Feature BMJ Winter Appeal

Lifebox: give a little, help a lot

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e313 (Published 17 January 2012) Cite this as: BMJ 2012;344:e313
  1. Iain H Wilson, president1,
  2. Isabeau A Walker, consultant anaesthetist2
  1. 1Association of Anaesthetists of Great Britain and Ireland, London, UK
  2. 2Great Ormond Street Hospital for Children, London, UK

In the 1980s pulse oximetry transformed the safety of anaesthesia in UK. For the first time anaesthetists in operating theatres could determine the oxygenation of unconscious patients accurately, rather than trying to estimate skin colour under green drapes with artificial light. Since most preventable deaths under anaesthesia involve hypoxia or hypotension, all UK hospitals purchased oximeters, and they rapidly became a universal standard. Initially oximeters were used in theatre, the anaesthetic room, and recovery but they rapidly spread to all areas of the hospital. Today arterial oxyhaemaglobin saturation (SpO2) is recorded almost as routinely as heart rate and blood pressure.

Anaesthesia in the UK is well resourced and safe, with mortality directly attributable to anaesthesia of around 1 in 200 000. The situation is completely different in poorer settings, where the mortality directly attributable to anaesthesia has been reported as up to 1%. Many of these deaths are thought to be due to undetected hypoxia.1 It is difficult to detect cyanosis when working alone, with poor lighting, limited equipment, and training. Dark skinned patients are at particular risk. Each of these deaths is a tragedy for all concerned, and many might be prevented if a pulse oximeter was available.

In 2008 when the World Health Organization was developing the surgical safety checklist, the anaesthetists on the working group made a strong case for every patient having anaesthesia to have a pulse oximeter in place. The issue was vigorously debated and the decision was difficult; everything else on the checklist concerned safety checks and teamwork and no extra resources were required. However, WHO thought that it was unacceptable that patients should face the (published) level of risk from undetected hypoxia during general anaesthesia and agreed that routine oximetry should become a standard of care.2 WHO does not supply pulse oximeters but set up a working group to develop oximeter standards, in addition to ISO 9919, to ensure maximum utility in all resource poor settings.

Lifebox is a charity formed by representatives of the Association of Anaesthetists of Great Britain and Ireland, the World Federation of Societies of Anaesthesiologists, and the Harvard School of Public Health and chaired by Atul Gawande, who led the development of the WHO checklist. Lifebox was formed to facilitate access to high quality, low cost pulse oximeters suitable for use in the operating theatre, along with training and support for the introduction of the WHO checklist for surgery.

The World Federation of Societies of Anaesthesiologists conducted an international tender exercise and sourced an oximeter that met the required specifications. The Lifebox oximeter is robust, battery or mains powered, accurate, clear, and easy to use with configurable alarms, a pulse waveform, and pulse signal that changes in tone as the saturation drops. Lifebox works directly with the manufacturer so that this oximeter can be supplied for $250 (£160; €196) along with high quality educational materials in six languages. Replacement probes are often expensive but are available through the charity for $25 and a rechargeable battery for $10. The oximeter meets the specifications required for the operating theatre, unlike some cheaper models available from the internet.

How can readers of the BMJ help Lifebox? We have estimated that there are 77 000 operating rooms without oximeters, but they are also needed in recovery rooms and intensive care, paediatrics, obstetrics, neonatal, and emergency units.3 As well as your financial support for the project, we need your links internationally to help recognise the gaps and to work with hospitals and clinicians to introduce both oximeters and the checklist alongside education. Contact us with your ideas and let us know how we can help your contacts in low resource settings get access to this life saving equipment.

Lifebox is working to make oximetry, which is an internationally recognised standard of care, a reality for millions of patients in low income settings. Pulse oximetry is affordable and should be universal. No woman having caesarean section should have an anaesthetic without a pulse oximeter; nor should any other patient who requires surgery, young or old.


Cite this as: BMJ 2012;344:e313


  • Provenance and peer review: Commissioned; externally peer reviewed.