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!
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
Rapid Response:
Re: Lifebox: give a little, help a lot
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