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Recent rapid responses
Rapid responses are electronic letters to the editor. They enable our users to debate issues raised in articles published on bmj.com. Although a selection of rapid responses will be included as edited readers' letters in the weekly print issue of the BMJ, their first appearance online means that they are published articles. If you need the url (web address) of an individual response, perhaps for citation purposes, simply click on the response headline and copy the url from the browser window.
Displaying 1-3 out of 3 published
24 January 2012
I was the first to write about the elevated cost of Lifebox pulse oximeters. 
I was the first who provided evidence for the existence of other, FDA approved, CE marked, TUV certified, high quality pulse oximeters which sell for 15 pounds, with free packing and postage to any Country in the World.
I was the first who proposed a change of provider, in order for the BMJ to help even more doctors in Developing Countries, for the same amount of money.
I was the first to report that rechargeable devices (like Lifebox pulse oximeter) are not very practical in a setting where electricity is often generator-produced, for only some hours in a day.
I was the first to answer to various Lifebox trustees who erroneously stated that their efficiency-safety-durability and accuracy tests were superior to those performed by the FDA, CE and TUV, for the other oximeters in the market.
I am indexing here my relative electronic letters to the Editor of the BMJ, in other sections. 
Competing interests: None declared
Private Surgery, Thessaloniki, Greece
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22 January 2012
We are surprised to read of Dr Bihari's reluctance to encourage the use of pulse oximeters during anaesthesia in low income countries, based on evidence from the Cochrane Collaboration (1). Surely it is an important part of critical appraisal to consider the evidence and whether it is applicable to your patient group?
Previous attempts to demonstrate whether pulse oximeters improve mortality have been substantially underpowered and have taken place in well-resourced healthcare facilities in the West - a world away from the hospitals that Lifebox is assisting (2). We agree that the reason that pulse oximeters are not more widely available is part of a huge failing of healthcare in many places, but pulse oximetry has particular significance to the safety of patients undergoing anaesthesia and surgery.
Most episodes of hypoxia during anaesthesia are related to an obstructed airway or inadequate ventilation and improve when these are resolved, even when oxygen is not available. Cyanosis is difficult to identify when lighting is poor, in dark skinned patients and when anaemia is present (common in many settings, particularly during pregnancy). When working with no other form of monitoring save a finger on a pulse and a precordial stethoscope, early warning of a falling saturation is invaluable.
Dr Bihari challenges Lifebox 'to do the trial', that is to test the question whether monitoring with pulse oximetry during anaesthesia saves lives. Pulse oximetry is mandated during anaesthesia in the UK and Australia, as well as by national anaesthesia organisations in all 58 countries that have national standards of monitoring (3). Given the financial barriers in low-income settings, it can only be 'highly recommended' by WHO and World Federation of Societies of Anaesthesiologists.
We believe the suggestion to perform a trial of oximetry on patients in poorer countries is misconceived and unethical, particularly since anaesthesia mortality may approach 1% in this setting, with the majority of deaths resulting from hypoxia and hypovolaemia.
After a combined 56 years of working as anaesthetists we believe oximetry is lifesaving. If Dr Bihari doesn't think that his pulse oximeters are necessary we would be delighted to receive them in the Lifebox office!
1. 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
2. Merry AF, Eichorn JH, Wilson IH. Extending the WHO 'Safe Surgery Saves Lives' project through Global Oximetry. Anaesthesia 2009 64: 1045 - 1050
3. Funk LM, Weiser TG, Berry WR et al Global operating theatre distribution and pulse oximetry supply: an estimation from reported data. Lancet 2010 376: 1055-61
Competing interests: Isabeau Walker is a member of Council of the AAGBI and a trustee of Lifebox Iain Wilson is President of the AAGBI and a trustee of Lifebox
Great Ormond Street Hospital NHS Trust, Great Ormond Street, London WC1N 3JH
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18 January 2012
As our friends in the Cochrane Collaboration have emphasised there is little or no evidence that monitoring by pulse oximetry during general anaesethsia saves lives! When I was a boy, many moons ago at the now demolished Middlesex Hospital, I was taught that hypoxia (recognised by central cyanosis in those days) was a late sign of disconnection during anaesthesia because of course it could be delayed or prevented by increasing the inspired oxygen concentration. More likely the terminal event in such cases (few as they were) was a respiratory acidosis with hyperkalaemia producing a cardiac arrhythmia.
The situation may be different in the developing world where for example in Central Africa, it is difficult to know what the concentration of oxygen is coming out of the cylinder or the oxygen port in the wall! A pulse oximeter in such a setting might help identify the infrastructure problem but it is the infrastructure that needs fixing! Running water in an ICU in Bangladesh is a rarity - monitoring by pulse oximetry is not going to prevent infection.
So given the lack of evidence for the intervention, why don't our friends at Lifebox do the trial .....and demonstrate that monitoring by pulse oximetry in the setting of the developing world saves lives? I think I know why! Pulse oximetry (just like pulmonary artery catheterisation) is only "monitoring" and unless there is some treatment associated with the observed physiological abnormality, there will be no change in outcome. If we can't control the oxygen concentration coming out of the wall / cylinder, monitoring arterial oxygen saturation will be a complete waste of time.
Competing interests: None declared
Prince of Wales Hospital, 15 Shepherd Rd, Artarmon, NSW 2064
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