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This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2014, Issue 3
http://www.thecochranelibrary.com
Tom Pedersen1 , Amanda Nicholson2 , Karen Hovhannisyan3 , Ann Merete Mller4 , Andrew F Smith5 , Sharon R Lewis6
1
Head and Orthopaedic Center, Rigshospitalet, Copenhagen, Denmark. 2 Liverpool Reviews and Implementation Group, University
of Liverpool, Liverpool, UK. 3 The Cochrane Anaesthesia Review Group, Rigshospitalet, Copenhagen, Denmark. 4 The Cochrane
Anaesthesia Review Group, Rigshospitalet & Department of Anaesthesiology, University of Copenhagen Herlev Hospital, Herlev,
Denmark. 5 Department of Anaesthetics, Royal Lancaster Infirmary, Lancaster, UK. 6 Patient Safety Research, Royal Lancaster Infirmary,
Lancaster, UK
Contact address: Amanda Nicholson, Liverpool Reviews and Implementation Group, University of Liverpool, Second Floor, Whelan
Building, The Quadrangle, Brownlow Hill, Liverpool, L69 3GB, UK. amanda.nicholson@liverpool.ac.uk.
Citation: Pedersen T, Nicholson A, Hovhannisyan K, Mller AM, Smith AF, Lewis SR. Pulse oximetry for perioperative monitoring.
Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD002013. DOI: 10.1002/14651858.CD002013.pub3.
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
ABSTRACT
Background
This is an update of a review last published in Issue 9, 2009, of The Cochrane Library. Pulse oximetry is used extensively in the perioperative
period and might improve patient outcomes by enabling early diagnosis and, consequently, correction of perioperative events that might
cause postoperative complications or even death. Only a few randomized clinical trials of pulse oximetry during anaesthesia and in the
recovery room have been performed that describe perioperative hypoxaemic events, postoperative cardiopulmonary complications and
cognitive dysfunction.
Objectives
To study the use of perioperative monitoring with pulse oximetry to clearly identify adverse outcomes that might be prevented or
improved by its use.
The following hypotheses were tested.
1. Use of pulse oximetry is associated with improvement in the detection and treatment of hypoxaemia.
2. Early detection and treatment of hypoxaemia reduce morbidity and mortality in the perioperative period.
3. Use of pulse oximetry per se reduces morbidity and mortality in the perioperative period.
4. Use of pulse oximetry reduces unplanned respiratory admissions to the intensive care unit (ICU), decreases the length of ICU
readmission or both.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 5), MEDLINE (1966 to June 2013),
EMBASE (1980 to June 2013), CINAHL (1982 to June 2013), ISI Web of Science (1956 to June 2013), LILACS (1982 to June 2013)
and databases of ongoing trials; we also checked the reference lists of trials and review articles. The original search was performed in
January 2005, and a previous update was performed in May 2009.
Pulse oximetry for perioperative monitoring (Review) 1
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Selection criteria
We included all controlled trials that randomly assigned participants to pulse oximetry or no pulse oximetry during the perioperative
period.
Data collection and analysis
Two review authors independently assessed data in relation to events detectable by pulse oximetry, any serious complications that
occurred during anaesthesia or in the postoperative period and intraoperative or postoperative mortality.
Main results
The last update of the review identified five eligible studies. The updated search found one study that is awaiting assessment but no
additional eligible studies. We considered studies with data from a total of 22,992 participants that were eligible for analysis. These
studies gave insufficient detail on the methods used for randomization and allocation concealment. It was impossible for study personnel
to be blinded to participant allocation in the study, as they needed to be able to respond to oximetry readings. Appropriate steps
were taken to minimize detection bias for hypoxaemia and complication outcomes. Results indicated 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 three times less. Postoperative cognitive function was independent
of perioperative monitoring with pulse oximetry. A single study in general surgery showed that postoperative complications occurred
in 10% of participants in the oximetry group and in 9.4% of those in the control group. No statistically significant differences in
cardiovascular, respiratory, neurological or infectious complications were detected in the two groups. The duration of hospital stay was
a median of five days in both groups, and equal numbers of in-hospital deaths were reported in the two groups. Continuous pulse
oximetry has the potential to increase vigilance and decrease pulmonary complications after cardiothoracic surgery; however, routine
continuous monitoring did not reduce transfer to an ICU and did not decrease overall mortality.
Authors conclusions
These studies confirmed that pulse oximetry can detect hypoxaemia and related events. However, we found no evidence that pulse
oximetry affects the outcome of anaesthesia for patients. The conflicting subjective and objective study results, despite an intense
methodical collection of data from a relatively large general surgery population, indicate that the value of perioperative monitoring
with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency. Routine continuous pulse
oximetry monitoring did not reduce transfer to the ICU and did not decrease mortality, and it is unclear whether any real benefit was
derived from the application of this technology for patients recovering from cardiothoracic surgery in a general care area.
Continuous pulse oximetry versus no/intermittent pulse oximetry for perioperative monitoring
Outcomes Illustrative comparative risks* (95% CI) Relative effect No. of participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Episodes of hypoxaemia See comment See comment Not estimable 235 See comment Results not pooled. Sig-
(SpO2 <90%) (two studies) nificantly lower incidence
of hypoxaemia in oxime-
try group in OR and in re-
covery room
Changes to patient care See comment See comment Not estimable 21,037 See comment Results not pooled.
(three studies) Two studies showed
increased numbers of
changes in ventilatory
support and increased
oxygen in oximetry group
Complications See comment See comment Not estimable 20,802 See comment No reduction seen in
(one study) number of cardiovascu-
lar, respiratory, neurolog-
ical or infectious compli-
cations
3
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Pulse oximetry for perioperative monitoring (Review)
In-hospital mortality See comment See comment Not estimable 22,021 See comment Results not pooled. No
(two studies) difference in mortality be-
tween oximetry and con-
trol groups
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.
Description of the intervention 3. Use of pulse oximetry per se reduces morbidity and
mortality in the perioperative period.
The introduction of the pulse oximeter, a clinical monitor of oxy-
gen saturation and pulsation levels, has made it possible to mon- 4. Use of pulse oximetry reduces unplanned respiratory
itor perioperative hypoxaemia by using a non-invasive continu- admissions to the ICU, decreases the length of ICU readmission
ous measuring technique (Severinghaus 1992). The greatest value or both.
of pulse oximetry lies in its ability to provide an early warning
of hypoxaemia. Monitoring with pulse oximetry might improve
patient outcomes by enabling early diagnosis and, consequently,
METHODS
correction of perioperative events that might cause postoperative
complications or even death (Cooper 1984). An operational def-
inition of such an event is an undesirable incident that required
intervention and did, or possibly could, cause complications or Criteria for considering studies for this review
death. Such events may be attributed to pathophysiological pro-
cesses, malfunction of the gas supply or equipment or human er-
ror, for example, oesophageal intubation or anaesthetic misman- Types of studies
agement. For many of these events, hypoxaemia is possibly the
We included all randomized and quasi-randomized controlled tri-
most common mechanism responsible for eventual adverse out-
als examining the use of pulse oximetry or no pulse oximetry dur-
comes (Cooper 1987).
ing the perioperative period, including in the operating theatre
and in the recovery room. We included trials irrespective of blind-
ing, numbers of participants randomly assigned or the language
Why it is important to do this review of the article.
Many departments and societies of anaesthesiology have adopted
standards for perioperative patient monitoring, including the use
Types of participants
of pulse oximetry, to improve anaesthesia care in accordance with
the hypothesis that this may reduce perioperative complications. We included patients,18 years of age and older, who were under-
Monitoring with pulse oximetry permits early diagnosis and treat- going surgery with anaesthesia.
ment of hypoxaemia, thus reducing the incidence and severity of
this condition (Canet 1991; Cote 1991). Only a few randomized
clinical trials of pulse oximetry performed during anaesthesia and Types of interventions
in the recovery room describe perioperative hypoxaemic events, We included the following intervention: monitoring with pulse
postoperative cardiopulmonary complications, cognitive dysfunc- oximetry compared to no monitoring with pulse oximetry during
tion or admission to the intensive care unit (ICU) (Cote 1988; the anaesthesia and recovery periods.
REFERENCES
References to studies included in this review Ochroch 2006 {published data only}
Ochroch EA, Russell MW, Hanson WC 3rd, Devine GA,
Bierman 1992 {published data only} Cucchiara AJ, Weiner MG, et al.The impact of continuous
Bierman MI, Stein KL, Snyder JV. Pulse oximetry in the pulse oximetry monitoring on intensive care unit admissions
postoperative care of cardiac surgical patients. Chest 1992; from a postsurgical care floor. Anesthesia and Analgesia
102:136770. [PUBMED: 1424853] 2006;102(3):86875. [PUBMED: 16492843]
Moller 1992a {published data only} References to studies excluded from this review
Moller JT, Jensen PF, Johannessen NW, Espersen K.
Hypoxaemia is reduced by pulse oximetry monitoring in the Cullen 1992 {published data only}
operating theatre and in the recovery room. British Journal
Cullen DJ, Nemeskal AR, Cooper JB, Zaslavsky A, Dwyer
of Anaesthesia 1992;68(2):14650. [PUBMED: 1540455] MJ. Effect of pulse oximetry, age, and ASA physical status
on the frequency of patients admitted unexpectedly to a
Moller 1993b {published data only} postoperative intensive care unit and the severity of their
Moller JT, Svennild I, Johannessen NW. Perioperative anesthesia-related complications. Anesthesia and Analgesia
monitoring with pulse oximetry and late postoperative 1992;74:17780. [PUBMED: 1731535]
cognitive dysfunction. British Journal of Anaesthesia 1993;
71(3):3407. [PUBMED: 8398512] Mateer 1993 {published data only}
Mateer JR, Olson DW, Stueven HA, Aufderheide TP.
Moller 1993c {published data only} Continuous pulse oximetry during emergency endotracheal
Moller JT, Johannessen NW, Espersen K, Ravlo O, intubation. Annals of Emergency Medicine 1993;22:6759.
Pedersen BD, Jensen PF, et al.Randomized evaluation of [PUBMED: 8457094]
pulse oximetry in 20,802 patients: II. Perioperative events
and postoperative complications. Anesthesiology 1993;78 References to studies awaiting assessment
(3):44553. [PUBMED: 8457045]
Moller JT, Pedersen T, Rasmussen LS, Jensen PF, Pedersen Haines 2012 {published data only}
BD, Ravlo O, et al.Randomized evaluation of pulse Haines KL, Downs JB, Mullen MB, Klonsky JA, Gallagher
oximetry in 20,802 patients: I. Design, demography, SF. Scheduled, Intermittent oximetry fails to detect
pulse oximetry failure rate, and overall complication rate. postoperative hypoxemia after bariatric surgery. Journal of
Anesthesiology 1993;78(3):43644. [PUBMED: 8457044] Surgical Research 2012;172(2):287. [EMBASE: 70651408]
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Mlinaric J, Nincevic N, Kostov D, Gnjatovic D. Pulse
Bendixen 1963 oximetry and capnometry in the prevention of perioperative
Bendixen HH, Hedley-Whyte J, Laver MB. Impaired morbidity and mortality. Lijecnicki Vjesnik 1997;119:
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with controlled ventilation. New England Journal of
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Canet 1991 H, Canet J, et al.Long-term postoperative cognitive
Canet J, Ricos M, Vidal F. Postanesthetic hypoxemia and dysfunction in the elderly ISPOCD1 study. ISPOCD
oxygen administration. Anesthesiolgy 1991;74:11612. Investigators. International Study of Post-Operative
[PUBMED: 2042775] Cognitive Dysfunction. Lancet 1998;351:85761.
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Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse
Mller 1994
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Mller JT. Anesthesia related hypoxemia. The effect of
Anesthesiology 1990;72:82833. [PUBMED: 2339799]
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Cooper 1984 postoperative complications. Danish Medical Bulletin 1994;
Cooper JB, Newbower RS, Kitz RJ. An analysis of major 41(5):489500. [PUBMED: 7859517 ]
errors and equipment failures in anesthesia management:
Nunn 1965
considerations for prevention and detection. Anesthesiology
Nunn JF, Bergman NA, Coleman AJ, Jones DD. Factors
1984;60:3442. [PUBMED: 6691595 ]
influencing the arterial oxygen tension during anaesthesia
Cooper 1987 with artificial ventilation. British Journal of Anaesthesia
Cooper JB, Cullen DJ, Nemeskal R, Hoaglin DC, Gevirtz 1965;37:898914.
CC, Csete M, et al.Effects of information feedback and
pulse oximetry on incidence of anesthesia complications. Pedersen 1994
Anesthesiology 1987;67:68694. [PUBMED: 3674468] Pedersen T. Complications and death following anaesthesia.
A prospective study with special reference to the influence
Cote 1988 of patient-, anaesthesia-, and surgery-related risk factors.
Cote CJ, Goldstein EA, Cote MA, Hoaglin DC, Ryan Danish Medical Bulletin 1994;41(3):31931. [PUBMED:
JF. A single-blind study of pulse oximetry in children. 7924461]
Anesthesiology 1988;68:1848. [PUBMED: 3277484]
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Cote 1991 The Nordic Cochrane Centre, The Cochrane Collaboration.
Cote CJ, Rolf N, Liu LM, Goudsouzian NG, Ryan JF, Review Manager (RevMan). 5.2. Copenhagen: The Nordic
Zaslavsky A, et al.A single-blind study of combined pulse Cochrane Centre, The Cochrane Collaboration, 2012.
oximetry and capnography in children. Anesthesiology 1991;
74:9807. [PUBMED: 1904206] Rheineck 1996
Rheineck-Leyssius AT, Kalkman CJ, Trouwborst A.
Guyatt 2008
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Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y,
of postoperative hypoxaemia in the recovery room. British
Schunemann HJ. What is quality of evidence and why is
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Severinghaus 1992
Higgins 2011
Severinghaus JW, Kelleher JF. Recent developments in pulse
Higgins JPT, Altman DG, Gtzsche PC, Jni P, Moher D,
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Krasheninnikoff 1993 Shah A, Shelley KH. Is pulse oximetry an essential tool or
Krasheninnikoff M, Ellitsgaard N, Rude C, Moller just another distraction? The role of the pulse oximeter in
JT. Hypoxaemia after osteosynthesis of hip fractures. modern anesthesia care. Journal of Clinical Monitoring and
International Orthopaedics 1993;17(1):279. [PUBMED: Computing 2013;27(3):23542. [PUBMED: 23314807]
8449619 ] Stausholm 1997
Laver 1964 Stausholm K, Rosenberg-Adamsen S, Edvardsen L, Kehlet
Laver MB, Morgan J, Bendixen HH, Radford EP. Lung H, Rosenberg J. Validation of pulse oximetry for monitoring
volume, compliance, and arterial oxygen tensions during of hypoxaemic episodes in the late postoperative period.
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19:72533. [PUBMED: 14195585] 9059211 ]
Bierman 1992
Other monitoring Continuous arterial BP, pulmonary art pressure, ECG and mixed venous saturation
monitoring
Location and duration of monitoring Participants monitored from arrival on cardiac ICU. Not clear how long monitoring
continued
Notes
Risk of bias
Random sequence generation (selection Unclear risk patients were randomly assigned. No fur-
bias) ther details
Allocation concealment (selection bias) Unclear risk patients were randomly assigned. No fur-
ther details
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Hypoxaemia
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Interventions
Blinding of outcome assessment (detection Low risk Same monitors used in intervention and
bias) control groups. Trend recordings printed
Hypoxaemia every 12 hours and examined to determine
number and duration of desaturations to <
94%
Blinding of outcome assessment (detection Unclear risk Not clear whether information on inter-
bias) ventions was based on automated data or
Interventions was manually recorded
Incomplete outcome data (attrition bias) High risk 1/ 21 withdrawn from intervention group
All outcomes because of cardiovascular problems
3/18 withdrawn from control group: two
for problems with telemetry and one be-
cause of respiratory problems
Selective reporting (reporting bias) Low risk All outcomes specified in Methods reported
Other bias Unclear risk Nellcor loaned telemetry system and two
pulse oximeters
Moller 1992a
Methods Two-centre RCT: one teaching hospital and one major hospital in Denmark
Participants 200 adult participants undergoing elective surgery expected to last longer than 20 minutes
and performed under general, spinal or epidural anaesthesia
Outcomes Episodes of hypoxia: mild 86% to 90% oxygen saturation, moderate 81% to 85%; severe
76% to 80%; extreme < 76%
Time spent hypoxic < 90% SpO2
Other monitoring OR: ECG, arterial pressure every 5 minutes, central venous pressure (CVP) if indicated
Recovery ECG and CVP continuous BP, HR and respiratory rate every 15 minutes
Location and duration of monitoring Monitoring in OR and in recovery room. From arrival in OR to discharge from recovery
room or after six hours if still in recovery room
Notes
Risk of bias
Random sequence generation (selection Unclear risk patients allocated randomly to two group
bias) (s). No further details given
Allocation concealment (selection bias) Unclear risk patients allocated randomly to two group
(s). No further details given
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Hypoxaemia
Blinding of outcome assessment (detection Low risk Same monitors in use in intervention and
bias) control groups. Data stored electronically
Hypoxaemia
Incomplete outcome data (attrition bias) Low risk 4/104 in intervention group & 2/ 102 in
All outcomes control group excluded because of lack of
co-operation or poor peripheral perfusion
Selective reporting (reporting bias) Low risk All outcomes specified in Methods reported
Moller 1993b
Methods Two-centre cluster-randomized RCT: one teaching hospital and one major hospital in
Denmark
Participants 736 adult participants undergoing elective surgery expected to last longer than 20 minutes
and performed under general, spinal or epidural anaesthesia. Each day, four participants
from each surgical department selected for cognitive testing
Interventions Intervention group: N = 358. pulse oximetry (Radiometer/Ohmeda). Intervene if SpO2 <
93%. Finger probe
Control group: N = 378. Not monitored by pulse oximetry at any time
Outcomes Incidence of hypoxia during anaesthesia defined as cyanosis, arterial oxygen < 7.8 kPa,
SaO2 < 90%, or SpO2 < 90%
Changes to patient care
Cognitive function (Wechsler memory scale): preoperatively, POD7. Participants with
score decreased by 10 or more points were tested again after three months
Participant-reported assessment of whether cognitive abilities had changed following
anaesthesia at six weeks postoperatively
Other monitoring OR: ECG, arterial pressure every 5 minutes, CVP if indicated
Recovery room -ECG & CVP continuously. BP, HR & respiratory rate every 15 minutes
Location and duration of monitoring Monitoring in the operating theatre and in the recovery room. Monitored from just
before induction until discharge from recovery room
Notes
Risk of bias
Random sequence generation (selection Unclear risk ORs were cluster-randomized on a daily ba-
bias) sis after participants had been assigned. No
details of randomization method
Allocation concealment (selection bias) Unclear risk Allocation sent in sealed envelope after
allocation of participants. No possibility
of changing participants. For emergency
cases, an envelope containing the random
assignment was drawn from a stack
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Hypoxaemia
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Interventions
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Complications/mortality/cognitive func-
tion
Blinding of outcome assessment (detection High risk Hypoxia detection differed in intervention
bias) and control groups and was recorded by
Hypoxaemia OR personnel who were not blinded to par-
ticipant allocation
Blinding of outcome assessment (detection High risk Changes in care recorded by OR personnel
bias) who were not blinded to participant allo-
Interventions cation
Blinding of outcome assessment (detection Low risk Nurses undertaking cognitive function
bias) testing unaware of allocation. Patient re-
Complications/mortality/cognitive func- ported outcome unclear
tion
Incomplete outcome data (attrition bias) Low risk 125/861 (14.6%) participants did not
All outcomes complete study, but equally distributed be-
tween intervention and control groups
Selective reporting (reporting bias) Low risk All outcomes specified in Methods reported
Other bias Unclear risk Statistical methods have not allowed for
clustering
Ohmeda and Radiometer provided meters
for study
Many other funders listed. None obviously
commercial
Moller 1993c
Methods Multi-centre cluster-randomized RCT, three teaching hospitals and two major hospitals
in Denmark
Not blinded, elective participants were assigned to an operating room the day before
surgery, and pulse oximeters were assigned to operating rooms randomly
Participants 20,802 adult participants undergoing elective surgery expected to last longer than 20
minutes and performed under general, spinal or epidural anaesthesia
Outcomes Incidence of hypoxia during anaesthesia defined as cyanosis, arterial oxygen < 7.8 kPa,
SaO2 < 90% or SpO2 < 90%
Events during monitoring:
Changes to patient care
Postoperative complications: respiratory, cardiovascular, neurological and infectious; du-
ration of recovery room stay and ICU admittance. At POD7 or discharge
Death
Other monitoring OR: ECG, arterial pressure every 5 minutes, CVP if indicated
Recovery room: ECG and CVP continuously. BP, HR and respiratory rate every 15
minutes
Location and duration of monitoring Participants assigned a pulse oximeter were monitored from just before induction of
anaesthesia until discharge from the PACU
Notes
Risk of bias
Random sequence generation (selection Unclear risk ORs were cluster-randomized on a daily ba-
bias) sis after participants had been assigned. No
details of randomization method
Allocation concealment (selection bias) Unclear risk Allocation sent in sealed envelope after
allocation of participants. No possibility
of changing participants. For emergency
cases, an envelope containing the random
assignment was drawn from a stack
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Hypoxaemia
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Interventions
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Complications/mortality/cognitive func-
tion
Blinding of outcome assessment (detection High risk Hypoxia recorded by OR personnel (form
bias) A). These staff members were not blinded,
Hypoxaemia and methods for detecting hypoxaemia dif-
fered in the two groups
Blinding of outcome assessment (detection High risk Changes in care recorded by OR personnel
bias) (form A). These staff members were not
Interventions blinded to allocation
Blinding of outcome assessment (detection Low risk Form B for complications completed by
bias) staff unaware of allocation. Standardized
Complications/mortality/cognitive func- definitions for complications
tion
Incomplete outcome data (attrition bias) Low risk 938/21,740 excluded: 366 because partic-
All outcomes ipant was receiving a second anaesthetic
during admission, 475 for randomizing er-
rors. Exclusions were equally distributed
between control and intervention groups
Selective reporting (reporting bias) Low risk All outcomes specified in Methods reported
Other bias Unclear risk Statistical methods have not allowed for
clustering
Ohmeda and Radiometer provided meters
for study
Interventions Intervention group: N = 589. Continuous monitoring using Nellcor central station
network CPOX system Oxinet II via telemetry station
Control group: N = 630. Intermittent assessment as nurse required. Standalone monitors
available. Typical use
Location and duration of monitoring Surgery care ward-telemetry station. USA. Monitored from admission to discharge/
transfer to ICU/other ward
Notes
Risk of bias
Random sequence generation (selection Unclear risk randomly generated group assignments.
bias) No further details
Allocation concealment (selection bias) Unclear risk Sequential sealed envelopes. No further
details
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
Complications/mortality/cognitive func-
tion
Blinding of participants and personnel High risk Staff responded to available data and mod-
(performance bias) ified treatment accordingly
ICU admission
Blinding of outcome assessment (detection Low risk In-hospital mortality at low risk of bias
bias)
Complications/mortality/cognitive func-
tion
Selective reporting (reporting bias) Low risk All outcomes specified in Methods reported
Other bias Unclear risk Only 1219 of a total of 8300 potential par-
ticipants enrolled. Not clear why so many
participants not enrolled, possibly related
to nurse staffing levels
Study funded by Nellcor-unrestricted grant
Cullen 1992 A non-randomized study of 17,093 surgical participants expected to enter the recovery room and then return to floor
care. During the first 28 weeks of the study, only seven pulse oximeters were available for shared use in 51 ORs. For the
subsequent 37 weeks, pulse oximeters were placed and were used on essentially all participants in all 51 anaesthetizing
locations
Mateer 1993 A non-randomized study of 191 consecutive adult participants to determine whether pulse oximetry improves recog-
nition of hypoxaemia during emergency endotracheal intubation. An observation period of complications lasted only
five minutes after intubation, and no events or complications were observed during anaesthesia or in the postoperative
period
min: Minutes.
OR: Operating room.
Haines 2012
Methods Published in abstract only. Unclear design. May not be a randomized trial
Interventions Continuous pulse oximetry in 24 hours postoperatively versus intermittent pulse oximetry
APPENDICES
WHATS NEW
Last assessed as up-to-date: 30 June 2013.
14 March 2014 New search has been performed The existing search strategy was updated from May 2009
to June 2013. This yielded 261 new potential titles. We
found no new included studies, but one additional study
is awaiting assessment
The review was converted to new review format, and we
used the Cochrane Risk of bias tool to assess the quality
of included studies. We added a Summary of findings
table
14 March 2014 New citation required but conclusions have not changed This review is an update of the previous Cochrane sys-
tematic review
(Pedersen 2009), which included five RCTs. Three new
authors joined the review team for this update: Amanda
Nicholson, Andrew Smith and Sharon Lewis. The con-
tact person has been changed to Amanda Nicholson
Our review reached the same conclusions as were reached
in the previous version
HISTORY
Protocol first published: Issue 2, 2000
Review first published: Issue 3, 2001
15 May 2009 New citation required but conclusions have not A new author Karen Hovhannisyan has joined the re-
changed view team.
He replaces Bente Dyrlund Pedersen who co-authored
Pedersen 2003a.
15 May 2009 New search has been performed We 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
reviews conclusion.
27 July 2005 New search has been performed Second Update, Issue 4, 2005:
We found no new randomized controlled trials examin-
ing the impact of perioperative monitoring with pulse
oximetry
31 January 2003 New citation required and conclusions have changed First Update, Issue 2, 2003.
We found no new randomized controlled trials examin-
ing the impact of perioperative monitoring with pulse
oximetry
CONTRIBUTIONS OF AUTHORS
Tom Pedersen (TP), Amanda Nicholson (AN), Karen Hovhannisyan (KH), Ann Merete Mller (AM), Andrew F Smith (AS), Sharon
R Lewis (SL)
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, AN
Organizing retrieval of papers: KH
Screening retrieved papers against inclusion criteria: TP, AM, KH, AN,AS
Appraising quality of papers: TP, AM, AN, AS
Extracting data from papers: TP, AM, AN
Pulse oximetry for perioperative monitoring (Review) 30
Copyright 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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 5.2): TP, KH
RevMan statistical data: TP, AM
Other statistical analysis not using RevMan: TP, AM
Double entry of data: TP, AM
Interpretation of data: TP, AM
Statistical inferences: TP, AM
Writing the review: TP, AM, KH, AN, SL
Securing funding for the review: TP
Guarantor for the review (one author): TP
Person responsible for reading and checking review before submission: TP
DECLARATIONS OF INTEREST
Tom Pedesen is a co-author of one study included in the review (Moller 1993c).
Amanda Nicholson: From March to August 2011, AN worked for the Cardiff Research Consortium, which provided research and
consultancy services to the pharmaceutical industry. The Cardiff Research Consortium has no connection with ANs work with The
Cochrane Collaboration. ANs husband has small direct holdings in several drug and biotech companies as part of a wider balanced
share portfolio. See Sources of support.
Karen Hovhannisyan: none known.
Ann Merete Mller: none known.
Andrew F Smith: none known.
Sharon R Lewis: none known.
SOURCES OF SUPPORT
Internal sources
No sources of support supplied
INDEX TERMS
Oximetry; Anesthesia Recovery Period; Anoxia [ diagnosis; mortality]; Hospital Mortality; Monitoring, Intraoperative [ methods];
Postoperative Complications [ prevention & control]; Randomized Controlled Trials as Topic