Routine Use Of Pulse Oximetry Research Articles

Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations

BackgroundSedation is commonly used in gastrointestinal endoscopy; however, considerable variability in sedation practices has been reported. The objective of this review was to identify and synthesize existing recommendations on sedation practices for routine gastrointestinal endoscopy procedures.MethodsWe systematically reviewed guidelines and position statements identified through a search of PubMed, guidelines databases, and websites of relevant professional associations from January 1, 2005 to May 10, 2019. We included English-language guidelines/position statements with recommendations relating to sedation for adults undergoing routine gastrointestinal endoscopy. Documents with guidance only for complex endoscopic procedures were excluded.We extracted and synthesized recommendations relating to: 1) choice of sedatives, 2) sedation administration, 3) personnel responsible for monitoring sedated patients, 4) skills and training of individuals involved in sedation, and 5) equipment required for monitoring sedated patients. We assessed the quality of included documents using the Appraisal of Guidelines for Research & Evaluation (AGREE) II tool.ResultsWe identified 19 guidelines and 7 position statements meeting inclusion criteria. Documents generally agreed that a single, trained registered nurse can administer moderate sedation, monitor the patient, and assist with brief, interruptible tasks. Documents also agreed on the routine use of pulse oximetry and blood pressure monitoring during endoscopy. However, recommendations relating to the drugs to be used for sedation, the healthcare personnel capable of administering propofol and monitoring patients sedated with propofol, and the need for capnography when monitoring sedated patients varied. Only 9 documents provided a grade or level of evidence in support of their recommendations.ConclusionsRecommendations for sedation practices in routine gastrointestinal endoscopy differ across guidelines/position statements and often lack supporting evidence with potential implications for patient safety and procedural efficiency.

Cost-effectiveness analysis of newborn pulse oximetry screening to detect critical congenital heart disease in Colombia

BackgroundIn many countries, economic assessments of the routine use of pulse oximetry in the detection of Critical Congenital Heart Disease (CCHD) at birth has not yet been carried out. CCHDs necessarily require medical intervention within the first months of life. This assessment is a priority in low and medium resource countries. The purpose of this study was to assess the cost-effectiveness (CE) relation of pulse oximetry in the detection of cases of CCHD in Colombia.MethodsA full economic assessment of the cost-effectiveness type was conducted from the perspective of society. A decision tree was constructed to establish a comparison between newborn physical examination plus pulse oximetry, versus physical examination alone, in the diagnosis of CCHDs. The sensitivity and specificity of pulse oximetry were estimated from a systematic review of the literature; to assess resource use, micro-costing analyses and surveys were conducted. The time horizon of the economic evaluation was the first week after birth and until the first year of life. The incremental cost-effectiveness ratio (ICER) was determined and, to control for uncertainty, deterministic and probabilistic sensitivity analysis were made, including the adoption of different scenarios of budgetary impact. All costs are expressed in US dollars from 2017, using the average exchange rate for 2017 [$2,951.15 COP for 1 dollar].ResultsThe costs of pulse oximetry screening plus physical examination were $102; $7 higher than physical examination alone. The effectiveness of pulse oximetry plus the physical examination was 0.93; that is, 0.07 more than the physical examination on its own. The ICER was $100 for pulse oximetry screening; that is, if one wishes to increase 1% the probability of a correct CCHD diagnosis, this amount would have to be invested. A willingness to pay of $26.292 USD (direct medical cost) per probability of a correct CCHD diagnosis was assumed.ConclusionsAt current rates and from the perspective of society, newborn pulse oximetry screening at 24 h in addition to physical examination, and considering a time horizon of 1 week, is a cost-effective strategy in the early diagnosis of CCHDs in Colombia.Trial registration “retrospectively registered”.

Use of pulse oximetry during initial assessments of children under five with pneumonia: a retrospective cross-sectional study from 14 hospitals in Ethiopia.

BackgroundHypoxemia, a fatal condition characterized by low concentration of oxygen in the blood, is strongly associated with death among children with pneumonia. Ethiopia’s Federal Ministry of Health launched its first National Oxygen and Pulse Oximetry Scale-up road map to improve access and utilization of pulse oximetry and oxygen. This study aimed to describe the use of pulse oximetry during the initial patient assessment among children under five diagnosed with pneumonia and serves as a benchmark to measure progress of the road map.MethodsThe study design was an observational study using retrospective review of patient medical records at 14 hospitals. Medical records of 443 children age 0-59 months with a primary diagnosis of pneumonia were randomly selected for review. The primary outcome was whether an arterial blood oxygen saturation (SpO2) measurement was recorded in the patient’s medical record at the initial assessment.ResultsOverall, 10% (95% confidence interval CI = 4%-22%) of patient medical records had a SpO2 measurement. Admitted patients were more likely to have a SpO2 measurement recorded in their medical records than patients treated in the outpatient department (P<0.01). Among admitted patients, 19% (95% CI = 8%-38%) had a SpO2 measurement compared to 3% (95% CI = 1%-11%) of patients treated in the outpatient department.ConclusionIn Ethiopia, patients under five with a primary diagnosis of pneumonia are rarely screened for hypoxemia with a pulse oximeter, and hypoxemia may be severely underdiagnosed. Much needs to be done to improve the routine use of pulse oximetry.

Newborn Screening for Critical Congenital Heart Disease Using Pulse Oximetry: A Quality Improvement Project Proposal

Critical congenital heart disease (CCHD) is a leading cause of death in the neonatal period. It accounts for approximately one-third of the cases of mortality due to birth defects [1]. Some infants with CCHD may initially be asymptomatic and look healthy. There is an increasing body of evidence that CCHD could be missed in the first few days, therefore, resulting in increased morbidity and mortality. In the US, the CDC estimates the number of infants where the diagnosis of CCHD is delayed at 1755 cases per annum. Half of those cases would have been diagnosed earlier by Pulse Oximetry [2]. Figures from New Zealand estimate that 1 in 5 babies with undiagnosed CCHD are discharged home [3]. Routine use of pulse oximetry has been recommended recently in the UK by PECSIG to help improve the detection rates of CCHD [4]. In this project, a proposal to adopt routine Pulse Oximetry at DGH level is discussed.

Routine Use of Pulse Oximetry in the Newborn to Detect Critical Congenital Heart Disease

Critical Congenital Heart Disease’s (CCHD’s) are potentially life-threatening cardiac abnormalities where the systemic or pulmonary circulation is dependent on a patent ductus arteriosus and include those with duct-dependent pulmonary blood flow, inter-circulatory mixing, and systemic hypoperfusion. The seven main CCHD’s screening targets for neonatal pulse oximetry are hypoplastic left heart syndrome, pulmonary atresia (with intact ventricular septum), Tetralogy of Fallot, total anomalous pulmonary venous return, transposition of the great arteries, tricuspid atresia and truncus arteriosus. Early diagnosis improves outcomes. Systematic review and metaanalysis of pulse oximetry screening for critical congenital heart defects in asymptomatic newborn babies revealed that the overall sensitivity was 76.5% and specificity was 99.9%. The false-positive rate was low when it was done after 24 hours from birth [1]. The American Heart Association and the American Academy of Pediatrics suggest that routine pulse oximetry done on asymptomatic newborns after 24 hours of life but before discharge may detect critical CHD, incurs very low cost, and there is a low risk of harm [2]. European studies suggest that screening is cost-effective in identifying newborns with CCHD [3,4]. Over half of babies discharged with CHD detected in the first year of life were discharged from the hospital with a normal routine neonatal examination and the 6 week exam missed one-third of the patients [5]. In many countries, births are not attended and infants are discharged within hours of birth without medical evaluation by a qualified practioner. CCHD’s will go undetected in this setting.

Effectiveness of pulse-oximetry in addition to routine neonatal examination in detection of congenital heart disease in asymptomatic newborns

Objective: To assess the feasibility and effectiveness of pulse-oximetry as a screening tool in the detection of critical congenital heart disease (CCHD) in newborns.Methods: Post-natal babies born between 01/01/2007–31/12/2009 were eligible. Post-ductal pulse-oximetry was performed using Nellcor® NPB 40 pulse oximeter with reusable OXI-A/N saturation probe. Saturations ≥95% were deemed normal. If saturations were <95%, an echocardiogram was done. The regional paediatric cardiology database and death records identified babies later diagnosed with CCHD.Results: 6329/9613 eligible babies were studied and pulse-oximetry was performed at a mean age of 28 hours (range 6–72 hours). Fourteen babies had saturations <95%. CCHD was diagnosed in 7/14 babies; 4/7 had no clinical signs. Of the remaining 7 babies, 3 had non-critical but significant CHD and 4 had an undiagnosed respiratory illness or sepsis. All babies with low saturations had identifiable pathologies. One baby with normal saturations was later diagnosed with transposition of the great arteries. The sensitivity and specificity of identifying an unwell baby was 93.3% and 100% respectively; the sensitivity and specificity of identifying CCHD was 87.5% and 99.8% respectively. Clinical examination alone would have missed 4/7 (57%) of these.Conclusion: Pulse-oximetry is safe, acceptable, non-invasive and effective. Our study supports the routine use of pulse oximetry as part of the newborn check.

Impact of medical training and clinical experience on the assessment of oxygenation and hypoxaemia after general anaesthesia: an observational study.

In Germany it is common practice to use pulse oximetry and supplementary oxygen only on request in patients breathing spontaneously transferred to the post-anaesthesia care unit (PACU) following surgery under general anaesthesia. The main aim was to study the influence of medical training and clinical experience on assessing SpO(2) and detecting hypoxaemia in these patients. The second aim was to do a preliminary assessment whether this practice can be found in countries other than Germany. Anaesthetists, nurses and medical students estimated SpO(2) in patients breathing room air at the end of transfer to the PACU following surgery (including all major surgical fields) under general anaesthesia. Estimated SpO(2) was compared to SpO(2) measured by pulse oximetry. A survey was carried out among European anaesthesists concerning the use of pulse oximetry and supplementary oxygen during patient transfer to the PACU. Hypoxaemia (SpO(2) < 90 %) occurred in 154 (13.5 %) out of 1,138 patients. Anaesthetists, nurses, and medical students identified only 25, 23, and 21 patients of those as being hypoxaemic, respectively. Clinical experience did not improve detection of hypoxaemia both in anaesthetists (p = 0.63) and nurses (p = 0.18). Use of pulse oximetry and supplemental oxygen during patient transfer to the PACU in European countries differs to a large extent. It seems to be applied only on request in many hospitals. Considering the uncertainty about deleterious effects of transient, short lasting hypoxaemia routine use of pulse oximetry is advocated for patient transfer to the PACU.

Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.

Routine use of pulse oximetry has been associated with changes in bronchiolitis management and may have lowered the hospitalization threshold for patients with bronchiolitis. To examine if infants with bronchiolitis whose displayed oximetry measurements have been artificially elevated 3 percentage points above true values experience hospitalization rates at least 15% lower compared with infants with true values displayed. Randomized, double-blind, parallel-group trial conducted from 2008 to 2013 in a tertiary-care pediatric emergency department in Toronto, Ontario, Canada. Participants were 213 otherwise healthy infants aged 4 weeks to 12 months with mild to moderate bronchiolitis and true oxygen saturations of 88% or higher. Pulse oximetry measurements with true saturation values displayed or with altered saturation values displayed that have been increased 3 percentage points above true values. The primary outcome was hospitalization within 72 hours, defined as inpatient admission within this interval or active hospital care for greater than 6 hours. Secondary outcomes included the use of supplemental oxygen in the emergency department, level of physician agreement with discharge from the emergency department, length of emergency department stay, and unscheduled visits for bronchiolitis within 72 hours. Forty-four of 108 patients (41%) in the true oximetry group and 26 of 105 (25%) in the altered oximetry group were hospitalized within 72 hours (difference, 16% [95% CI for the difference, 3.6% to 28.4%]; P = .005). Using the emergency department physician as a random effect, the primary treatment effect remained significant (adjusted odds ratio, 4.0 [95% CI, 1.6 to 10.5]; P = .009). None of the secondary outcomes were significantly different between the groups. There were 23 of 108 (21.3%) subsequent unscheduled medical visits for bronchiolitis in the true oximetry group and 15 of 105 (14.3%) in the altered oximetry group (difference, 7% [95% CI, -0.3% to 0.2%]; P = .18). Among infants presenting to an emergency department with mild to moderate bronchiolitis, those with an artificially elevated pulse oximetry reading were less likely to be hospitalized within 72 hours or to receive active hospital care for more than 6 hours than those with unaltered oximetry readings. This suggests that oxygen saturation should not be the only factor in the decision to admit, and its use may need to be reevaluated. clinicaltrials.gov Identifier: NCT00673946.

G423(P) Antenatal detection of critical congenital heart disease and the need for pulse-oximetry – a retrospective audit

AimThere is developing consensus regarding routine use of pulse-oximetry. Studies have shown that pulse-oximetry screening can substantially reduce the postnatal diagnostic gap in critical congenital heart disease (CHD)1. Aims of...

Anesthesia Dogmas and Shibboleths

Anesthesia Dogmas and Shibboleths

Learning Disability and Repeated Anesthetics: Drugs or Airway Management Issues?

Harvard Medical School, Mass General Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts. cjcote@partners.orgRegarding the article by Wilder et al. ,1this research is an important step in the right direction to either prove or disprove the association of learning disabilities with multiple exposures to anesthesia in the early years of life possibly caused by anesthetic agent–induced neuroapoptosis. The authors are to be congratulated for making a stab at this complex issue, and not connecting the dots directly but rightfully pointing out that many factors might contribute to their findings that are unrelated to anesthesia. However, one important factor that seems to have been overlooked is that the majority of these children were likely anesthetized before the routine use of pulse oximetry and capnography (1976–1982) became our standard of care. We do not know what happens to a child who is excessively ventilated for prolonged periods of time, resulting in severe hypocapnia and possibly reduced areas of cerebral perfusion. Nor do we know how many of these children experienced prolonged or repeated short episodes of hypoxemia that were either unrecognized or only recognized late in the event, when the child developed bradycardia that could have resulted in subtle neurologic insults. In the early years when capnography was first being advocated but not yet a standard of care, in a prospective study of 331 children, we found an 11% incidence of hypocapnia (expired carbon dioxide value ≤ 30 mmHg) in intubated children, with a very high incidence in children younger than 1 yr.2Likewise, in two randomized blinded studies involving 554 children, we found 94 major desaturation events (oxygen saturation measured by pulse oximetry ≤ 85% for 30 s or longer) in 67 children with a higher incidence by a factor of 2 in those whose anesthesiologist did not have the oximeter data available. These studies suggested that the oximeter allowed early recognition and intervention, thus preventing a minor desaturation event from progressing to a major desaturation event.3,4We also found a higher incidence of these major desaturation events in children younger than 2 yr. I do not know whether it is possible for Wilder et al. to go back and examine the anesthesia records from the 144 children in their cohort who had two or more anesthetic exposures to determine whether hypoxic events were recorded, but it might be a useful endeavor. I suggest that we need to look at other issues beyond simple exposure to anesthetic agents as possible contributory factors and look forward to more wonderful work from the Mayo group.Harvard Medical School, Mass General Hospital for Children, Massachusetts General Hospital, Boston, Massachusetts. cjcote@partners.org

Extending the WHO ‘Safe Surgery Saves Lives’ project through Global Oximetry

Extending the WHO ‘Safe Surgery Saves Lives’ project through Global Oximetry

Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease: A Scientific Statement from the AHA and AAP

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD). A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours. Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Role of Pulse Oximetry in Examining Newborns for Congenital Heart Disease

The purpose of this statement is to address the state of evidence on the routine use of pulse oximetry in newborns to detect critical congenital heart disease (CCHD). A writing group appointed by the American Heart Association and the American Academy of Pediatrics reviewed the available literature addressing current detection methods for CCHD, burden of missed and/or delayed diagnosis of CCHD, rationale of oximetry screening, and clinical studies of oximetry in otherwise asymptomatic newborns. MEDLINE database searches from 1966 to 2008 were done for English-language papers using the following search terms: congenital heart disease, pulse oximetry, physical examination, murmur, echocardiography, fetal echocardiography, and newborn screening. The reference lists of identified papers were also searched. Published abstracts from major pediatric scientific meetings in 2006 to 2008 were also reviewed. The American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. In an analysis of pooled studies of oximetry assessment performed after 24 hours of life, the estimated sensitivity for detecting CCHD was 69.6%, and the positive predictive value was 47.0%; however, sensitivity varied dramatically among studies from 0% to 100%. False-positive screens that required further evaluation occurred in only 0.035% of infants screened after 24 hours. Currently, CCHD is not detected in some newborns until after their hospital discharge, which results in significant morbidity and occasional mortality. Furthermore, routine pulse oximetry performed on asymptomatic newborns after 24 hours of life, but before hospital discharge, may detect CCHD. Routine pulse oximetry performed after 24 hours in hospitals that have on-site pediatric cardiovascular services incurs very low cost and risk of harm. Future studies in larger populations and across a broad range of newborn delivery systems are needed to determine whether this practice should become standard of care in the routine assessment of the neonate.

Prevalence of Nocturnal Oxygen Desaturation and Self-reported Sleep-disordered Breathing in Glaucoma

To evaluate the prevalence of nocturnal oxygen desaturation and sleep-disordered breathing symptoms within a glaucoma population. One hundred and twelve subjects (glaucoma=52, control=60) aged between 45 and 80 years were recruited for the study. Clinical assessment included overnight ambulatory pulse oximetry monitoring and administration of a self-reported sleep-disordered breathing questionnaire. There were no differences in age, sex, body mass index, or prevalence of systemic hypertension between the groups. The mean oxygen desaturation index of the glaucoma group (8.6) did not differ significantly from that of the control group (9.6) (P=0.715). The prevalence of moderate to severe respiratory dysfunction (oxygen desaturation index >20) in the glaucoma group (17%) was similar to that in the control group (12%) (P=0.463). The severity of sleep-disordered breathing symptoms was similar between the groups (P=0.157). No statistically significant association was found between glaucoma and either nocturnal oxygen desaturation or sleep-disordered breathing. Although this study cannot exclude the possibility of either impaired optic nerve head autoregulation or hypoxic damage occurring secondary to sleep apnea syndrome, the findings do not support the routine use of pulse oximetry in the workup of individuals with glaucoma.

Bronchoscopy in India 2005

A postal survey of bronchoscopic practice in India was carried out in July 2005. The questionnaire was intended to ascertain the present trends in certain aspects of conventional procedures and advanced techniques. A total of 250 bronchoscopists were polled, and 149 (60%) responded to the questionnaire. Results were compared with a similar survey carried out in India in 1997 and those from other countries. The results revealed that in India in 2005, routine use of pulse oximetry, supplemental oxygen, and videobronchoscopy has increased since 1997. Stent insertion and balloon dilatation have increased significantly; brachytherapy and electrocautery are also being increasingly used. There is a lesser increase in the use of bronchoalveolar lavage, fluoroscopy for transbronchial lung biopsy, lasers, and flexible bronchoscopic removal of foreign bodies. There was a decreased usage of the transbronchial needle. None of the respondents did endobronchial ultrasound, or photodynamic therapy. Constraints for the Indian bronchoscopists such as financial stringency, availability of equipment, and lack of training facilities, are major limiting factors. Recommendations for further improvement have been given to the Indian Association for Bronchology and discussed with bronchoscopists at the last annual Indian Association for Bronchology conference.

Effect of routine pulse oximetry measurements on ED triage classification

Pulse oximetry is commonly used to rapidly determine oxygen saturation and is incorporated in emergency triage as a screening for potential cardiopulmonary complications. This study examined the effect of routine pulse oximetry measurements on emergency department (ED) triage classification. Using a portable pulse oximeter, oxygen saturation of 1,235 adults presenting to a university-based, urban ED was obtained and each patient was assigned a classification of severity based on a standard 1-to-4 scale before and after the measurement. According to data obtained, a small but statistically significant group (2.8%) benefitted from the routine use of pulse oximetry in an emergency triage system and only 40% of these patients required admission or extended care. Although this group is small in number, the potential consequences of missing a hypoxic condition could be devastating for the individual patient. Since pulse oximetry is presently an inexpensive technology, it would seem to be a worthwhile screening tool for emergency triage.

Effect of pregnancy on maternal oxygen saturation values: use of reflectance pulse oximetry during pregnancy.

Our objective was to evaluate the usefulness of pulse oximetry monitoring in a large population of pregnant patients. We designed our study to measure pulse oximetry saturation in a cross section of 952 obstetric inpatients and outpatients. A group of 366 patients identified as normal were compared with abnormal subgroups. A subgroup of 64 patients with saturation measurements less than 96% were further evaluated. Our results indicated that oxygen saturation values did not change appreciably during the course of pregnancy in normal patients. Hypoxemia (saturation measurement less than 96%) was associated with smoking, and hypoxemia with preterm labor occurred more frequently in patients who smoked. Obesity and magnesium sulfate use appeared to be synergistic in the presence of hypoxemia. We concluded that the routine use of pulse oximetry during pregnancy may not be justified. Smoking, obesity, and magnesium sulfate use have some effect on oximetry in pregnant patients.

Utility of pulse oximetry in the early recognition of intraoperative hypoxaemia in tetralogy of Fallot

Undetected hypoxaemia in an anaesthetised patient can prove fatal. Pulse oximetry has been widely used to detect hypoxaemia and intracardiac shunts in congenital cyanotic heart diseases. In two patients with tetralogy of Fallot, intraoperative pulse oximetry was helpful in detecting hypoxaemia where the oxygen saturation fell to22and28 per cent with concomitant fall in PaO2. Immediate therapeutic measures were taken and patients’ oxygen saturation improved. We suggest routine use of pulse oximetry in patients undergoing corrective or palliative surgery for tetralogy of Fallot.

Pattern of Non-ICU Inpatient Supplemental Oxygen Utilization in a University Hospital

Random assessments of SaO2 were performed via pulse oximetry in 274 hospitalized non-ICU patients prescribed supplemental O2 in a large tertiary care university hospital. In 507 assessments performed in patients inspiring the prescribed O2, 426 were receiving excessive amounts of O2 to maintain a SaO2 > or = 92 percent. In 233 of these assessments, SaO2 was > or = 92 percent while breathing ambient air. In an additional 193 assessments, the concentration of inspired supplemental O2 was excessive to maintain a SaO2 > or = 92 percent. However, in 81 assessments performed in patients inspiring O2, the prescribed amount was insufficient to maintain SaO2 > or = 92 percent. These results indicate that O2 prescription in hospitalized non-ICU patients is excessive or not required in the majority of cases. Furthermore, routine use of pulse oximetry in hospitalized patients prescribed O2 may be useful in determining the continued need for supplemental O2 and adjusting the proper concentration needed to avoid hypoxemia.