximetry and 11% in the group without pulse oximetry believed their cognitive abilities had decreased. There was no statistically significant difference in the ability to concentrate (10% versus 9%). The study showed no evidence of less postoperative cognitive impairment after perioperative monitoring with pulse oximetry.

 

Study using clinical measures of complications to the time of discharge

The study of Moller 1993c, including 20,802 surgical patients randomly assigned to monitoring with pulse oximetry or not, found that one or more postoperative complications occurred in 10% of the patients in the oximetry group and in 9.4% in the control group. The two groups did not differ in the number of cardiovascular, respiratory, neurologic, or infectious complications. The duration of hospital stay was a median of five days in both groups. An equal number of in-hospital deaths occurred in the two groups, 1.1% in the oximeter group and 1.0% in the control group; a total of seven deaths were classified as possibly anaesthesia related, three deaths in the oximetry group and four in the control group. The seven deaths did not display any specific pattern. A questionnaire that was completed by the anaesthesiologists revealed that 18% of the anaesthesiologists had experienced a situation in which a pulse oximeter helped to avoid a serious event or complication and that 80% of the anaesthesiologists felt more secure when they used a pulse oximeter. Although monitoring with pulse oximetry prompted a number of changes in patient care, there was no evidence of a reduction in the overall rate of postoperative complications using perioperative pulse oximetry.

 

Study using pulse oximetry monitoring on intensive care unit admissions from postsurgical care

The study of Ochroch 2006 included 1219 patients enrolled from approximately 8300 patients who met the eligibility criteria. Rates of readmission to the ICU were similar in the monitored and unmonitored groups. Of the 93 patients (8% of all participants) who were transferred to the ICU after enrolment, 40 were in the monitored group of 589 participants (6.7%) and 53 were in the unmonitored group of 630 participants (8.5%) (P < 0.33). Participants transferred to the ICU did not differ from those not transferred to the ICU (“discharged”) in terms of age, gender, race, or surgical service. Starting in the cardiothoracic intensive care unit (CTICU) before transfer to the study floor was significantly associated with return to an ICU (odds ratio (OR) 2.1; 95% confidence interval (CI) 1.3 to 4.9; P < 0.001). The reasons for transfer back to the ICU (determined by blinded review of the ICU transfer notes) differed between monitored and unmonitored groups, with more pulmonary events in the unmonitored group compared with the continuous pulse oximetry (CPOX) monitored group (27 versus 8; P < 0.003). The use of CPOX did not impact on duration of stay in the hospital or total estimated cost of hospitalization when examining the entire cohort. Routine CPOX and usual care groups had similar numbers of days from enrolment to discharge from the study, number of days from enrolment to discharge from the hospital, estimated costs while on the study floor, and estimated costs for the entire hospital stay. There were 14 in-hospital deaths in each group. The effects of the deaths on the study outcomes were assessed by re-examining the study outcomes without these patients’ data, in a sensitivity analysis. The deaths did not affect outcomes or produce or enhance differences between groups.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

The studies confirmed that pulse oximetry can detect hypoxaemia and related events. The conflicting subjective and objective results of the studies, despite an intense methodical collection of data from a relatively large population, indicate that perioperative monitoring with pulse oximetry can reduce pulmonary events, but in general monitoring does not lead to improvements in patient outcomes, or effectiveness and efficiency of care.

 

Perioperative hypoxaemia and postoperative complications

Comparisons of the overall rates of perioperative hypoxaemia and postoperative complications are difficult with the present randomized studies because of the limited number of studies and participants, and differences in the types of outcomes investigated. It appears that the general rates of hypoxaemia and complications in the present studies are at the same level as reported in other studies (Mlinaric 1997; Moller 1998; Pedersen 1994; Rheineck 1996; Stausholm 1997).

The demonstration of reduced extent of hypoxaemia, the ability to detect and correct potential harmful events and to make several changes in patient care with pulse oximetry monitoring is in contrast to the fact that no reduction in the number of postoperative complications was found (Moller 1993c). The fact that patients monitored with pulse oximetry have no change in outcome, despite the fact that they tend to be given more oxygen and naloxone (Moller 1993c), is worth emphasizing. It indicates that merely increasing saturation levels from marginal to satisfactory is probably not going to make any difference in patient outcomes. In other words, the use of pulse oximetry as an early warning of moderate hypoxaemia does not appear to be beneficial even if the appropriate responses are instituted earlier than they would have been without pulse oximetry. This result conflicts with most anaesthesiologists' beliefs. In the closed claims analyses of adverse respiratory events in anaesthesia, reviewers judged that better monitoring would have prevented adverse outcome in 72% of the claims (Caplan 1990; Tinker 1989). In the general analysis of the role of monitoring devices in the prevention of anaesthetic mishaps, nearly 60% of the instances of death and brain damage were considered preventable by application of additional monitors. These studies exhibit a number of limitations including absence of a control group, a probable bias toward adverse outcomes, and reliance on data from the participants rather than objective observers.

The study of Moller 1993c showed that 18% of the participating anaesthesiologists reported one or more situations in which they thought pulse oximetry helped to avoid a serious event or complication. This subjective reporting suggests an effect of pulse oximetry monitoring on outcome, but objective figures for the rate of postoperative complications does not confirm this. There was also a large contrast between the objective results of the study of Moller 1993c and the subjective opinions of the participating anaesthesiologists regarding the usefulness of pulse oximetry.

 

Postoperative cognitive dysfunction

The relationship between perioperative hypoxaemia and impaired postoperative cognitive function is debated (Krasheninnikoff 1993). Moller 1993b found that 9% of the surgical patients thought that their mental function had deteriorated. In a more recent study (Moller 1998) postoperative cognitive dysfunction in the elderly, as identified with neuropsychological tests, was present in 25.8% of patients one week after surgery, and in 9.9% three months after surgery. However, hypoxaemia was not a significant risk factor for cognitive dysfunction at any time. Perioperative monitoring with pulse oximetry did not appear to affect the patients' postoperative cognitive function.

 

Pulse oximetry monitoring on intensive care unit admissions from postsurgical care

The randomized clinical trial of third generation CPOX technology (Ochroch 2006) reported that monitoring did reduce respiratory readmissions to an ICU after cardiothoracic surgery. It is possible that CPOX monitoring increases overall nursing vigilance, resulting in increased non-respiratory ICU transfers. If appropriate, such transfers may contribute to the benefits of CPOX observed in this study. If such transfers represent inappropriately aggressive care then there is the potential for routine CPOX monitoring to further reduce ICU readmissions with further training of nurses. If there is a real benefit of CPOX in reducing ICU transfer, the lack of reduction in the absolute rate of return to an ICU by CPOX use can also be considered a dilutional effect. The large group of patients who did well regardless of the monitoring overwhelms any beneficial effect of monitoring in the much smaller group who may have benefited from the monitoring. This is similar to the perioperative data, which show a decreased rate of hypoxaemia when pulse oximetry is used (Moller 1992a) but no change in rare outcomes (myocardial infarction, stroke, and death) (Moller 1993c). In conclusion, in this population of patients the use of CPOX was associated with reduced postoperative ICU admission for pulmonary complications. Routine CPOX monitoring was not associated with an overall decreased transfer to ICU or mortality.

 

Methods of assessing cognitive function

Tests of cognitive function are valuable when studying anaesthetic drug effects but a number of patients have unexplained complaints of impaired cognitive function that are not verified by objective tests (Moller 1998). One may speculate that application of a broader range of neuropsychological assessments than used in the Moller 1998 study could have detected varying deficits of an enduring nature. Using a broad range of tests, investigators have described moderate to severe cognitive dysfunction that lasted for several months after coronary bypass surgery (Townes 1989).

 

Methodological quality

The quality of blinding and allocation concealment in the included studies was variable. Although pulse oximetry monitoring techniques were well standardized (Cullen 1992; Mateer 1993) these trials did not all use correct randomized designs or outcome variables. Three of the studies (Bierman 1992; Moller 1992a; Moller 1993b) used adequate randomization and were blinded, however two studies (Moller 1993c; Ochroch 2006) were not blinded and used sequential sealed envelopes (see table 'Characteristics of included studies'). Furthermore, power analyses were seldom conducted to determine adequate sample sizes. Consequently, even the studies with high-quality blinding and allocation concealment may still not provide reliable results.

 

Statistical analysis of data

Due to the variety of outcome variables used in the five studies, there are no two groups which could be compared directly by formal meta-analysis.

 

Has pulse oximetry monitoring improved the safety of anaesthesia?

The proliferation of monitors in anaesthesia is obvious. The goal of monitoring as an adjunct to clinical decision making is to directly reduce the incidence of complications. This is based on the premise that unambiguous and accurate information, which is readily interpretable and available, will help the anaesthetist in deciding and initiating correct therapeutic interventions. The unanswered question is whether the individual anaesthesiologist's performance, the human factor, is perhaps far more important than implementing new monitoring equipment or other new safety initiatives in a situation in which we wish to reduce the rate of postoperative complications. However, we do not know whether pulse oximetry might protect against the human factor, when that factor is negligent.

Other factors have to be considered. The overwhelming majority of patients in the included studies come from a region where standards of anaesthesia and nursing care are good. Almost all the data were collected by a single group of people. This reduces the generality of the results in terms of what might be found in other geographical areas where standards of care and assessment methods may be different. Since the detected hypoxic events were treated, we do not really know what the differences in outcomes would have been if hypoxic events were neither detected nor treated. The studies were relatively well controlled and did not reproduce situations where there is a high likelihood of disaster.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

 

Implications for practice

Pulse oximetry monitoring substantially reduced the extent of perioperative hypoxaemia, enabled the detection and treatment of hypoxaemia and related respiratory events, and promoted several changes in patient care. The implementation of perioperative pulse oximetry monitoring was not, however, the breakthrough which could reduce the number of postoperative complications. The question remains whether pulse oximetry improves outcome in other situations. Pulse oximetry has already been adopted into clinical practice all over the world. It may be a tool that guides the anaesthesiologists in the daily management of patients, in teaching situations, emergencies, and especially in caring for children. Although the results of the studies are not conclusive, the data suggest that there may be a benefit for a population at high risk of postoperative pulmonary complications. The results of the studies of general surgery indicate that perioperative monitoring with pulse oximetry does not improve clinically relevant outcomes, effectiveness or efficiency of care despite an intense, methodical collection of data from a large population.

 
Implications for research

It is time to focus on which technologies are needed. The science of human factors includes the psychological and mental factors affecting performance in the workplace. Monitoring systems should fit naturally with the way the anaesthetist works, thinks, and interacts with the patient, equipment, and operating room environment so they can, together with vigilance and clinical decision-making, bring significant benefits.

Future work in this area would benefit from greater attention to methods of randomization, as we found only a few appropriately randomized studies. The impact of new monitoring equipment on outcomes should be evaluated and controlled in the same way as is customary when introducing new drugs. The potential for continuous pulse oximetry to allow for early intervention, or perhaps prevention of pulmonary complications, needs to be explored. As the present studies illustrate, the problems are multitudinous. The worst problem is clearly the huge number of patients needed. By limiting the inclusion criteria to a specific subgroup of patients (for example patients aged greater than 65 years, with cardiac risk factors, with ASA physical status III and IV, or undergoing acute abdominal surgery), isolating more rigorous outcome variables, and establishing wide co-operation between departments and countries new monitoring and anaesthesia safety studies could be launched in the future.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

We thank Mathew Zacharias for editing the current updated version of this review.

We would like to acknowledge Nete Villebro, Janet Wale and Kathie Godfrey for their contribution to the plain language summary. We would also like to acknowledge Dr Bente Dyrlund Pedersen's contribution to our previous review (Pedersen 2003a).

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms
 

Appendix 1. Search strategy for CENTRAL, The Cochrane Library

#1 (operation or peri?op* or post?op* or intra?op* or surg*):ti,ab
#2 (pulse near ox?met*)
#3 MeSH descriptor Oximetry explode all trees
#4 (#1 AND ( #2 OR #3 ))

 

Appendix 2. Search strategy for MEDLINE (Ovid SP)

1 (operation or perioperat* or postoperat* or intraoperat* or surg*).mp.
2 ((pulse adj6 oximet*) or (pulse adj6 oxymet*)).mp. or exp Oximetry/ or oxymet*.ti,ab.
3 ((randomized controlled trial or controlled clinical trial).pt. or randomized.ab. or placebo.ab. or clinical trials as topic.sh. or randomly.ab. or trial.ti.) and humans.sh.
4 1 and 3 and 2

 

Appendix 3. Search strategy for EMBASE (Ovid SP)

1 (operation or perioperat* or postoperat* or intraoperat* or surg*).mp.
2 exp Pulse Oximetry/ or exp Oximetry/
3 ((pulse adj6 oximet*) or (pulse adj6 oxymet*) or oxymet* or oximet*).mp.
4 3 or 2
5 (placebo.sh. or controlled study.ab. or "random*".ti,ab. or trial*.ti.) and human*.ec,hw,fs.
6 1 and 4 and 5

 

Appendix 4. Search strategy for CINAHL (EBSCOhost)

S1 TX (operation or perioperat* or postoperat* or intraoperat* or surg*)
S2 (MH "Perioperative Care+")
S3 (MH "Postoperative Care+")
S4 (MH "Intraoperative Care+") or (MH "Intraoperative Monitoring+")
S5 S4 or S3 or S2 or S1
S6 (MM "Pulse Oximeters") or (MM "Pulse Oximetry")
S7 TX (pulse and ox?met*)
S8 S7 or S6
S9 S8 and S5
S10 (MM "Random Assignment") or (MH "Clinical Trials+")
S11 AB random*
S12 TI trial
S13 AB placebo
S14 S13 or S12 or S11 or S10
S15 S14 and S9

 

Appendix 5. Search strategy for ISI Web of Science

# 1 TS=(operation or perioperat* or postoperat* or intraoperat* or surg*)
# 2 TS=((pulse SAME oximet*) or (pulse SAME oxymet*) or oxymet*)
# 3 #2 AND #1
# 4 TS=(random* or ((controlled or clinical) SAME trial*) or placebo)
# 5 #4 AND #3

 

Appendix 6. Search strategy for LILACS (BIREME)

("OXYMETER" or "OXYMETRY" or "puls oximet$") and (operation or perioperat$ or postoperat$ or intraoperat$ or surg$)

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Last assessed as up-to-date: 30 April 2009.


DateEventDescription

12 October 2010AmendedContact details updated.



 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Protocol first published: Issue 2, 2000
Review first published: Issue 3, 2001


DateEventDescription

7 September 2009AmendedNew order of authors, previously: Pedersen T, Møller AM, Hovhannisyan K; now:Møller AM.

15 May 2009New citation required but conclusions have not changedA new author Karen Hovhannisyan has joined the review team.

He replaces Bente Dyrlund Pedersen who co-authored Pedersen 2003a.

15 May 2009New search has been performedWe re-ran the search strategy in all the databases up to May 2009. We searched three new databases (CINAHL, ISI Web of Science, and LILACS). We retrieved 133 studies. We identified and included one new randomized controlled trial in the review (Ochroch 2006). This new study has not changed the review's conclusion.

16 January 2008AmendedConverted to new review format.

27 July 2005New search has been performedSecond Update, Issue 4, 2005:
We found no new randomized controlled trials examining the impact of perioperative monitoring with pulse oximetry.

31 January 2003New citation required and conclusions have changedFirst Update, Issue 2, 2003.
We found no new randomized controlled trials examining the impact of perioperative monitoring with pulse oximetry.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

Conceiving the review: TP, AM

Co-ordinating the review: TP, AM

Undertaking electronic and manual searches: TP, AM, KH

Screening search results: TP, AM, KH

Organizing retrieval of papers: KH

Screening retrieved papers against inclusion criteria: TP, AM, KH

Appraising quality of papers: TP, AM

Extracted data from papers: TP, AM

Writing to authors of papers for additional information: TP

Obtaining and screening data on unpublished studies: TP

Data management for the review: TP, AM

Entering data into Review Manager (RevMan 5.0): TP, KH

RevMan statistical data: TP, AM

Other statistical analysis not using RevMan: TP, AM

Double entry of data: ( data entered by person two:) TP, AM

Interpretation of data: TP, AM

Statistical inferences: TP, AM

Writing the review: TP, AM, KH

Securing funding for the review: TP

Performing previous work that was the foundation of the present study:

Guarantor for the review (one author): TP

Person responsible for reading and checking review before submission: TP

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Index terms

One of the authors (TP) is a co-author of one study included in the review (Moller 1993c).

All other authors: none known.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Bierman 1992 {published data only}
Moller 1992a {published data only}
  • Moller JT, Jensen PF, Johannessen NW, Espersen K. Hypoxaemia is reduced by pulse oximetry monitoring in the operating theatre and in the recovery room. British Journal of Anaesthesia 1992;68(2):146-50. [PUBMED: 1540455]
Moller 1993b {published data only}
  • Moller JT, Svennild I, Johannessen NW. Perioperative monitoring with pulse oximetry and late postoperative cognitive dysfunction. British Journal of Anaesthesia 1993;71(3):340-7. [PUBMED: 8398512]
Moller 1993c {published data only}
  • Moller JT, Johannessen NW, Espersen K, Ravlo O, Pedersen BD, Jensen PF, et al. Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology 1993;78(3):445-53. [PUBMED: 8457045]
Ochroch 2006 {published data only}
  • Ochroch EA,  Russell MW,  Hanson WC 3rd,  Devine GA,  Cucchiara AJ,  Weiner MG, et al. The impact of continuous pulse oximetry monitoring on intensive care unit admissions from a postsurgical care floor. Anesthesia and Analgesia 2006;102(3):868-75. [PUBMED: 16492843]

References to studies excluded from this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Cullen 1992 {published data only}
  • Cullen DJ, Nemeskal AR, Cooper JB, Zaslavsky A, Dwyer MJ. Effect of pulse oximetry, age, and ASA physical status on the frequency of patients admitted unexpectedly to a postoperative intensive care unit and the severity of their anesthesia-related complications. Anesthesia and Analgesia 1992;74:177-80. [PUBMED: 1731535]
Mateer 1993 {published data only}

Additional references

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Bendixen 1963
  • Bendixen HH, Hedley-Whyte J, Laver MB. Impaired oxygenation in surgical patients during general anaesthesia with controlled ventilation. New England Journal of Medicine 1963;269:991-6. [PUBMED: 14059732]
Canet 1991
Caplan 1990
Cooper 1984
  • Cooper JB, Newbower RS, Kitz RJ. An analysis of major errors and equipment failures in anesthesia management: Considerations for prevention and detection. Anesthesiology 1984;60:34-42. [PUBMED: 6691595 ]
Cooper 1987
  • Cooper JB, Cullen DJ, Nemeskal R, Hoaglin DC, Gevirtz CC, Csete M, et al. Effects of information feedback and pulse oximetry on incidence of anesthesia complications. Anesthesiology 1987;67:686-94. [PUBMED: 3674468]
Cote 1988
  • Cote CJ, Goldstein EA, Cote MA, Hoaglin DC, Ryan JF. A single-blind study of pulse oximetry in children. Anesthesiology 1988;68:184-8. [PUBMED: 3277484]
Cote 1991
  • Cote CJ, Rolf N, Liu LM, Goudsouzian NG, Ryan JF, Zaslavsky A, et al. A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology 1991;74:980-7. [PUBMED: 1904206]
Krasheninnikoff 1993
  • Krasheninnikoff M, Ellitsgaard N, Rude C, Moller JT. Hypoxaemia after osteosynthesis of hip fractures. International Orthopaedics 1993;17(1):27-9. [PUBMED: 8449619 ]
Laver 1964
  • Laver MB, Morgan J, Bendixen HH, Radford EP. Lung volume, compliance, and arterial oxygen tensions during controlled ventilation. Journal of Applied Physiology 1964;19:725-33. [PUBMED: 14195585]
Mlinaric 1997
  • Mlinaric J, Nincevic N, Kostov D, Gnjatovic D. Pulse oximetry and capnometry in the prevention of perioperative morbidity and mortality. Lijecnicki Vjesnik 1997;119:113-6. [PUBMED: 9490372]
Moller 1998
  • Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, et al. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet 1998;351:857-61. [PUBMED: 9525362]
Møller 1994
  • Møller JT. Anesthesia related hypoxemia. The effect of pulse oximetry monitoring on perioperative events and postoperative complications. Danish Medical Bulletin 1994;41(5):489-500. [PUBMED: 7859517 ]
Nunn 1965
Pedersen 1994
  • Pedersen T. Complications and death following anaesthesia. A prospective study with special reference to the influence of patient-, anaesthesia-, and surgery-related risk factors. Danish Medical Bulletin 1994;41(3):319-31. [PUBMED: 7924461]
RevMan 5.0
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.
Rheineck 1996
  • Rheineck-Leyssius AT, Kalkman CJ, Trouwborst A. Influence of motivation of care providers on the incidence of postoperative hypoxaemia in the recovery room. British Journal of Anaesthesia 1996;77:453-7. [PUBMED: : 8942327]
Severinghaus 1992
  • Severinghaus JW, Kelleher JF. Recent developments in pulse oximetry. Anesthesiology 1992;76:1018-38. [PUBMED: 1599088]
Stausholm 1997
  • Stausholm K, Rosenberg-Adamsen S, Edvardsen L, Kehlet H, Rosenberg J. Validation of pulse oximetry for monitoring of hypoxaemic episodes in the late postoperative period. British Journal of Anaesthesia 1997;78:86-7. [PUBMED: 9059211 ]
Tinker 1989
Townes 1989
  • Townes BD, Bashein G, Hornbein TF, Coppel DB, Goldstein DE, Davis KB, et al. Neurobehavioral outcomes in cardiac operations. Journal of Thoracic and Cardiovascular Surgery 1989;98:774-82. [PUBMED: 2811413]

References to other published versions of this review

  1. Top of page
  2. Abstract摘要Résumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. History
  14. Contributions of authors
  15. Declarations of interest
  16. Characteristics of studies
  17. References to studies included in this review
  18. References to studies excluded from this review
  19. Additional references
  20. References to other published versions of this review
Pedersen 2003a
Pedersen 2003b
  • Pedersen T, Dyrlund Pedersen B, Møller AM. Pulse oximetry for perioperative monitoring: systematic review of randomized trials. Anesthesia and Analgesia 2003;96:426-31. [PUBMED: 12917918 ]
Pedersen 2003c
  • Poulsen A, Pedersen T. Pulse oximetry in perioperative monitoring. Ugeskrift for Laeger 2003;165(42):4025-7. [PUBMED: 14610837]
Pedersen 2005
  • Pedersen T. Does perioperative pulse oximetry improve outcome? Seeking the best available evidence to answer the clinical question. Best Practice and Research. Clinical Anaesthesiology 2005;19(1):111-23. [PUBMED: 15679062 ]