pulse oximetry with poor perfusion

[Colba55o]

Had a 90 yr old for elective lap chole other day. Chronic rate controlled A fib, not anticoagulated, moderate COPD, HTN, DM 2, normal weight, pretty active per wife.
Patient rolled into OR, could not get a SpO2 reading. We have the non disposable pulse ox probes, and and initially tried multiple fingers and toes, no reading. Placed upper bair hugger, waited several minutes and nurse massages the guys hands, no luck. Tried probe on both ears with ear probes no luck. PA runs to ER where they have disposable adult sized probes, and I place on forehead (not sure why this works but Ive seen it done) Here I got a very nice waveform but no number reading for the sat. At this point I call for partner of mine for advice, and after 15 minutes, a 3rd partner comes in and somehow manages to get a number reading on the finger, but waveform is basically flat, and number bounces around between low 80s and high 90s. At this point an hour has been spent in the OR. Upon questioning preop nurse she says it took her 30 minutes to find a sat and at one point a 93 "popped up" and she recorded it.
Did not think it was safe to induce this patient unable to get a reliable spO2, but not sure what to do at this point. Any advice? tips?

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[OB1🤙]

If you have cerebral oximetry, you can use that. Get an awake baseline and keep it above that number.

Usually under anesthesia there's enough vasodilation for the pulse ox to start picking up.

Or you can put in an arterial line and monitor pO2.

 

[Mman]

I've been there and don't have a great answer or great solution, but that story can be the start of how things end badly.

 

[Ignatius J]

I've been there and don't have a great answer or great solution, but that story can be the start of how things end badly.

I had this happen often in the burn room, when the full body prep would get into the connector and break any probe that got some on it.

I just remembered- etCO2, EKG, BP, and patient color are your friends. In this event, and I'll admit I am a cowboy, I would document that I couldn't pick up a tracing 2/2.....and proceed. How can this patient be optimized to get a tracing? Perhaps after induction a tracing would come up.

 

[Chloroform4Life]

Had a 90 yr old for elective lap chole other day. Chronic rate controlled A fib, not anticoagulated, moderate COPD, HTN, DM 2, normal weight, pretty active per wife.
Patient rolled into OR, could not get a SpO2 reading. We have the non disposable pulse ox probes, and and initially tried multiple fingers and toes, no reading. Placed upper bair hugger, waited several minutes and nurse massages the guys hands, no luck. Tried probe on both ears with ear probes no luck. PA runs to ER where they have disposable adult sized probes, and I place on forehead (not sure why this works but Ive seen it done) Here I got a very nice waveform but no number reading for the sat. At this point I call for partner of mine for advice, and after 15 minutes, a 3rd partner comes in and somehow manages to get a number reading on the finger, but waveform is basically flat, and number bounces around between low 80s and high 90s. At this point an hour has been spent in the OR. Upon questioning preop nurse she says it took her 30 minutes to find a sat and at one point a 93 "popped up" and she recorded it.
Did not think it was safe to induce this patient unable to get a reliable spO2, but not sure what to do at this point. Any advice? tips?

Did you cancel, procceed, or still waiting around to get tip from SDN??

If you cancel case, is it going to change anything next time the guy come back for procedure?

I think pulse ox just works poorly on some folks. Their 660:940 ratio is just off somehow and does not cooperate with the pulse ox's algorithm. I have encountered this before in patients who i thought was relatively well perfused.

I think perfusion is only one part of it. Ive seen patients in the ICU on 3 pressors, with good pulse ox waveform..... there must be more to it.

Try using different pulse ox machines? If that doesn't work, I dont know a good answer. Ive done these cases by placing an a line though. Check pao2 and o2 sat on abg periodically throughout case. As long as you are ventilating well with adequate fi02, your patient's oxygenation shouldn't change much.

 

[deleted126335]

Digital block to improve perfusion to finger. I have done it a few times.


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[OB1🤙]

Digital block to improve perfusion to finger. I have done it a few times.

Oohh I like that. Nice.

 

[deleted162650]

Try the foreskin. Seriously. This is what they have to do when they anesthetize great apes like orangutans and gorillas.

If that doesn't, work do as Doze suggested and combine with a penile block

 

[ranvier]

While you are down there, place the foley and second IV.

 

[chocomorsel]

This happened to me about two weeks ago. Hands were cold, tried new disposable finger probes, changed out the cords and nothing. Called my partner, who tried taping it to the nose. Some intermittent readings. Then I asked for a portable 02 sat monitor and that worked, so I used it.

I have no idea why it wasn't working and I tried it on myself and it didn't work continuously either. So maybe it was the equipment plus cold fingers combination. My hands are always cold too.

 

[vector2]

 

[Noyac]

I usually go to the portable monitor. This works 90% of the time. If not then I put a sticky probe across the bridge of the nose. This usually fixes the remaining 10%. I love the digital block idea. I've heard it before but completely forgot it. Penile pulse Ox is interesting as well.
Funny you bring this up now. Just last week I had a run of pts with poor sats. All resolved by the ear probe tho.

 

[deleted162650]

I've had good luck with the ear probe clipped on the nares. The ear probe in the corner of the mouth so it's shining through the buccal mucosa has never failed me either.

 

[Chloroform4Life]

These are some neat tricks to learn. I cant wait for my next patient with a sh*tty pulse ox reading.

I think I'll try the penile block first.

 

[Colba55o]

Thanks for all the replies. After much hemming and hawing I told surgeon I was not ok with proceeding with case and of course she was pissed but I would have been a nervous wreck the entire case. I told her I would do some research on it, and we could hopefully reschedule once I had a better plan in place, this wasn't an urgent procedure and the guy could wait at least a few days.
We tried two different portable machines from pre-An in addition to our anesthesia machine with no luck. We did ear probe on lips, nares..and nada.
I thought about A-line but we don't have ABG machines in our ORs, have to send the samples to RT and they take 20 minutes to get back results.
Did not try the adhesive probe on the nose.
This guy also has some type of choreiform movement disorder (that he called restless legs but seemed to involve his whole body ) which most likely contributed to the problem.
I'm going to have him return to our preadmission clinic, apply warm compresses to hands, ears and see if that helps

 

[Noyac]

I'm going to have him return to our preadmission clinic, apply warm compresses to hands, ears and see if that helps

I think you are going to need a better plan than that. Or just proceed with the case next time.

 

[jwk]

I think you are going to need a better plan than that. Or just proceed with the case next time.

Although it's not ideal, cases can be done without a pulse ox. I did anesthesia without them my first 10 years in practice.

 

[Chloroform4Life]

If none of the tricks above to get your pulse oximetry to function works, you can place an a-line and periodically draw back on it to note the color of the blood. Take a picture with your phone for future comparisons. Run an initial abg to correlate. Also check color on inside of lips regularly during case. Send abg to lab every 20-30 minutes to reassure yourself since looking at colors can be somewhat subjective, but good enough to indicate moderate to severe deoxigenation i think.

 

[ranvier]

He's 90, you can't delay this case.....joking.

At least for a lap chole you will have an ETT in place.

I predict after nmb, his movement disorder will go away and the pulse ox will work.

Agree, very unsettling not to have all your monitors working.

In residency, we had a run of take back VADs for quick cases like dental work and driveline debridements. The pulse ox and NIBP would not work on these folks due to non-pulsatile flow.

We stopped doing arterial lines and did manual bp after awhile.

I hated those cases but one can still perform a safe anesthetic.

 

[deleted162650]

Digital block is a cool idea, but real men would just do a stellate ganglion block.

 

[pgg]

If you have cerebral oximetry, you can use that. Get an awake baseline and keep it above that number.

I like this answer a lot.

 

[jwk]

Although it's not ideal, cases can be done without a pulse ox. I did anesthesia without them my first 10 years in practice.

I occasionally cover up / turn off monitors with my students and ask them "now what?" There are lots of things that can be done - but the first one is always "take care of the patient". Would you be able to do a case without a pulse ox and EtCO2 and NIBP? You should. Not as a matter of routine of course, but you should be able to do it. The only true monitor I had when I started my career was a "bouncing ball" EKG. Everything else was manual, and pulse ox and EtCO2 monitors were years away.

If you ever go to a 3rd world country for some medical mission work, it's quite likely that you'll be without one or more of your favorite monitors. Could you do it?

 

[Chloroform4Life]

I occasionally cover up / turn off monitors with my students and ask them "now what?" There are lots of things that can be done - but the first one is always "take care of the patient". Would you be able to do a case without a pulse ox and EtCO2 and NIBP? You should. Not as a matter of routine of course, but you should be able to do it. The only true monitor I had when I started my career was a "bouncing ball" EKG. Everything else was manual, and pulse ox and EtCO2 monitors were years away.

If you ever go to a 3rd world country for some medical mission work, it's quite likely that you'll be without one or more of your favorite monitors. Could you do it?

There's a reason mortality rate from anesthesia has plummeted since you started your carreer.

...but I get your point.....I think

 

[Ignatius J]

There's a reason mortality rate from anesthesia has plummeted since you started your carreer.

...but I get your point.....I think

You think pulse oximetry is a sole reason for that? As in, it potentially dropped the mortality rate of a lap chole?

 

[vector2]

You think pulse oximetry is a sole reason for that? As in, it potentially dropped the mortality rate of a lap chole?

If I had to venture a guess, I would say EtCO2 was 60% responsible for reduced morbidity/mortality, pulse ox 30%, other safety innovations 10%. Fun fact, though, commercial pulse oximeters became available in 1981 and the first lap chole was performed in 1985

edit: apparently this was a landmark closed claims study:

http://www.ncbi.nlm.nih.gov/pubmed/2508510

Anesthesiology. 1989 Oct;71(4):541-6.
Role of monitoring devices in prevention of anesthetic mishaps: a closed claims analysis.
Tinker JH1, Dull DL, Caplan RA, Ward RJ, Cheney FW.
Author information

Abstract
Anesthesiologist-reviewers examined 1,175 anesthetic-related closed malpractice claims from 17 professional liability insurance companies. The claims were filed between 1974 and 1988. The reviewers were asked to determine if the negative outcome was preventable by proper use of additional monitoring devices available at the time of the review even if not available at the time the incident occurred, and if so, which devices could have been preventative. In 1,097 cases sufficient information was available to make a judgment regarding preventability of the morbidity or mortality by application of additional monitoring devices. It was determined that 31.5% of the negative outcomes could have been prevented by application of additional monitors. Using the insurance industry's scale of 0 (no injury) to 9 (death), the median severity of injury for incidents deemed preventable was 9 compared with 5 for those deemed not preventable (P less than 0.01, scale detailed in text). The severity of injury scores were the same for preventable mishaps occurring during regional or general anesthesia, suggesting that additional monitoring devices may be equally efficacious in preventing serious negative outcomes during either regional or general anesthesia. The judgements or settlements of the incidents judged preventable by additional monitoring were 11 times more costly (P less than 0.01) than those mishaps not judged preventable. The monitors determined by the reviewers to be most useful in mishap prevention were pulse oximetry plus capnometry. Applied together, these two technologies were considered potentially preventative in 93% of the preventable mishaps.(ABSTRACT TRUNCATED AT 250 WORDS)

 

[Chloroform4Life]

You think pulse oximetry is a sole reason for that? As in, it potentially dropped the mortality rate of a lap chole?

No...that was not my implication.

I was responding to jwk who noted that when he started, he did not use pulse oximetry, etco2, or NIBP. Im sure he didn't have ET agent either.

If we were to lack those monitors, I'm sure mortality rate would be higher......especially among the independent practice CRNAs and even those being "supervised" 1:10.

 

[Ignatius J]

If I had to venture a guess, I would say EtCO2 was 60% responsible for reduced morbidity/mortality, pulse ox 30%, other safety innovations 10%. Fun fact, though, commercial pulse oximeters became available in 1981 and the first lap chole was performed in 1985

edit: apparently this was a landmark closed claims study:

Why I said "potentially". I honestly can't remember the last time I did a lap chole and I changed management based off of a pulse ox reading. If ever.

 

[Ignatius J]

No...that was not my implication.

I was responding to jwk who noted that when he started, he did not use pulse oximetry, etco2, or NIBP. Im sure he didn't have ET agent either.

If we were to lack those monitors, I'm sure mortality rate would be higher......especially among the independent practice CRNAs and even those being "supervised" 1:10.

Gotcha. I for one think ETCO2 is the game changer. Pulse ox, meh.

 

[pgg]

If you ever go to a 3rd world country for some medical mission work, it's quite likely that you'll be without one or more of your favorite monitors. Could you do it?

If you ever go to a 3rd world country for some medical mission work, and you don't bring along a pulse ox, you shouldn't be allowed back into the 1st world country you came from.

I don't think I'd go without capnography, either.

 

[Ignatius J]

If you ever go to a 3rd world country for some medical mission work, and you don't bring along a pulse ox, you shouldn't be allowed back into the 1st world country you came from.

I don't think I'd go without capnography, either.

Eh, people need help and the outreach programs are expensive. I'm not going to penalize someone for not having port-a-anesthesia kit.

 

[jwk]

No...that was not my implication.

I was responding to jwk who noted that when he started, he did not use pulse oximetry, etco2, or NIBP. Im sure he didn't have ET agent either.

If we were to lack those monitors, I'm sure mortality rate would be higher......especially among the independent practice CRNAs and even those being "supervised" 1:10.

Right - it wasn't that we didn't use them - they weren't invented yet.

Emory (in 1979) had a mass spectrometer that covered the entire OR. It had a monitor in each OR, but the attachment to the circuit hooked to a line hanging from the ceiling that fed to the mass spec through a "stepper valve" that switched to each OR for a 10-second look. That means you got 10 seconds of EtCO2 data about every 2.5 minutes. You could get a STAT reading which meant every other reading would come from your OR, but you couldn't leave it there for long because it screwed every other room. Pulse ox was still several years off, and non-academic centers didn't have anything. Of course this is also back when we had head-only CT scanners too.

At my first gig, we had one of the original blue Dinamap NIBP monitors for our 9-bed OR. Otherwise, BP's were done manually, and we used a pre-cordial stethoscope on every patient (gold star if you know what a Ploss valve is, and double gold star if you ever used one). We had two hanging bellows ventilators that we moved from room to room - so we made sure if we needed a vent we got there first and claimed it for our room. If you were late, you bagged them the entire case. Hell, we even had reusable red rubber Carlens double lumen tubes with carinal hooks! Ah, the good old days.

I have no desire to go back to doing anesthesia that way - but power failures, gas supply failures, and monitor malfunctions do occur from time to time - and it never hurts to know what to do when that happens.

 

[fakin' the funk]

Continuous ScvO2 central line

 

[nimbus]

If you ever go to a 3rd world country for some medical mission work, and you don't bring along a pulse ox, you shouldn't be allowed back into the 1st world country you came from.

I don't think I'd go without capnography, either.

Agree. A pulse ox is $20 on Amazon.

 

[deleted126335]

If I had to venture a guess, I would say EtCO2 was 60% responsible for reduced morbidity/mortality, pulse ox 30%, other safety innovations 10%. Fun fact, though, commercial pulse oximeters became available in 1981 and the first lap chole was performed in 1985

edit: apparently this was a landmark closed claims study:

I don't think that you give enough credit to the practice of endotracheal intubation becoming routine and preferred as opposed to mask anesthesia which was very common.


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[pgg]

Eh, people need help and the outreach programs are expensive. I'm not going to penalize someone for not having port-a-anesthesia kit.

I will. In the context of a plane ticket, a place to sleep, stuff to eat, and lost wages from not working the day job ... one-time equipment expenses of under $100 are less than negligible.

Charity work abroad isn't an excuse to practice anesthesia without basic standard monitors.

 

[Ignatius J]

I will. In the context of a plane ticket, a place to sleep, stuff to eat, and lost wages from not working the day job ... one-time equipment expenses of under $100 are less than negligible.

Charity work abroad isn't an excuse to practice anesthesia without basic standard monitors.

Eh, pulse oximetry is more of a convenience than a necessity, imo.

 

[urge]

I will. In the context of a plane ticket, a place to sleep, stuff to eat, and lost wages from not working the day job ... one-time equipment expenses of under $100 are less than negligible.

Charity work abroad isn't an excuse to practice anesthesia without basic standard monitors.

I take it you have never been on mission.

 

[pgg]

I take it you have never been on mission.

That there is funny.

 

[pjl]

These look cool, not price effectively for a mission, but cool.


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[deleted171991]

Agree. A pulse ox is $20 on Amazon.

That's not one you want to quote in a malpractice suit. Get yourself an FDA-approved professional one, like Nonin Onyx, for about $200. One of my best investments.

 

[Ronin786]

That's not one you want to quote in a malpractice suit. Get yourself an FDA-approved professional one, like Nonin Onyx, for about $200. One of my best investments.

Where do you find yourself needing to use a portable pulse oximeter? ICU admits?

 

[deleted171991]

Where do you find yourself needing to use a portable pulse oximeter? ICU admits?

Patient transport to PACU as an anesthesiologist. Always have the pulse ox on their finger, so I don't get antsy while the nurses do stuff.

I tend to forget to carry it with me in the ICU, although I am sure that it would pick up some unobtainable sats.

 

[Ignatius J]

Patient transport to PACU as an anesthesiologist. Always have the pulse ox on their finger, so I don't get antsy while the nurses do stuff.

I tend to forget to carry it with me in the ICU, although I am sure that it would pick up some unobtainable sats.

That's a very good idea.

I'm not a fan of the ol "pacu dance", where untangling lines all of a suddenly becomes more important than the monitoring of the patient's oxygenation and ventilation.