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Background: Pulse oximetry is a noninvasive method widely used in critical care and various clinical settings to monitor blood oxygen saturation. During the COVID-19 pandemic, its application for at-home oxygen saturation monitoring became prevalent. Further investigations found that pulse oximetry devices show decreased accuracy when used on individuals with darker skin tones. This study aimed to investigate the influence of X (previously known as Twitter) on the dissemination of information and the extent to which it raised health care sector awareness regarding racial disparities in pulse oximetry., Objective: This study aimed to explore the impact of social media, specifically X, on increasing awareness of racial disparities in the accuracy of pulse oximetry and to map this analysis against the evolution of published literature on this topic., Methods: We used social network analysis drawing upon Network Overview Discovery and Exploration for Excel Pro (NodeXL Pro; Social Media Research Foundation) to examine the impact of X conversations concerning pulse oximetry devices. Searches were conducted using the Twitter Academic Track application programming interface (as it was known then). These searches were performed each year (January to December) from 2012 to 2022 to cover 11 years with up to 52,052 users, generating 188,051 posts. We identified the nature of influencers in this field and monitored the temporal dissemination of information about social events and regulatory changes. Furthermore, our social media analysis was mapped against the evolution of published literature on this topic, which we located using PubMed., Results: Conversations on X increased health care awareness of racial bias in pulse oximetry. They also facilitated the rapid dissemination of information, attaining a substantial audience within a compressed time frame, which may have impacted regulatory action announced concerning the investigation of racial biases in pulse oximetry. This increased awareness led to a surge in scientific research on the subject, highlighting a growing recognition of the necessity to understand and address these disparities in medical technology and its usage., Conclusions: Social media platforms such as X enabled researchers, health experts, patients, and the public to rapidly share information, increasing awareness of potential racial bias. These platforms also helped connect individuals interested in these topics and facilitated discussions that spurred further research. Our research provides a basis for understanding the role of X and other social media platforms in spreading health-related information about potential biases in medical devices such as pulse oximeters., (©Wasim Ahmed, Mariann Hardey, Bradford David Winters, Aarti Sarwal. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 08.10.2024.)

Introduction: Current standards for hemoglobin monitoring during air transports of U.S. combat wounded are invasive and intermittent. Fielded pulse co-oximeters can noninvasively measure total hemoglobin, but this parameter is not currently utilized. The primary objective of this study was to assess the percentage of vital sign measurements with successful capture of total noninvasive hemoglobin measurement using spectrophotometry-based technology for Hb (SpHb) measurements in healthy participants during training flights. Secondary objectives were to assess the feasibility of a novel electronic data capture mechanism from usual patient movement items and perform a pilot analysis of SpHb changes in healthy participants during transitions from ground to air transport., Methods: We conducted a feasibility study enrolling healthy participants who had hemodynamic monitoring during usual U.S. Air Force Critical Care Air Transport (CCAT) flight training exercises from 2022 to 2023. Usual CCAT monitoring equipment and currently used Masimo Rainbow® pulse co-oximeters had the capability to measure SpHb. After each training exercise, the study team wirelessly downloaded case files from patient monitors utilizing the Battlefield Assisted Trauma Distributed Observation Kit (BATDOKTM) Case Downloader application. We then calculated point and precision estimates for the percentage of time for successful SpHb capture during the exercise and compared this to pulse oximetry (SpO2) capture. An a priori precision analysis for percentage of flight-time with successful SpHb data capture and descriptive statistics were performed. This study received Exempt Determination by the 59th Medical Wing IRB., Results: We analyzed 26 records with mean monitoring durations of 94.5 [59.3-119.9] minutes during ground phases and 78.0 [59.9-106.5] minutes during flight phases. SpHb measures were successfully captured for 97.7% (n = 4,620) of possible ground measurements and 97.2% (n = 3,973) of possible in-flight measurements compared to 99.5% ground and 98.2% in-flight capture for SpO2. Mean intervals of missing SpHb data were 2 ± 5 minutes on the ground and 4 ± 6 minutes in-flight. Mean SpHb increased by 0.93 ± 0.96 g/dL during the ground phase, but had minimal changes during ascent, cruising altitude or descent. The BATDOKTM Case downloader completed transfer for all files., Conclusion: Masimo Rainbow® SpHb pulse co-oximeters reliably captured continuous, noninvasive hemoglobin measurements using usual CCAT patient movement items in healthy participants during both ground and flight training. The BATDOKTM Case Downloader successfully imported case files from CCAT patient monitors. Mean SpHb measures had a small increase during the ground phase of monitoring followed by minimal changes when transitioning to flight altitude., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2024. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

This study develops machine learning-based algorithms that facilitate accurate prediction of cerebral oxygen saturation using waveform data in the near-infrared range from a multi-modal oxygen saturation sensor. Data were obtained from 150,000 observations of a popular cerebral oximeter, Masimo O3™ regional oximetry (Co., United States) and a multi-modal cerebral oximeter, Votem (Inc., Korea). Among these observations, 112,500 (75%) and 37,500 (25%) were used for training and test sets, respectively. The dependent variable was the cerebral oxygen saturation value from the Masimo O3™ (0-100%). The independent variables were the time of measurement (0-300,000 ms) and the 16-bit decimal amplitudes values (infrared and red) from Votem (0-65,535). For the right part of the forehead, the root mean square error of the random forest (0.06) was much smaller than those of linear regression (1.22) and the artificial neural network with one, two or three hidden layers (2.58). The result was similar for the left part of forehead, that is, random forest (0.05) vs logistic regression (1.22) and the artificial neural network with one, two or three hidden layers (2.97). Machine learning aids in accurately predicting of cerebral oxygen saturation, employing the data from a multi-modal cerebral oximeter., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: National guidelines recommend against continuous pulse oximetry use for hospitalized children with bronchiolitis who are not receiving supplemental oxygen, yet guideline-discordant use remains high., Objectives: To evaluate deimplementation outcomes of educational outreach and audit and feedback strategies aiming to reduce guideline-discordant continuous pulse oximetry use in children hospitalized with bronchiolitis who are not receiving supplemental oxygen., Design, Setting, and Participants: A nonrandomized clinical single-group deimplementation trial was conducted in 14 non-intensive care units in 5 freestanding children's hospitals and 1 community hospital from December 1, 2019, through March 14, 2020, among 847 nurses and physicians caring for hospitalized children with bronchiolitis who were not receiving supplemental oxygen., Interventions: Educational outreach focused on communicating details of the existing guidelines and evidence. Audit and feedback strategies included 2 formats: (1) weekly aggregate data feedback to multidisciplinary teams with review of unit-level and hospital-level use of continuous pulse oximetry, and (2) real-time 1:1 feedback to clinicians when guideline-discordant continuous pulse oximetry use was discovered during in-person data audits., Main Outcomes and Measures: Clinician ratings of acceptability, appropriateness, feasibility, and perceived safety were assessed using a questionnaire. Guideline-discordant continuous pulse oximetry use in hospitalized children was measured using direct observation of a convenience sample of patients with bronchiolitis who were not receiving supplemental oxygen., Results: A total of 847 of 1193 eligible clinicians (695 women [82.1%]) responded to a Likert scale-based questionnaire (71% response rate). Most respondents rated the deimplementation strategies of education and audit and feedback as acceptable (education, 435 of 474 [92%]; audit and feedback, 615 of 664 [93%]), appropriate (education, 457 of 474 [96%]; audit and feedback, 622 of 664 [94%]), feasible (education, 424 of 474 [89%]; audit and feedback, 557 of 664 [84%]), and safe (803 of 847 [95%]). Sites collected 1051 audit observations (range, 47-403 per site) on 709 unique patient admissions (range, 31-251 per site) during a 3.5-month period of continuous pulse oximetry use in children with bronchiolitis not receiving supplemental oxygen, which were compared with 579 observations (range, 57-154 per site) from the same hospitals during the baseline 4-month period (prior season) to determine whether the strategies were associated with a reduction in use. Sites conducted 148 in-person educational outreach and aggregate data feedback sessions and provided real-time 1:1 feedback 171 of 236 times (72% of the time when guideline-discordant monitoring was identified). Adjusted for age, gestational age, time since weaning from supplemental oxygen, and other characteristics, guideline-discordant continuous pulse oximetry use decreased from 53% (95% CI, 49%-57%) to 23% (95% CI, 20%-25%) (P < .001) during the intervention period. There were no adverse events attributable to reduced monitoring., Conclusions and Relevance: In this nonrandomized clinical trial, educational outreach and audit and feedback deimplementation strategies for guideline-discordant continuous pulse oximetry use among hospitalized children with bronchiolitis who were not receiving supplemental oxygen were positively associated with clinician perceptions of feasibility, acceptability, appropriateness, and safety. Evaluating the sustainability of deimplementation beyond the intervention period is an essential next step., Trial Registration: ClinicalTrials.gov Identifier: NCT04178941.

Late diagnosis of critical congenital heart disease (CCHD) is associated with higher levels of morbidity and mortality in neonates. Nearly all states have passed laws mandating universal pulse oximetry screening (POxS) of newborns to improve early detection rates of CCHD. We performed a retrospective chart review of all transthoracic echocardiograms (TTEs) interpreted by our institution on patients between 0 and 30 days of life in the years 2010 (prior to POxS) and 2015 (after POxS). Between 2010 and 2015, the number of neonatal TTEs interpreted by our institution decreased by 18.2%. In 2015, there were 46 neonates diagnosed with CCHD with a 78% prenatal detection rate. There was only one case of a true-positive POxS. Our study demonstrated that the initiation of POxS coincided with a significant decrease in neonatal TTEs, suggesting universal POxS may impart reassurance to primary providers leading to a decrease in TTE utilization.

Objective: To define reference ranges for the 3% oxygen desaturation index (DI3) in healthy children under 12 years old during sleep., Design: Observational., Setting: Home., Subjects: Healthy children aged 6 months to 12 years of age., Intervention: Nocturnal pulse oximetry at home. Parents documented sleep times. Visi-Download software (Stowood Scientific) analysed data with artefact and wake periods removed., Main Outcome Measures: The following oximetry parameters used in the assessment of sleep-disordered breathing conditions were measured: 3% (DI3) and 4% (DI4) oxygen desaturation indices-the number of times per hour where the oxygen saturation falls by at least 3% or 4% from baseline, mean saturations (SAT50), minimum saturations (SATmin), delta index 12 s (DI12s), and percentage time with saturations below 92% and 90%., Results: Seventy-nine children underwent nocturnal home pulse oximetry, from which there were 66 studies suitable for analysis. The median values for DI3 and DI4 were 2.58 (95% CI 1.96 to 3.10) and 0.92 (95% CI 0.73 to 1.15), respectively. The 95th and 97.5th centiles for DI3 were 6.43 and 7.06, respectively, which inform our cut-off value for normality. The mean values for SAT50 and SATmin were 97.57% (95% CI 97.38% to 97.76%) and 91.09% (95% CI 90.32% to 91.86%), respectively., Conclusion: In children aged 6 months to 12 years, we define normality of the 3% oxygen desaturation index as <7 using standalone, motion-resistant pulse oximeters with short averaging times., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To determine the of undiagnosed lower extremity artery disease using the pulse oximetry in a type 2 diabetic population sample. Methods: Observational, cross-sectional, descriptive study that included 594 type 2 diabetic patients, with no previous history of lower extremity artery disease. Medical history, physical examination, determination of the ankle-brachial index (portable Doppler) and measurement of oxygen saturation in upper and lower extremities (pulse oximeter) were performed. Results: Frequency of lower extremity artery disease determined by ankle-brachial index was 18.4%. No significant correlations were detected between oxygen saturation and the ankle-brachial index except for the relationship between ankle-brachial index vs. oxygen saturation at 30 cm lower limb elevation vs. the supine position at no elevation (0 cm) in subjects under the age of 40. Pulse oximetry showed little diagnostic value in the screening of lower extremity artery disease. A relationship between lower extremity artery disease and age has been found. Its diagnosis was associated with a lower body mass index and lower systolic blood pressure in the lower extremities and higher in the upper extremities. Conclusions: We conclude that pulse oximetry is not useful in the screening for asymptomatic lower extremity artery disease in type 2 diabetics., Competing Interests: Competing Interests: The authors have declared that no competing interest exists., (© The author(s).)

Background: There have been insufficient data for African patients with COVID-19 who are critically ill. The African COVID-19 Critical Care Outcomes Study (ACCCOS) aimed to determine which resources, comorbidities, and critical care interventions are associated with mortality in this patient population., Methods: The ACCCOS study was a multicentre, prospective, observational cohort study in adults (aged 18 years or older) with suspected or confirmed COVID-19 infection who were referred to intensive care or high-care units in 64 hospitals in ten African countries (ie, Egypt, Ethiopia, Ghana, Kenya, Libya, Malawi, Mozambique, Niger, Nigeria, and South Africa). The primary outcome was in-hospital mortality censored at 30 days. We studied the factors (ie, human and facility resources, patient comorbidities, and critical care interventions) that were associated with mortality in these adult patients. This study is registered on ClinicalTrials.gov, NCT04367207., Findings: From May to December, 2020, 6779 patients were referred to critical care. Of these, 3752 (55·3%) patients were admitted and 3140 (83·7%) patients from 64 hospitals in ten countries participated (mean age 55·6 years; 1890 [60·6%] of 3118 participants were male). The hospitals had a median of two intensivists (IQR 1-4) and pulse oximetry was available to all patients in 49 (86%) of 57 sites. In-hospital mortality within 30 days of admission was 48·2% (95% CI 46·4-50·0; 1483 of 3077 patients). Factors that were independently associated with mortality were increasing age per year (odds ratio 1·03; 1·02-1·04); HIV/AIDS (1·91; 1·31-2·79); diabetes (1·25; 1·01-1·56); chronic liver disease (3·48; 1·48-8·18); chronic kidney disease (1·89; 1·28-2·78); delay in admission due to a shortage of resources (2·14; 1·42-3·22); quick sequential organ failure assessment score at admission (for one factor [1·44; 1·01-2·04], for two factors [2·0; 1·33-2·99], and for three factors [3·66, 2·12-6·33]); respiratory support (high flow oxygenation [2·72; 1·46-5·08]; continuous positive airway pressure [3·93; 2·13-7·26]; invasive mechanical ventilation [15·27; 8·51-27·37]); cardiorespiratory arrest within 24 h of admission (4·43; 2·25-8·73); and vasopressor requirements (3·67; 2·77-4·86). Steroid therapy was associated with survival (0·55; 0·37-0·81). There was no difference in outcome associated with female sex (0·86; 0·69-1·06)., Interpretation: Mortality in critically ill patients with COVID-19 is higher in African countries than reported from studies done in Asia, Europe, North America, and South America. Increased mortality was associated with insufficient critical care resources, as well as the comorbidities of HIV/AIDS, diabetes, chronic liver disease, and kidney disease, and severity of organ dysfunction at admission., Funding: The ACCCOS was partially supported by a grant from the Critical Care Society of Southern Africa., Competing Interests: Declaration of interests MMe has received honoraria for services related to speakers bureau and advisory boards. These have related to purely educational talks that have been given in an objective fashion for educational purposes and with no vested interest or agenda other than for educational purposes. Companies that MMe gave talks to were Pfizer, Merck, Astellas, Sanofi-Aventis, Aspen, and Sun. IJ is the former president of the Critical Care Society of Southern Africa and is a current councillor and board member of the Critical Care Society of Southern Africa. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Study highlights the need for symptom assessment in addition to oximetry measurement., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

For wearable electronics/optoelectronics, thermal management should be provided for accurate signal acquisition as well as thermal comfort. However, outdoor solar energy gain has restricted the efficiency of some wearable devices like oximeters. Herein, wireless/battery-free and thermally regulated patch-type tissue oximeter (PTO) with radiative cooling structures are presented, which can measure tissue oxygenation under sunlight in reliable manner and will benefit athlete training. To maximize the radiative cooling performance, a nano/microvoids polymer (NMVP) is introduced by combining two perforated polymers to both reduce sunlight absorption and maximize thermal radiation. The optimized NMVP exhibits sub-ambient cooling of 6 °C in daytime under various conditions such as scattered/overcast clouds, high humidity, and clear weather. The NMVP-integrated PTO enables maintaining temperature within ≈1 °C on the skin under sunlight relative to indoor measurement, whereas the normally used, black encapsulated PTO shows over 40 °C owing to solar absorption. The heated PTO exhibits an inaccurate tissue oxygen saturation (StO 2 ) value of ≈67% compared with StO 2 in a normal state (i.e., ≈80%). However, the thermally protected PTO presents reliable StO 2 of ≈80%. This successful demonstration provides a feasible strategy of thermal management in wearable devices for outdoor applications., Competing Interests: The authors declare no conflict of interest., (© 2021 The Authors. Advanced Science published by Wiley‐VCH GmbH.)

Importance: Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them., Objective: To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization., Design, Setting, and Participants: This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020., Exposures: After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home., Main Outcomes and Measures: The primary outcome was desaturation (ie, Spo2 < 90%) during the first 36 hours., Results: Of 239 infants enrolled, with a median (interquartile range [IQR]) age of 3.9 (1.5-6.5) months, 116 (48.5%) were boys and desaturation occurred in 165 infants (69.0%). Median (IQR) time to desaturation was 3.6 (1.8-9.4) hours. The rate of desaturation was similar between infants hospitalized and those discharged home (137 of 200 infants [68.5%] vs 28 of 39 infants [71.8%]; difference, -3.3%; 95% CI, -18.8% to 12.2%; P = .85). A more severe initial clinical presentation with moderate or severe retractions was the only independent risk factor associated with desaturation (odds ratio, 2.73; 95% CI, 1.49 to 5.02; P = .001). Of 39 infants discharged home, 22 infants (56.4%) experienced major desaturations. However, infants with desaturations, including those with major desaturations, had rates of rehospitalization similar to those of infants without desaturations (8 of 28 infants [28.5%] vs 3 of 11 infants [27.3%]; difference, 1.2%; 95% CI, -29.9% to 32.5; P > .99)., Conclusions and Relevance: These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.

Aim: The aim of this study was to evaluate the effects of a carbon dioxide pneumoperitoneum on cerebral and renal oxygenation and oxygen extraction, in a cohort of infants from the neonatal intensive care unit, undergoing laparoscopic gastrostomy., Methods: After institutional review board approval, between February 2018 and June 2019, infants 0-3 mo corrected age, undergoing laparoscopic gastrostomy tube placement, were included. Strict exclusion criteria created a homogeneous cohort. Cerebral and renal tissue oxygen saturation (rSO 2 ) by near-infrared spectroscopy, skin surface oxygen saturation (SpO 2 ), by pulse oximetry, and amplitude-integrated electroencephalography were measured. Monitoring was divided into preoperative, intraoperative and postoperative time periods. Cerebral and renal fractional tissue oxygen extraction was calculated using arterial (SpO 2 ) and tissue oxygen saturation (rSO 2 ): (SpO 2 -rSO 2 SpO 2 )X100. Data were averaged into one-minute epochs and significant changes from baseline during the intraoperative and postoperative periods were detected using one-way analysis of variance with repeated measures., Results: This pilot study examined sixteen infants, born at a median gestational age of 34.2 wk (range: 23.0-40.6) with a median corrected age of 42.9 wk (range: 40.0-46.3) at operation. None had seizure activity or altered sleep-wake cycles. No statistically significant variations in cerebral and renal tissue oxygenation and extraction were observed. Pulse oximetry did demonstrate significant variation from baseline on analysis of variance, but post hoc analysis did not identify any one specific time point at which this difference was significant., Conclusions: During a short infant laparoscopic procedure, no significant alteration in cerebral or renal oxygenation or oxygen extraction was observed. No seizure activity or changes in infant sleep-wake cycles occurred., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Traditional methods for the quantification of OSA severity may not encapsulate potential relationships between hypoxemia in OSA and cardiovascular risk., Research Question: Do novel nocturnal oxygen saturation (Spo 2 ) metrics have prognostic value in patients with OSA and high cardiovascular event risk?, Study Design and Methods: We conducted post hoc analyses of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial. In 2687 individuals, Cox proportional hazards models that were stratified for treatment allocation were used to determine the associations between clinical characteristics, pulse oximetry-derived metrics that were designed to quantify sustained and episodic features of hypoxemia, and cardiovascular outcomes. Metrics included oxygen desaturation index, time <90% Spo 2 , average Spo 2 for the entire recording (mean Spo 2 ), average Spo 2 during desaturation events (desaturation Spo 2 ), average baseline Spo 2 interpolated across episodic desaturation events (baseline Spo 2 ), episodic desaturation event duration and desaturation/resaturation-time ratio, and mean and SD of pulse rate., Results: Neither apnea-hypopnea index, oxygen desaturation index, nor any of the novel Spo 2 metrics were associated with the primary SAVE composite cardiovascular outcome. Mean and baseline Spo 2 were associated with heart failure (hazard ratio [HR], 0.81; 95% CI, 0.69-0.95; P = .009; and HR, 0.78; 95% CI, 0.67-0.90; P = .001, respectively) and myocardial infarction (HR, 0.86; 95% CI, 0.77-0.95; P = .003; and HR, 0.81; 95% CI, 0.73-0.90; P < .001, respectively). Desaturation duration and desaturation/resaturation time ratio, with established risk factors, predicted future heart failure (area under the curve, 0.86; 95% CI, 0.79-0.93)., Interpretation: Apnea-hypopnea index and oxygen desaturation index were not associated with cardiovascular outcomes. In contrast, the pattern of oxygen desaturation was associated with heart failure and myocardial infarction. However, concomitant risk factors remained the predominant determinants for secondary cardiovascular events and thus deserve the most intensive management., (Copyright © 2020. Published by Elsevier Inc.)

Objective: The novel virus known as severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has led to a terrifying pandemic. The range of illness severity among children is variable. This study aims to assess the characteristics of newborns born to SARS-CoV-2-positive women compared with those mothers who tested negative., Study Design: This was a retrospective cohort study performed at Brookdale Hospital Medical Center in New York City from March to May 2020. Electronic medical records of mother-baby dyads were reviewed., Results: Seventy-nine mothers tested for SARS-CoV-2 were included, out of which 18.98% of mothers tested SARS-CoV-2 positive. We found a significant association between symptoms and SARS-CoV-2 status. We observed a significant association between newborns of SARS-CoV-2 positive and SARS-CoV-2 negative mothers regarding skin-to-skin contact ( p  < 0.001). Both groups showed significant differences regarding isolation ( p  < 0.001). Interestingly, regarding SARS-CoV-2 infection in newborns, only one newborn tested SARS-CoV-2 positive and was unstable in the neonatal intensive care unit (NICU). With the multivariable logistic regression model, babies of SARS-CoV-2 positive mothers were three times as likely to have desaturations in comparison to newborns from negative mothers. Also, newborns of SARS-CoV-2-positive mothers were four times more likely to have poor feeding, compared with newborns of SARS-CoV-2-negative mothers. Finally, babies of SARS-CoV-2-positive mothers were ten times more likely to be symptomatic at the 2-week follow-up., Conclusion: SARS-CoV-2 has caused major morbidity and mortality worldwide. Neonates born to mothers with confirmed or suspected SARS-CoV-2 are most of the time asymptomatic. However, neonatal critical illness due to SARS-CoV-2 is still a possibility; thus, isolation precautions (such as avoiding skin-to-skin contact and direct breastfeeding) and vertical transmission should be studied thoroughly. In addition, testing these newborns by nasopharyngeal swab at least at 24 hours after birth and monitoring them for the development of symptoms for 14 days after birth is needed., Key Points: · For SARS-CoV-2-positive mothers, reducing transmission of infection to newborns is crucial.. · Newborns of SARS-CoV-2-positive mothers are usually asymptomatic and may not be easily infected.. · Critical illness in the newborn may still happen, so monitoring is needed.., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Hypoxia is common during daily nursing procedures (DNPs) routinely performed on mechanically ventilated patients. The impact of automated ventilation on the incidence and severity of blood oxygen desaturation during DNPs remains unknown., Methods: A prospective randomized controlled crossover trial was carried out in a French intensive care unit to compare blood oxygen pulse saturation (SpO 2 ) during DNPs performed on patients mechanically ventilated in automated and conventional ventilation modes (AV and CV, respectively). All patients with FiO 2  ≤ 60% and without prone positioning or neuromuscular blocking agents were included. Patients underwent two DNPs on the same day using AV (INTELLiVENT-ASV®) and CV (volume control, biphasic positive airway pressure, or pressure support ventilation) in a randomized order. The primary outcome was the percentage of time spent with SpO 2 in the acceptable range of 90-95% during the DNP., Results: Of the 265 included patients, 93% had been admitted for a medical pathology, the majority for acute respiratory failure (52%). There was no difference between the two periods in terms of DNP duration, sedation requirements, or ventilation parameters, but patients had more spontaneous breaths and lower peak airway pressures during the AV period (p <  0.001). The percentage of time spent with SpO 2 in the acceptable range during DNPs was longer in the AV period than in the CV period (48 ± 37 vs. 43 ± 37, percentage of DNP period; p = 0.03). After adjustment, AV was associated with a higher number of DNPs carried out with SpO 2 in the acceptable range (odds ratio, 1.82; 95% CI, 1.28 to 2.6; p = 0.001) and a lower incidence of blood oxygen desaturation ≤ 85% (adjusted odds ratio, 0.50; 95% CI, 0.30 to 0.85; p = 0.01)., Conclusion: AV appears to reduce the incidence and severity of blood oxygen desaturation during daily nursing procedures (DNPs) in comparison to CV., Trial Registration: This study was registered in clinical-trial.gov ( NCT03176329 ) in June 2017.

Since the outbreak of COVID-19 in China in December 2019, a pandemic has rapidly developed on a scale that has overwhelmed health services in a number of countries. COVID-19 has the potential to lead to severe hypoxia; this is usually the cause of death if it occurs. In a substantial number of patients, adequate arterial oxygenation cannot be achieved with supplementary oxygen therapy alone. To date, there has been no clear guideline endorsement of ward-based non-invasive pressure support (NIPS) for severely hypoxic patients who are deemed unlikely to benefit from invasive ventilation. We established a ward-based NIPS service for COVID-19 PCR-positive patients, with severe hypoxia, and in whom escalation to critical care for invasive ventilation was not deemed appropriate. A retrospective analysis of survival in these patients was undertaken. Twenty-eight patients were included. Ward-based NIPS for severe hypoxia was associated with a 50% survival in this cohort. This compares favourably with Intensive Care National Audit and Research Centre survival data following invasive ventilation in a less frail, less comorbid and younger population. These results suggest that ward-based NIPS should be considered as a treatment option in an integrated escalation strategy in all units managing respiratory failure secondary to COVID-19., Competing Interests: Competing interests: GPB is the president elect of the British Thoracic Society., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Pulse oximetry (POS) has been proposed as a screening tool for CCHD in newborn. The aim was to identify the effect of POS on the rate of diagnosis after discharge and survival to one year in cases with CCHD. Material and Methods: All cases of CCHD from three tertiary level hospitals in the Northern region of UK between 1st January 2001 and 31st December 2011 were identified from the Northern Congenital Abnormality Survey (NorCAS). A retrospective cohort study comparing screened and unscreened population for CCHD was undertaken. The main outcome was post discharge diagnosis rate and mortality at one year between the cohorts. Results: Total number of births during the 11 years was 138,176. A total of 147 cases had CCHD, 59 diagnosed postnatally. Five and eight cases were diagnosed after discharge in the screened and the unscreened cohort respectively. The rate of post-discharge diagnosis in the screened population was 7/100,000 and 13/100,000 in the unscreened population with a relative risk of 0.52 (CI 0.2 to 1.42). Mortality at one year in postnatally diagnosed cases was five and one in the screened and unscreened cohorts respectively. Conclusion: With good antenatal detection rates, POS did not have a statistically significant impact in identifying cases of CCHD, when added to the present screening process of antenatal ultrasound and postnatal examination. The same conclusion cannot be made for regions with lower antenatal detection rates; perhaps it may be more appropriate to consider pulse oximetry as a screening tool for hypoxemia of any cause. Brief rationale This is the first study evaluating the contemporaneous post-discharge diagnosis rate between screened and unscreened populations. The rate of post-discharge diagnosis was 7/100,000 in the screened and 13/100,000 in the unscreened populations. However, this did not achieve statistical significance and in a setting with high antenatal diagnosis a very large study would be required to demonstrate efficacy of POS.

Importance: US national guidelines discourage the use of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis who do not require supplemental oxygen., Objective: Measure continuous pulse oximetry use in children with bronchiolitis., Design, Setting, and Participants: A multicenter cross-sectional study was performed in pediatric wards in 56 US and Canadian hospitals in the Pediatric Research in Inpatient Settings Network from December 1, 2018, through March 31, 2019. Participants included a convenience sample of patients aged 8 weeks through 23 months with bronchiolitis who were not receiving active supplemental oxygen administration. Patients with extreme prematurity, cyanotic congenital heart disease, pulmonary hypertension, home respiratory support, neuromuscular disease, immunodeficiency, or cancer were excluded., Exposures: Hospitalization with bronchiolitis without active supplemental oxygen administration., Main Outcomes and Measures: The primary outcome, receipt of continuous pulse oximetry, was measured using direct observation. Continuous pulse oximetry use percentages were risk standardized using the following variables: nighttime (11 pm to 7 am), age combined with preterm birth, time after weaning from supplemental oxygen or flow, apnea or cyanosis during the present illness, neurologic impairment, and presence of an enteral feeding tube., Results: The sample included 3612 patient observations in 33 freestanding children's hospitals, 14 children's hospitals within hospitals, and 9 community hospitals. In the sample, 59% were male, 56% were white, and 15% were black; 48% were aged 8 weeks through 5 months, 28% were aged 6 through 11 months, 16% were aged 12 through 17 months, and 9% were aged 18 through 23 months. The overall continuous pulse oximetry monitoring use percentage in these patients, none of whom were receiving any supplemental oxygen or nasal cannula flow, was 46% (95% CI, 40%-53%). Hospital-level unadjusted continuous pulse oximetry use ranged from 2% to 92%. After risk standardization, use ranged from 6% to 82%. Intraclass correlation coefficient suggested that 27% (95% CI, 19%-36%) of observed variation was attributable to unmeasured hospital-level factors., Conclusions and Relevance: In a convenience sample of children hospitalized with bronchiolitis who were not receiving active supplemental oxygen administration, monitoring with continuous pulse oximetry was frequent and varied widely among hospitals. Because of the apparent absence of a guideline- or evidence-based indication for continuous monitoring in this population, this practice may represent overuse.

Background: The prevalence of nuisance (technical) alarms is the leading cause of alarm fatigue resulting in decreased awareness and a reduction in effective care. The Joint Commission identified in their National Patient Safety goals alarm fatigue as a major safety issue. The introduction of noninvasive respiratory volume monitoring (RVM) has implications for effective perioperative respiratory status management. We evaluated this within the Kaiser Permanente health system., Methods: This observational study was conducted at 4 hospitals in the Kaiser Permanente system. Standard data from RVM, pulse oximetry, and capnography were collected postoperatively in the post-anesthesia care unit (PACU) and/or on the general hospital floor. Device-specific alarm types, rates, and respective actions were recorded and analyzed by non-study staff., Results: RVM was applied to 247 subjects (143 females, body mass index 32.3 ± 8.7 kg/m 2 , age 60.9 ± 13.9 y) providing 2,321 h. RVM alarms occurred 605 times (0.25 alarms/h); 64% were actionable and addressed, 17% were not addressed, 13% were self-resolved, and only 6% were nuisance. In a subgroup, RVM completed all 127 h of monitoring, whereas oximetry with capnography only completed 51 h with 12.9 alarms/h (73% nuisance). The overall RVM alarm rate was significantly lower than with either pulse oximeters or capnography monitors. We saw a nearly 1,000-fold reduction in nuisance alarms compared to capnography and a 20-50-fold reduction in nuisance alarms compared to pulse oximetry., Conclusions: Our study indicates that alarm fatigue due to nuisance alarms continues to be a clinical challenge in perioperative settings. Among the 3 common technologies for respiratory function monitoring, RVM had the lowest rate of overall technical alarms and the highest rate of compliance. Furthermore, with early interventions, none of the subjects monitored with RVM suffered any negative outcomes., (Copyright © 2020 by Daedalus Enterprises.)

Femoral access in extracorporeal life support (ECLS) has been associated with regional variations in arterial oxygen saturation, potentially predisposing the patient to ischemic tissue damage. Current monitoring techniques, however, are limited to intermittent bedside evaluation of capillary refill among other factors. The aim of this study was to assess whether cerebral and limb regional tissue oxygen saturation (rSO 2 ) values reflect changes in various patient-related parameters during venoarterial ECLS (VA-ECLS). This retrospective observational study included adults assisted by femorofemoral VA-ECLS. Bifrontal cerebral and bilateral limb tissue oximetry was performed for the entire duration of support. Hemodynamic data were analyzed parallel to cerebral and limb rSO 2 . A total of 23 patients were included with a median ECLS duration of 5 [1-20] days. Cardiac arrhythmias were observed in 12 patients, which was associated with a decreased mean rSO 2 from 61%±11% to 51%±10% during atrial fibrillation and 67%±9% to 58%±10% during ventricular fibrillation ( P <0.001 for both). A presumably sudden increase in cardiac output due to myocardial recovery (n=8) resulted in a significant decrease in mean cerebral rSO 2 from 73%±7% to 54%±6% and from 69%±9% to 53%±8% for the left and right cerebral hemisphere, respectively ( P =0.012 for both hemispheres). Also, right radial artery partial gas pressure for oxygen decreased from 15.6±2.8 to 8.3±1.9 kPa ( P =0.028). No differences were found in cerebral desaturation episodes between patients with and without neurologic complications. In six patients, limb rSO 2 increased from on average 29.3±2.7 to 64.0±5.1 following insertion of a distal cannula in the femoral artery ( P =0.027). Likewise, restoration of flow in a clotted distal cannula inserted in the femoral artery was necessary in four cases and resulted in increased limb rSO 2 from 31.3±0.8 to 79.5±9.0; P =0.068. Non-invasive tissue oximetry adequately reflects events influencing cerebral and limb perfusion and can aid in monitoring tissue perfusion in patients assisted by ECLS.

Background: The role of oxygen therapy in end-of-life care for patients with advanced cancer is incompletely understood. We aimed to evaluate the association between oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care., Methods: We conducted a retrospective cohort study at a primary care practice in suburban Tokyo. Adult patients in home care with advanced cancer demonstrating first low oxygen saturation (less than 90%) detected in home visits were consecutively included in the study. Cox proportional hazards regression was used to investigate the effect of oxygen use on overall survival and survival at home, adjusted for systolic blood pressure, decreased level of consciousness, dyspnea, oral intake, performance status, and cardiopulmonary comorbidity., Results: Of 433 identified patients with advanced cancer, we enrolled 137 patients (oxygen use, n = 35; no oxygen use, n = 102) who developed low oxygen saturation. In multivariable analysis, the adjusted hazard ratio (HR) of oxygen use was 0.68 (95% confidence interval 0.39-1.17) for death and 0.70 (0.38-1.27) for death at home. In patients with dyspnea, the HR was 0.35 (0.13-0.89) for death and 0.33 (0.11-0.96) for death at home; without dyspnea, it was 1.03 (0.49-2.17) for death and 0.84 (0.36-1.96) for death at home., Conclusions: Oxygen use was not significantly associated with survival in patients with advanced cancer and low oxygen saturation, after adjusting for potential confounders. It may not be necessary to use oxygen for prolongation of survival in such patients, particularly in those without dyspnea.

Aim: To assess local and individual factors that should be considered in the design of a pulse oximetry screening strategy in New Zealand's midwifery-led maternity setting., Methods: An intervention study was conducted over 2 years. Three hospitals and four primary maternity units participated in the study. Post-ductal saturation levels were measured on well infants with a gestation of ≥35 weeks. Infant activity and age (hours) at the time of the test were recorded., Results: Screening was performed on 16 644 of 27 172 (61%) eligible infants. The age at which the screening algorithm was initiated varied significantly among centres. The probability of achieving a pass result (saturations ≥95%) in the context of no underlying pathology ranged from .94 for an unsettled infant screened <4 hours of age to .99 (P < .001) when the test was performed after 24 hours on a settled infant. Forty-eight (0.3%) infants failed to reach saturation targets: 37 had significant pathology of which three had cardiac disease., Conclusion: Screening practices were influenced by the setting in which it was undertaken. Infant activity and age at the time of testing can influence saturation levels. Screening is associated with the identification of significant non-cardiac pathology., (©2019 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Aim: Assess the potential additional benefit from pulse oximetry screening in the early detection of critical congenital heart disease in a country with a well-developed antenatal ultrasound screening programme., Methods: Live-born infants, pregnancy terminations and stillbirths from 20 weeks' gestational age, between 2013 and 2015, with critical cardiac defects defined as primary or secondary targets of pulse oximetry screening were identified. Critical defects were those resulting in the death of a fetus or an infant in the first 28 days after birth, or a defect requiring intervention in the first 28 days., Results: Two hundred and sixty-eight infants and Fetuses were identified. Antenatal detection rates improved from 69% to 77% over the study period. An associated co-morbidity improved antenatal detection rates. Twenty-seven live-born infants were diagnosed after discharge: 15 aortic arch obstruction (AAO); 10 d-loop transposition of the great arteries (d-TGA), and two total anomalous pulmonary venous drainage (TAPVD). Of these, five with AAO, nine with d-TGA and likely both with TAPVD could potentially have been detected with oximetry screening., Conclusion: The antenatal detection of critical cardiac anomalies continues to improve in New Zealand. Despite high antenatal detection rates for most lesions, universal postnatal oximetry screening has the potential to improve early detection., (©2019 The Authors. Acta Paediatrica published by John Wiley & Sons Ltd on behalf of Foundation Acta Paediatrica.)

Background: Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use., Methods and Findings: We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups., Conclusions: There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: ME receives research funding from the Wellcome Trust and the Gates Foundation to study implementation in Kenya and this includes ongoing work that studies pulse oximetry amongst other technologies.

Introduction: The purpose of this study was to assess the evolution of newborn pulse oximetry screening (+POx) among Army, Air Force, and Naval military hospitals (MH), including prevalence, protocol use, quality assurance processes, access to echocardiography, and use of telemedicine. This is a follow-up from a prior study published in 2011., Materials and Methods: An Internet-based questionnaire was forwarded to the chief pediatrician at MH worldwide which support newborn deliveries. Descriptive data were reported using percentages. Grouped responses, as applicable, were further compared using the chi-square test. A p-value < 0.05 was considered statistically significant., Results: Seventy-eight percent (36/46) of MH supporting deliveries worldwide responded to the survey (17 Army hospitals, 11 Navy Hospitals, 8 Air Force hospitals). All responding hospitals utilize +POx, of which 94% endorsed protocol compliance with the American Academy of Pediatrics guidelines. Nine (25%) hospitals were located outside of the United States. Delivery volumes (infants per month) range between 1-49 (36%), 50-99 (28%), 100-199 (19%), and 200-300 (17%). Eleven hospitals reported regular review of +POx data, with most reviewing them monthly. Four MH share findings with state institutions. Ten hospitals either have a staff pediatric cardiologist or use tele-echocardiography for on-site evaluations. Ten hospitals are located greater than 60 miles from the nearest center with echocardiography capabilities. Of the five hospitals using tele-echocardiography, four confirmed critical congenital heart disease (CCHD) using this practice, and all five reported averting transfer of an infant using this technology. Of the 22 hospitals lacking the ability to obtain on-site echocardiography, 12 (55%) are interested in implementing a tele-echocardiography protocol., Conclusions: All responding MH use +POx, representing significant increase from the 30% of MH reporting use of +POx seven years ago. The majority of MH follow AAP +POx guidelines, and though most have providers review results prior to discharge, only one-third report periodic chart review for quality assurance. Most MH transfer infants with positive +POx results for evaluation due to a lack of on-site echocardiography. Tele-echocardiography was reported as a potential solution to diagnose or rule out CCHD. Over half of remaining hospitals without cardiologists are interested in using this technology to evaluate stable infants with positive CCHD screening., (© Association of Military Surgeons of the United States 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: High-flow nasal cannula (HFNC) oxygen therapy is a routine, evidence-based treatment in the ICU. Due to its ease of application, non-evidence-based use of HFNC has spread to non-ICU wards. This study reports on the experience with HFNC outside the ICU., Methods: This is an observational study of HFNC prescribed by treating physicians in non-ICU areas. Primary outcomes included change in dyspnea visual analog scale score and physiological variables both before and 30 min after initiation of HFNC treatment. Secondary outcomes included mortality, ICU admission, and intubation., Results: We observed decreased median (interquartile range) visual analog scale scores after initiation of HFNC: 8 (6-9) versus 5 (4-6) ( P < .001) in 90 of 111 subjects (81%, 95% CI 72.5-87.9%, P < .001). Breathing frequency (31 ± 10 vs 26 ± 7 breaths/min, P < .001) and saturation (84 ± 12% vs 94 ± 5%, P < .001) also improved. Overall cohort mortality was 55 of 111 subjects (50%); however, 41 of 111 subjects (33%) had a do not resuscitate (DNR) order. Among 70 non-DNR subjects, early mortality (< 72 h) occurred in 9 of 70 subjects (13%), and late mortality in 12 of 70 subjects (17%). The composite end point (ie, discharged alive, non-intubated, not admitted to ICU) was met by 35 of 70 subjects (50%) without a DNR order. An increased ROX index ([S pO 2 /F IO 2 ]/breathing frequency) was the only independent predictor associated with achieving the composite outcome (odds ratio 1.51, 95% CI 1.1-2.0, P = .01). Higher pre-connection visual analog scale score (odds ratio 1.75, 95% CI 1.35-2.28, P < .001) and a history of respiratory disease (odds ratio 3.52, 95% CI 1.27-9.72, P = .01) were predictors of greater improvement in dyspnea with HFNC. No variable predicted mortality., Conclusions: HFNC outside the ICU was associated with improved visual analog scale score, breathing frequency, and saturation but with a relatively high mortality, even in non-DNR subjects. HFNC was used in many subjects who had a DNR order. This therapy may have been palliative in intent. Care should be exercised in using this therapy in a setting that is not continuously monitored., Competing Interests: The authors have disclosed no conflicts of interest., (Copyright © 2019 by Daedalus Enterprises.)

Objectives: To describe health care quality indicators in cases of carbon monoxide (CO) exposure attended by prehospital services and to explore factors associated with the use of pulse CO-oximetry (SpCO) for the noninvasive estimation of CO saturation of arterial blood., Material and Methods: Cohort study of patients exposed to CO and transported by advanced life support units of the Emergency Medical Services of Catalonia between January 2015 and December 2017. We selected 11 applicable quality indicators and used multivariate analysis to explore factors associated with the recording of SpCO., Results: We studied 1676 cases of CO exposure. SpCO was recorded in 1108 cases (66.1%). CO saturation exceeded 10% in 358 patients (32.3%). Adherence was deficient in 5 of the 11 applicable quality indicators. Multivariate analysis showed less use of pulse CO-oximetry when another toxic exposure was present (odds ratio [OR], 0.34; 95% CI, 0.11- 1.00) and when the first responder was from the advanced life support service (OR, 0.43; 95% CI, 0.31-0.59). SpCO was used more in the presence of a history of mental health problems (OR, 3.01; 95% CI,1.27-7.17), headache (OR, 2.13; 95% CI, 1.2-3.72), and along with use of oxygen therapy (OR, 10.33; 95% CI, 5.46-19.53)., Conclusion: Prehospital attendance of episodes of CO exposure is marked by failure to comply with some health care quality indicators. We detected factors associated with under use of SpCO as well as areas to target for improvement.

Background: Postoperative cognitive dysfunction (POCD) occurs commonly after cardiac surgery. Near-infrared spectroscopy (NIRS) has been used to monitor regional cerebral oxygen saturation (rScO 2 ) in order to minimise the occurrence of POCD by applying dedicated interventions when rScO 2 decreases. However, the association between rScO 2 intraoperatively and POCD has not been clarified., Methods: This is a secondary analysis of a randomised trial with physician-blinded NIRS monitoring and cognitive testing at discharge from hospital and at 3 months after surgery. The association between intraoperative rScO 2 values and POCD at discharge from hospital and at 3 months after surgery was investigated. The prespecified candidate predictive variable of interest was cumulative time during surgery with rScO 2 ≥10% below its preoperative value., Results: One hundred and fifty-three patients had complete NIRS data and neurocognitive assessments at discharge, and 44 of these patients (29%) had POCD. At 3 months, 148 patients had complete data, and 12 (8%) of these patients had POCD. The median time with rScO 2 >10% below preoperative values did not differ for patients with and without POCD at discharge (difference=0.0 min; Hodges-Lehmann 95% confidence interval, -3.11-1.47, P=0.88). Other rScO 2 time thresholds that were assessed were also not significantly different between those with and without POCD at discharge. This applied both to absolute rScO 2 values and relative changes from preoperative values. Similar results were found in relation to POCD at 3 months., Conclusions: No significant association was found between intraoperative rScO 2 values and POCD. These findings bring into question the rationale for attempting to avoid decreases in rScO 2 if the goal is to prevent POCD., Clinical Trial Registration: NCT02185885., (Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Introduction: In Michigan, pulse oximetry screening rates for critical congenital heart defects (CCHDs) are assessed for birthing hospitals but have not been assessed for the midwife-attended births that occur in the out-of-hospital birth community. This analysis was conducted to determine pulse oximetry screening rates among the midwife-attended out-of-hospital birth community in Michigan overall, and among midwives provided with loaned pulse oximeters from the Michigan Department of Health and Human Services (MDHHS)., Methods: Records for midwife-attended out-of-hospital births between April 1, 2014, and December 31, 2016, were linked via probabilistic matching with newborn screening records. Pulse oximetry screening rates were calculated for the midwife-attended out-of-hospital birth population overall, by midwife, and stratified by receipt of loaned pulse oximeters from MDHHS. Births from midwives who attended 5 or more nonhospital births during the study period were included in this analysis., Results: Of the 3410 midwife-attended out-of-hospital births, 20.8% (n = 710) reported as having received a pulse oximetry screening for CCHDs. For births attended by midwives who received pulse oximeters from MDHHS, 50.5% had pulse oximetry screening results reported, compared with 12.7% among births attended by midwives without a loaned pulse oximeter. Of the 78 total midwives, 18% (n = 14) reported pulse oximetry screening results on more than half of the births they attended. Of the 14 midwives who received a pulse oximeter from MDHHS, 50.0% (n = 7) reported screening results for more than half of all births they attended., Discussion: Our findings indicate that CCHD screening rates are low among midwife-attended out-of-hospital birth community. Screening rates were higher among midwives who received a pulse oximeter from MDHHS, but fewer than half of the attended births had a reported pulse oximetry screening. Further discussions with the midwife-attended out-of-hospital birth community to better understand screening barriers may be beneficial., (© 2019 by the American College of Nurse-Midwives.)

Objectives: Pulse oximetry (PO) has been frequently used as an alternative test to polysomnography (PSG) in children. We conducted this study to determine which statistical parameters obtained from overnight PO monitoring would be most suitable and to evaluate its diagnostic performance., Methods: We prospectively recruited children with snoring referred for PSG. Subjects were monitored with PO while performing PSG. Eight statistical parameters of SpO 2 data were analyzed to identify which had the best diagnostic performance as assessed by the area under the receiver-operating characteristic curve (AUC). To validate this parameter (which was found to be the standard deviation, SD) in a larger population, we retrospectively extracted raw data of SpO 2 from our previous PSG records, calculated the SD of each patient, and assessed its AUC., Results: A total of 166 children were recruited in the first phase. SD of SpO 2 was found to have the largest AUC. In the second phase, raw data of 457 patients were extracted. SD of SpO 2 correlated well with the apnea/hypopnea index (AHI) (r = 0.6, P < 0.001). For diagnosis of moderate to severe obstructive sleep apnea (OSA) (AHI ≥5 events/h), AUC was 0.74. SD of SpO 2 ≥1.06 representing mean + 2SD of normal to mild OSA (AHI <5) provided 97% specificity and 92% positive predictive value. The positive likelihood ratio was 11., Conclusion: Calculating the SD of SpO 2 , which quantifies the amount of dispersion of SpO 2 values, is a useful initial investigation in childhood OSA. An SD ≥ 1.06 can predict moderate to severe OSA with confidence. This parameter is simple, practical, and readily accessible., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Respiratory disease in children can contribute to damaged alveoli, frailty of respiratory muscles, reduced lung function, impaired gas exchange, and gas retention in the airway. Such condition may lead to disruption of oxygen status. This study aimed to examine the effects of modified pursed lips breathing (PLB) by blowing into a water-filled bottle through a straw and a party whistle on the oxygenation status in children with oxygenation problems. This study used a quasi-experiment method with a pretest-posttest without a control group design approach. The sample consisted of 32 school-aged children and adolescents who were divided into two intervention groups. Group 1 underwent modified PLB by blowing into a water-filled bottle through a straw and Group 2 was provided with modified PLB by blowing a party whistle. The intervention was conducted one time in a day, in a rest time, for 10 min. The results showed that modified PLB by blowing into a water-filled bottle through a straw was more effective in reducing respiratory rate (RR) and improving oxygen saturation (SpO 2 ) than modified PLB by blowing a party whistle. Modified PLB intervention by blowing into a water-filled bottle through a straw improved the oxygenation status of children affected by oxygenation problems. This intervention can be implemented as an independent nursing intervention to improve children's oxygenation status.

This study explores the association between postadmission and intraoperative cerebral oxygenation (ScO 2 ), reflecting systemic perfusion, and postoperative mortality and delirium. Forty elderly (age > 65 years) patients with hip fractures were included in this prospective observational study. The ScO 2 was determined using near-infrared spectroscopy at initial resuscitation after patients were admitted to the hospital and during surgery. Postoperative delirium was assessed up to seven days after surgery using the memorial delirium assessment scale and the confusion assessment method. Ten patients (25%) developed postoperative delirium within the first seven postoperative days. At initial resuscitation ScO 2 was lower in patients that later developed delirium, but the difference was not significant (p = 0.331). Intraoperative ScO 2 values remained similar in the two groups. Mortality regardless of cause was 10% (4 out of 40 patients) after 30 days. At initial resuscitation ScO 2 was significant lower in the mortality group than in the surviving group (p = 0.042), and the ScO 2 nadir values were also significant lower (p = 0.047). Low ScO 2 during initial resuscitation (defined as ScO 2  < 55 for a minimum of two consecutive minutes) was also significantly associated with 30-day mortality (p = 0.015). There were no associations between low blood pressure and postoperative delirium or 30-day mortality. We found that low preoperative ScO 2 was better associated with 30-day all-cause mortality in elderly patients undergoing surgery for hip fracture than blood pressure measurements. Future studies in preoperative resuscitation of hip fracture patients should focus on perfusion measures as opposed to conventional haemodynamic.

The evolution of non-invasive hemoglobin measuring technology would save time and improve transfusion practice. The validity of pulse co-oximetry hemoglobin (SpHb) measurement in the perioperative setting was previously evaluated; however, the accuracy of SpHb in different volume statuses as well as in different perfusion states was not well investigated. The aim of this work is to evaluate the accuracy and trending of SpHb in comparison to laboratory hemoglobin (Lab-Hb) during acute bleeding and after resuscitation. Seventy patients scheduled for major orthopedic procedures with anticipated major blood loss were included. Radical-7 device was used for continuous assessment of SpHb, volume status [via pleth variability index (PVI)] and perfusion status [via perfusion index (PI)]. Lab-Hb and SpHb were measured at three time-points, a baseline reading, after major bleeding, and after resuscitation. Samples were divided into fluid-responsive and fluid non-responsive samples, and were also divided into high-PI and low-PI samples. Accuracy of SpHb was determined using Bland-Altman analysis. Trending of SpHb was evaluated using polar plot analysis. We obtained 210 time-matched readings. Fluid non-responsive samples were 106 (50.5%) whereas fluid responsive samples were 104 (49.5%). Excellent correlation was reported between Lab-Hb and SpHb (r = 0.938). Excellent accuracy with moderate levels of agreement was also reported between both measures among all samples, fluid non-responsive samples, fluid-responsive samples, high-PI samples, and low-PI samples [Mean bias (limits of agreement): 0.01 (- 1.33 and 1.34) g/dL, - 0.08 (- 1.27 and 1.11) g/dL, 0.09 (- 1.36 and 1.54) g/dL, 0.01 (- 1.34 to 1.31) g/dL, and 0.04 (- 1.31 to 1.39) g/dL respectively]. Polar plot analysis showed good trending ability for SpHb as a follow up monitor. In conclusion, SpHb showed excellent correlation with Lab-Hb in fluid responders, fluid non-responders, low-PI, and high PI states. Despite a favorable mean bias of 0.01 g/dL for SpHb, the relatively wide levels of agreement (- 1.3 to 1.3 g/dL) might limit its accuracy. SpHb showed good performance as a trend monitor.

Background: We previously showed, in a single-center study, that early heart rate (HR) characteristics predicted later adverse outcomes in very low birth weight (VLBW) infants. We sought to improve predictive models by adding oxygenation data and testing in a second neonatal intensive care unit (NICU)., Methods: HR and oxygen saturation (SpO 2 ) from the first 12 hours and first 7 days after birth were analyzed for 778 VLBW infants at two NICUs. Using multivariate logistic regression, clinical predictive scores were developed for death, severe intraventricular hemorrhage (sIVH), bronchopulmonary dysplasia (BPD), treated retinopathy of prematurity (tROP), late-onset septicemia (LOS), and necrotizing enterocolitis (NEC). Ten HR-SpO 2 measures were analyzed, with first 12 hours data used for predicting death or sIVH and first 7 days for the other outcomes. HR-SpO 2 models were combined with clinical models to develop a pulse oximetry predictive score (POPS). Net reclassification improvement (NRI) compared performance of POPS with the clinical predictive score., Results: Models using clinical or pulse oximetry variables alone performed well for each outcome. POPS performed better than clinical variables for predicting death, sIVH, and BPD (NRI > 0.5, p  < 0.01), but not tROP, LOS, or NEC., Conclusion: Analysis of early HR-SpO 2 characteristics adds to clinical risk factors to predict later adverse outcomes in VLBW infants., Competing Interests: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

The robust monitoring of heart rate from the video-photoplethysmogram (video-PPG) during challenging conditions requires new analysis techniques. The work reported here extends current research in this area by applying a motion tolerant algorithm to extract high quality video-PPGs from a cohort of subjects undergoing marked heart rate changes during a hypoxic challenge, and exhibiting a full range of skin pigmentation types. High uptimes in reported video-based heart rate (HR vid ) were targeted, while retaining high accuracy in the results. Ten healthy volunteers were studied during a double desaturation hypoxic challenge. Video-PPGs were generated from the acquired video image stream and processed to generate heart rate. HR vid was compared to the pulse rate posted by a reference pulse oximeter device (HR p ). Agreement between video-based heart rate and that provided by the pulse oximeter was as follows: Bias = - 0.21 bpm, RMSD = 2.15 bpm, least squares fit gradient = 1.00 (Pearson R = 0.99, p < 0.0001), with a 98.78% reporting uptime. The difference between the HR vid and HR p exceeded 5 and 10 bpm, for 3.59 and 0.35% of the reporting time respectively, and at no point did these differences exceed 25 bpm. Excellent agreement was found between the HR vid and HR p in a study covering the whole range of skin pigmentation types (Fitzpatrick scales I-VI), using standard room lighting and with moderate subject motion. Although promising, further work should include a larger cohort with multiple subjects per Fitzpatrick class combined with a more rigorous motion and lighting protocol.

Background: Simultaneous use of nasal cannula (NC) with noninvasive positive pressure ventilation (NIPPV) may help streamline the transition from preoxygenation to intubation with apneic oxygenation in patients with deteriorating respiratory status, but may also compromise preoxygenation by impairing NIPPV mask seal., Objectives: To demonstrate that end-tidal oxygen (EtO 2 ) after NIPPV with NC is noninferior to that of NIPPV without NC., Methods: We conducted a randomized cross-over noninferiority study using healthy volunteers. All subjects underwent a 3-min trial of NIPPV with or without high-flow NC at 15 L/min of oxygen, followed by a 5-min washout period, and then a second 3-min trial of the opposite intervention. We randomized subjects to order of interventions. The primary outcome was postintervention EtO 2 as measured by immediate exhalation into an oxygen analyzer after the 3-min ventilation period. We compared this outcome between the two study arms using an absolute 5% noninferiority margin., Results: We enrolled 37 subjects, each of whom underwent both interventions of NIPPV alone and NIPPV with 15 L/min NC. The paired mean difference in EtO 2 between NIPPV with NC measurements vs. NC alone measurements was 0.5% (95% confidence interval -∞ to 2.7%). Analyses stratified by order of intervention yielded similar results., Conclusions: The mean difference confidence interval did not include the noninferiority margin. Hence, NIPPV with NC seems noninferior to NIPPV alone with regard to EtO 2 . These results indicate that concomitant use of NC with NIPPV may be an appropriate preoxygenation strategy in anticipation of the potential need for transition to intubation., (Published by Elsevier Inc.)

We measured noninvasive hemoglobin (SpHb) levels during the pre-anesthesia visit in patients planning elective surgery. Differences between SpHb and laboratory-measured hemoglobin (Hb lab ) were compared between adult and pediatric patients. In the pre-anesthesia visiting office, we routinely monitor noninvasive Hb levels with oxygen saturation and heart rate using Masimo Radical-7® Pulse CO-Oximetry (Masimo Corp., Irvine, CA, USA). We attached the R1 20 (body weight, 10-50 kg) or R1 25 (body weight > 30 kg) probe on the index finger. After signal stabilization, SpHb and perfusion index (PI) were recorded. We retrospectively reviewed the recorded data and included patients who visited the anesthesiologist within 24 h after venous sampling. Bias was calculated by subtracting Hb lab from SpHb. We compared the biases of adult and pediatric patients (< 18 years) and evaluated correlation coefficients between the bias and Hb lab . Records of 105 patients were reviewed and 100 data points of 50 patients in each group were analyzed. The median ± interquartile range bias was - 2.6 ± 2.2 and - 1.2 ± 1.5 g/dL in adult and pediatric patients, respectively (P < 0.001); the corresponding mean ± standard deviation PIs were 4.4 ± 3.1 and 5.9 ± 2.7, respectively (P = 0.19). Bias was inversely proportional to Hb lab irrespective of age. The correlation coefficient between the bias and Hb lab was - 0.81 in adults and - 0.54 in pediatric patients (P < 0.001). SpHb and Hb lab measured during pre-anesthesia visits showed a smaller difference in pediatric than in adult patients. Lower Hb lab corresponded to higher accuracy.

The aim of the present study was to evaluate the performance of regional oxygen saturation (rSO 2 ) monitoring with near infrared spectroscopy (NIRS) during pediatric inter-hospital transports and to optimize processing of the electronically stored data. Cerebral (rSO 2 -C) and abdominal (rSO 2 -A) NIRS sensors were used during transport in air ambulance and connecting ground ambulance. Data were electronically stored by the monitor during transport, extracted and analyzed off-line after the transport. After removal of all zero and floor effect values, the Savitzky-Golay algorithm of data smoothing was applied on the NIRS-signal. The second order of smoothing polynomial was used and the optimal number of neighboring points for the smoothing procedure was evaluated. NIRS-data from 38 pediatric patients was examined. Reliability, defined as measurements without values of 0 or 15%, was acceptable during transport (> 90% of all measurements). There were, however, individual patients with < 90% reliable measurements during transport, while no patient was found to have < 90% reliable measurements in hospital. Satisfactory noise reduction of the signal, without distortion of the underlying information, was achieved when 20-50 neighbors ("window-size") were used. The use of NIRS for measuring rSO 2 in clinical studies during pediatric transport in ground and air-ambulance is feasible but hampered by unreliable values and signal interference. By applying the Savitzky-Golay algorithm, the signal-to-noise ratio was improved and enabled better post-hoc signal evaluation.

Objective: To avoid excessive oxygen exposure and achieve target oxygen saturation (SpO2) within intended range of 88%-95% among preterm neonates on oxygen therapy., Methods: 20 preterm neonates receiving supplemental oxygen in the first week of life were enrolled. The percentage of time per epoch (a consecutive time interval of 10 hours/day) spent by them within the target SpO2 range was measured in phase 1 followed by implementation of a unit policy on oxygen administration and targeting in phase 2. In phase 3, oxygen saturation histograms constructed from pulse-oximeter data were used as daily feedback to nurses and compliance with oxygen-targeting was measured again., Results: 48 epochs in phase 1 and 69 in phase 3 were analyzed. The mean (SD) percent time spent within target SpO2 range increased from 65.9% (21.4) to 76.5% (12.6) (P=0.001)., Conclusion: Effective implementation of oxygen targeting policy and feedback using oxygen saturation histograms may improve compliance with oxygen targeting.

Study Objectives: Hypoventilation in obesity is now divided into five stages; stage 0 (pure obstructive sleep apnea; OSA), stages I/II (obesity-related sleep hypoventilation; ORSH) and stages III/IV (awake hypercapnia, obesity hypoventilation syndrome; OHS). Hypercapnia during the day may be preceded by hypoventilation during sleep. The goal of this study was to determine the prevalence and to identify simple clinical measures that predict stages I/II ORSH. The effect of supine positioning on selected clinical measures was also evaluated., Methods: Ninety-four patients with a body mass index > 40 kg/m 2 and a spirometric ratio > 0.7 were randomized to begin testing either in the supine or upright seated position on the day of their diagnostic sleep study. Arterialized capillary blood gases were measured in both positions. Oxygen saturation measured by pulse oximetry was also obtained while awake. Transcutaneous CO 2 monitoring was performed during overnight polysomnography., Results: Stages I/II ORSH had a prevalence of 19% in an outpatient tertiary hospital setting compared with 61%, 17%, and 3% for stages 0, III/IV, and no sleep-disordered breathing respectively. Predictors for sleep hypoventilation in this group were an awake oxygen saturation of ≤ 93% (sensitivity 39%, specificity 98%, positive likelihood ratio of 22) and a partial pressure of carbon dioxide ≥ 45 mmHg (sensitivity 44%, specificity 98%, positive likelihood ratio of 24) measured in the supine position., Conclusions: ORSH has a similar prevalence to OHS. Awake oxygen saturation and partial pressure of carbon dioxide performed in the supine position may help predict obese patients with sleep hypoventilation without awake hypercapnia., Commentary: A commentary on this article appears in this issue on page 1455., Clinical Trial Registration: Registry: Australian New Zealand Clinical Trials Registry, Identifier: ACTRN 12615000135516, URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367493&isReview=true, Title: A cross-sectional study to identify obese patients who are at risk for developing obesity hypoventilation syndrome (OHS) by investigating the relationship between daytime measures (including supine hypercapnia, distribution of body fat and lung volumes) with the presence of hypoventilation during sleep., (© 2018 American Academy of Sleep Medicine.)

Clinical assessment of an infant's heart rate (HR) in the delivery room (DR) has been reported to be inaccurate. We compared auscultation of the HR using a stethoscope with electrocardiography (ECG) and pulse oximetry (PO) for determining the HR in 92 low-risk newborn infants in the DR. Caregivers auscultated the HR while masked to the HR on the monitor. Auscultation underestimated ECG HR (mean difference (95% CI) by -9 (-15 to -2) beats per minute (bpm)) and PO HR (mean difference (95% CI) by -5 (-12 to 2) bpm). The median (IQR) time to HR by auscultation was 14 (10-18) s. As HR was determined quickly and with reasonable accuracy by auscultation in low-risk newborns, study in high-risk infants is warranted., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Aims: To determine the effects of sponge baths and swaddled bathing on premature infants' vital signs, oxygen saturation levels, crying times, pain, and stress levels., Methods: This study was a clinical trial with a crossover design. Data were conducted in the neonatal intensive care unit of a public hospital in Denizli, Turkey. A total of 35 premature infants, who were born at 33-37 weeks gestation with a birth weight <1,500 g, were enrolled in the study. Two bathing methods were applied at 3-day intervals. Vital signs and oxygen saturation levels were measured before and at minutes 1, 5, 15, 30 after bathing. Infants' bathing was video recorded to assess pain and stress behaviors. The pain and stress behaviors of infants were evaluated by independent observers. A significance level of .05 was used for all statistical analyses., Results: There were statistically significant differences between bathing methods on vital signs, oxygen saturation levels, and crying times. Levels of stress and pain according to bathing type were significantly higher in the sponge bath condition (p < .05)., Linking Evidence to Action: Swaddled bathing has a positive effect on the infant's vital signs, oxygen saturation levels, crying time, and level of stress and pain compared to the sponge bath condition. Swaddled bathing is a harmless and safe nursing practice., (© 2018 Sigma Theta Tau International.)