| Title | Misalignment of disposable pulse oximeter probes results in false saturation readings that influence anesthetic management. | | Author(s) | Guan Z, Baker K, Sandberg WS | | Institution | Harvard Medical School, Boston, Massachusetts, USA. | | Source | Anesth Analg 2009 Nov; 109(5):1530-3. | | MeSH | Adhesiveness
Adult
Aged
Anesthesia, General
Anoxia
Artifacts
Biological Markers
Disposable Equipment
Equipment Design
Female
Fingers
Humans
Male
Monitoring, Intraoperative
Oximetry
Oxygen
Plethysmography
Predictive Value of Tests
Reproducibility of Results
Unnecessary Procedures
| | Abstract | We report a small case series in which misaligned disposable pulse oximeter sensors gave falsely low saturation readings. In each instance, the sensor performed well during preinduction oxygen administration and the early part of the case, most notably by producing a plethysmographic trace rated as high quality by the oximeter software. The reported pulse oximeter oxygen saturation eventually decreased to concerning levels in each instance, but the anesthesiologists, relying on the reported high-quality signal, initially sought other causes for apparent hypoxia. They undertook maneuvers and diagnostic procedures later deemed unnecessary. When the malpositioned sensors were discovered and repositioned, the apparent hypoxia was quickly relieved in each case. We then undertook a survey of disposable oximeter sensors as patients entered the recovery room, and discovered malposition of more than 1 cm in approximately 20% of all sensors, without apparent consequence. We conclude that the technology is quite robust, but that the diagnosis of apparent hypoxia should include a quick check of oximeter position early on. | | Language | eng | | Pub Type(s) | Case Reports
Journal Article
Research Support, Non-U.S. Gov't
| | PubMed ID | 19843792 |
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