Review
PULSE OXIMETRY MONITORING AND LATE
POSTOPERATIVE HYPOXEMIA ON THE GENERAL
CARE FLOOR
John H. Eichhorn, MD
From the Department of Anesthesiology, University of Mississippi
Medical Center, Jackson, Mississippi, U.S.A.
Received Oct 8, 1996. Accepted for publication Oct 11, 1997.
Address correspondence to John H. Eichhorn, Department of Anes-
thesiology, University of Mississippi Medical Center, 2500 N. State
Street, Jackson, MS 39216-4505, U.S.A.
Journal of Clinical Monitoring and Computing 14: 49^55, 1998.
1998 Kluwer Academic Publishers. Printed in the Netherlands.
Eichhorn JH. Pulse oximetry monitoring and late postoperative
hypoxemia on the general care oor.
J Clin Monit 1997; 14: 49^55
ABSTRACT. Hypoxemia has long been recognized as a risk to
patients in the operating room and postanesthesia care unit,
and hemoglobin oxygen saturation (HbO2 ) monitoring with
pulse oximetry has become a standard of care in these areas.
There is growing evidence, however, suggesting that later
postoperative hypoxemia also may play a role in organ dys-
function leading to morbidity and mortality. Economic pres-
sures to move patients earlier from expensive postanethesia
recovery and intensive care areas to the general care oor ^
where nurse-to-patient ratios are lower and lines of sight
and sound may be impaired by walls and curtains ^ may lead
to inadequate surveillance of at-risk patients. These patient-
management trends underscore the importance of improved
monitoring of respiratory status on the general care oor. In
this environment, telemetric pulse oximetry monitoring may
represent a cost-eective approach to maximizing quality of
care while enhancing risk management. This review discusses
late postoperative hypoxemia and identies areas for further
investigation.
KEY WORDS. Hypoxemia, arterial oxygen saturation, pulse
oximetry, monitoring, respiratory monitoring, sleep apnea,
myocardial ischemia, cerebral ischemia.
INTRODUCTION
Arterial hypoxemia, particularly that associated with
hypoventilation, is a major risk to patients during surgi-
cal anesthesia, especially for abdominal and thoracic
procedures, and it continues to be a risk through the
early postoperative period in the postanesthesia are unit
(PACU). While the risk of hypoxemia generally has
been thought to end by the time of discharge from the
PACU, a growing body of thought suggests that hypo-
xemia can persist in some patients on the general care
oor during the rst postoperative week. Although
monitoring of arterial oxygen saturation is mandated in
the operating room (OR) and PACU, such monitoring
generally is discontinued when the patient is discharged
to the general care oor, so that late postoperative
hypoxemia may go undetected and untreated. This
raises concerns, previously expressed in editorial com-
mentary [1, 2], that premature termination of respira-
tory monitoring is exposing already compromised pa-
tients to unnecessary risks. These concerns are timely
because increasing cost pressures are leading to earlier
discharge from expensive postanesthesia and intensive
care areas. This review considers evidence bearing on
these concerns.
50 Journal of Clinical Monitoring and Computing Vol 14 No 1 January 1998
HYPOXEMIA IN THE LATE POSTOPERATIVE PERIOD
Even after the direct respiratory depressant eects of
anesthetic medications and consequent ventilation-per-
fusion mismatch dissipate in the early postoperative
period, persistent eects of surgical stress appear to
compromise respiratory function for up to a week in
the late postoperative period [3^6]. Two patterns have
been identied [3^6] ^ constant, or persistent, hypoxe-
mia is related to preoperative respiratory function while
episodic noctural hypoxemia is closely related to episo-
dic sleep apnea that is aggravated by surgical stress and
postoperative physiological disturbances. Each pattern
occurs with major (e.g., abdominal and thoracic), but
not usually with minor surgical procedures [7], and
each is suspected of potentially contributing to the risk
of postsurgical morbidity and even mortality.
Constant, or persistent, hypoxemia is generally mild
and resolves in the course of the rst postoperative week.
The degree of hemoglobin desaturation is greatest on
the second and third postoperative nights and is related
to baseline levels of hemoglobin oxygen saturation
(HbO2 sat) during the immediate preoperative night
[6, 8] but is not predicted by preoperative spirometry
[8]. Constant relative hypoxemia is correlated with
decreased (by up to 20%) functional residual capacity
(FRC) in the daytime and is greatest at night [3, 4]. The
decrease of FRC may be due to multiple anesthetic and
surgical factors [3, 4, 8] including atelectasis of depend-
ent lung regions, changes of chest wall muscle tone and
function, and, possibly, changes of bronchomotor and
pulmonary vascular tone. Following surgery, the de-
crease of FRC and persistent hypoxemia are delayed
in onset, are maximal after 16^24 hours, and require
1 week to 10 days to resolve [4].
Episodic noctural hypoxemia can be superimposed
on a background of constant hypoxemia but primarily
involves disruptions of normal sleep patterns induced
by the stress and physiologic disruption of anesthesia
and surgery. It is characterized by episodic, brief (usu-
ally less than a minute) decreases in arterial hemoglobin
saturation during sleep. For instance, Rosenberg et al.
[6, 9] found that following major abdominal surgery,
episodes of desaturation of 5% or more were most
frequent on the second postoperative night and often
included episodes of saturation falling to less than 80%
(in the absence of oxygen therapy), representing a PaO2
in the 40 s (mm Hg). In other studies, brief (30^60 s)
episodes of desaturation were more frequent on the third
postoperative night [5, 8] following major abdominal
vascular surgery, although patients in these studies had
received supplemental oxygen on the rst two nights.
Other investigators [3, 10] have classied patterns of
HbO2 sat as stable or unstable depending on the per-
centage of each postoperative hour spent at a given
oxygen desaturation. Unstable hypoxemia, with inter-
mittent episodes of less than 85% saturation, is most
frequent on the rst and second postoperative nights. In
all studies, episodic or unstable hypoxemia resolved by
the end of the rst postoperative week.
Episodic hypoxemia is closely related to postsurgical
problems of respiratory control and the impact of surgi-
cal stress on sleep patterns [11] and sleep apnea [3, 5],
Reeder [8] and Rosenberg [9] each cite, and conrm,
sleep studies showing that surgical stress suppresses both
rapid eye movement and slow wave sleep, and that these
both rebound coincident with the onset of episodic
hypoxemia. The role of opiate administration is unclear.
There is evidence that opiates do not prevent [8] and
may even contribute to [10, 12] episodic hypoxemia,
while other investigators nd little or no direct eect
[9, 13]. Eects of patient obesity and advanced age in
increasing the duration of hypoxemia have been re-
ported [10, 14].
Administration of supplemental oxygen limits the
extent of both constant and episodic hypoxemia [8, 13,
15] without, however, aecting the frequency of apneic
and hypoxemic episodes [7, 13, 16]. The degree and
frequency of hypoxemic events are not predicted by
preoperative levels of HbO2 sat [5, 6].
CONSEQUENCES OF HYPOXEMIA
Studies of late postoperative hypoxemia have been
motivated by the concern [17] that hypoxemia in this
setting, especially the nocturnal episodic form, may
increase patients' risk of postoperative complications.
Of particular concern is the possible contribution of
nocturnal episodic myocardial ischemia to diurnal (cir-
cadian) variations of unexpected postoperative deaths
[18]. Some authors have found an association of episo-
dic hypoxemia with cardiac ischemia in patients having
risk factors for ischemic hart disease [19] and in patients
during the rst week following an acute myocardial
infarction [20]. Hypoxemia and associated cardiac ische-
mia also have been linked with cardiac events during
the perioperative period in surgical patients with [21,
22] or without [23, 24] known cardiovascular disease.
Such a linkage to cardiovascular events, however, has
not been found in all clinical studies [25, 26, 27].
The use of hemoglobin saturation monitoring to
detect and treat hypoxemia reduced the incidence of
myocardial ischema in the OR and PACU [28]. Such
observations have led to suggestions [17, 19, 29] that
detection and treatment of episodic hypoxemia could

reduce the risk of postoperative myocardial events. This
possibility demands further clinical investigation, par-
ticularly in the elderly and in others who may already
have compromised coronary function and vulnerability
to even moderate myocardial ischemia.
Another area of concern [17] is the potential contri-
bution of hypoxemia to postsurgical cerebral dysfunc-
tion, including confusion and delirium [30] especially
in susceptible elderly patients. As with episodic hypo-
xemia, confusion is more likely to be seen in surgical
patients after major surgery than minor surgery with
comparable general anesthetics [31]. Confusion is max-
imal on the third postoperative day, is signicantly
associated with arterial oxygen desaturation on the
second postoperative night, and is diminished by sup-
plemental oxygen treatment [32]. Contributory roles of
surgical trauma and age are suggested by the observa-
tion that only minor changes of cognitive function are
found in normal volunteers made hypoxemic to an
hemoglobin saturation level of 78% [33].
It has also been suggested that, in patients with already
compromised cerebral circulation, hypoxemia may play
a role in the development of ischemic stroke [34]. This
connection has been previously been demonstrated in
non-surgical patients [35] and warrants further inves-
tigation.
Impairment of wound healing during periods of
hypoxemia has also been raised as a concern [17], given
the dependence on tissue oxygenation of wound heal-
ing rates and clinical outcomes [36]. Although to date
there are no studies directly relating episodic hypoxe-
mia to wound healing or infection, subcutaneous tissue
oximetry revealed that postoperative oxygen therapy
increased would oxygenation [37].
While the clinical consequences of constant and epi-
sodic hypoxemia in the postoperative period are yet to
be fully elaborated, the history of widespread adoption
of pulse oximetry in other clinical settings suggests that
it may oer a resource-eective approach to detecting
hypoxemia on the general care oor, whether used
around-the-clock, or intermittently during the day (as
a ``5th vital sign,'' [38] for example) and continuously
only during the night.
MONITORING ARTERIAL HEMOGLOBIN SATURATION WITH
PULSE OXIMETRY
The risk of hypoxemia and the clear need for pulse
oximetry monitoring of hemoglobin saturation in both
the operating room and the postanesthesia care unit are
well-recognized and have been formalized in treatment
standards adopted by the American Society of Anes-
Eichhorn: Hypoxemia on the General Care Floor 51
thesiologists (ASA) [2]. These standards were instituted
to help maximize successful tolerance of and recovery
from ventilatory and respiratory perturbations associ-
ated with anesthesia and surgery, and they have received
widespread support and compliance within the anes-
thesiology community. Since its introduction into clin-
ical practice in the mid-1980s, pulse oximetry moni-
toring has enabled continuous measurement of blood
hemoglobin saturation (HbO2 sat) in a variety of clinical
settings and in virtually all of the studies cited above. Its
clinical and scientic utility stems from the fact that it
provides a noninvasive and continuous estimation of an
otherwise dicult-to-measure clinical parameter. The
instrumentation is relatively inexpensive, the technology
is stable, and it is amenable to computer networking for
central monitoring, as described in recent comprehen-
sive reviews [39^41].
As with all clinical instrumentation, there are limita-
tions that must be recognized and mitigated for eective
use of pulse oximetry in clinical settings [39, 42, 43].
Pulse oximetry monitoring (POM) provides a spectro-
scopic estimate of hemoglobin oxygen saturation rather
than a direct measure of the total oxygen content of the
blood (oxemia), yet hemoglobin saturation fraction is
generally taken to reect changes of ventilatory/respi-
ratory status rather than changes of hemoglobin con-
centration that would aect total oxygen content. It is
important to remember, also, that registered oximetry
values can be confounded by congenital or pharmaco-
logical methemaglobinemias, certain vital dyes, exces-
sive ambient light, and by circumstances where tissue
perfusion is limited. In addition, false alarms may occur
due to artifacts of patient motion, transducer displace-
ment, or when there is venous congestion or pulsation
[44, 45]. Recently developed artifact rejection algo-
rithms can better distinguish arterial pulse waveforms
(i.e., rapid onset, slow decay) from movement-induced
pulse (generally slow onset and decay) and can substan-
tially reduce the incidence of false alarms and move-
ment artifacts [46, 47]. Although these technical limita-
tions can be controlled [38, 39], the clinical eectiveness
of pulse oximetry depends on establishing clear guide-
lines for using POM and proper training for medical
and nursing sta in its theory and practice [48^51].
EXPERIENCE WITH PULSE OXIMETRY IN THE OR AND PACU
The use of pulse oximetry monitoring has been con-
sidered a minimum standard of care in ORs and PACUs
in the United States since its mandate by ASA standards
adopted in 1989. These standards evolved largely to
codify and validate existing anesthesiology practices as
52 Journal of Clinical Monitoring and Computing Vol 14 No 1 January 1998
well as to accelerate a trend toward increasing reliance
on oximetry in the PACU. The consensus among anes-
thesiologists is that pulse oximetry is critical for mini-
mizing the risk of catastrophic events through its early
warning function. In support of this, pulse oximetry is
credited with contributing to a drop in injury claims
against anesthesiologists and in reduced malpractice costs
since hemoglobin saturation monitoring came into
common use in the 1980s [52]. Pulse oximetry also is
credited, in part, with reducing unanticipated intensive
care unit admissions associated with anesthesia in a large
teaching hospital [53]. Despite this consensus support,
the actual impact of pulse oximetry use on limiting
cardiac and respiratory events continues to be debated
largely due to an understandable lack of controlled trials
demonstrating an oximetry monitoring-related reduc-
tion of morbidity and mortality.
Moller et al. [25], in the only large, multi-institution
prospective controlled clinical trial of pulse oximetry,
found that the use of pulse oximetry reduced the inci-
dence of recognized hypoxemic and other respiratory
events. As noted above, pulse oximetry monitoring also
reduced the incidence of recognized myocardial ische-
mia. Although the number of cardiac arrests was de-
creased from 11 to 4, there were far too few patients
even in this large study to demonstrate a statistically
signicant preventive benet of pulse oximetry mon-
itoring with regard to extremely rare catastrophic
events [25, 28]. It is very likely that this fact will persist
permanently due to the obvious logistic and ethical
problems of conducting such a clinical investigation.
What remains, therefore, is the strongly supported,
inherently logical, inferential conclusion that the ear-
liest possible warning of developing hypoxemia aords
the maximum possible time for diagnostic and thera-
peutic intervention, thus reducing the likelihood of an
untoward patient outcome.
MONITORING RESPIRATORY STATUS ON THE GENERAL CARE
FLOOR
Several patient management treads call for improved
surveillance of respiratory status on the general care
oor. As noted above, pressures for early discharge
from PACU, ICU, and coronary care units may result
in the premature (compared with prior practices) release
to the general care oor of at-risk patients. Pressures to
increase work loads and decrease stang on nursing
teams likely result in less intensive scrutiny of patients.
As postsurgical patients are moved from the PACU to
private and semiprivate rooms, surveillance becomes
much more dicult due to long hallways, closed-door
rooms, and blocked lines of sight and sound.
Given the inferred increased risk to vulnerable pa-
tients in these situations, current methods of respiratory
monitoring appear to be inadequate for maintaining
traditionally high standards of patient care. Physical
evaluation using respiratory rate, labor of breathing,
and possible cyanosis is too insensitive and too casually
applied to be useful in identifying all but the most
severely hypoxemic patients. Other routine clinical pa-
rameters and radiographic ndings also are of little use
in predicting or detecting hypoxemia [54]. The count-
ing of respirations is, at best, a dicult-to-use and very
indirect measure of hypoxemia. The ``gold standard'' ^
arterial blood gas analysis ^ while accurate, involves
several familiar drawbacks. It is, rst of all, invasive and
often suciently painful so that hyperventilation may
artifactually raise arterial oxygen tension during the
procedure itself. Furthermore, the time involved, ex-
pense, demand for skilled sta, and reporting delays
make it poorly suited for routine use, particularly if
episodic hypoxemia is to be detected. Pulse oximetry,
on the other hand, provides noninvasive, potentially
continuous, and readily determined levels of arterial
hemoglobin saturation in most clinical situations. Com-
bined with modern telemetry networking (telemetric
pulse oximetry ^ TPON) and enhanced artifact rejec-
tion algorithms, oximetry can provide continuous res-
piratory monitoring [14] displayed at nursing stations
as well as at the bedside.
Principles and guidelines for use of pulse oximetry
on the general care oor have been recently published
[51] as have detailed nursing guidelines for respiratory
monitoring of postsurgical patients [50]. In each, it is
emphasized that POM is likely to be of use in a variety
of high-risk patients including those with pre-existing
pulmonary disease, obese patients, and patients receiving
ventilation-depressing analgesics. Once hemoglobin
desaturation is detected and measurement artifacts have
been ruled out, physicians may order conrmatory
arterial blood gas measurements, administer supple-
mental oxygen, and review treatment protocols to
identify iatrogenic causes.
RESOURCE-EFFECTIVENESS ISSUES
Although additional and more denitive data would be
desirable, pulse oximetry monitoring on the general
care oor has been advocated for at-risk patients as a
cost-eective approach to maximizing quality of care
while enhancing risk management. The relatively low
expense of pulse oximetry systems may even be oset
by operational cost savings if adequate guidelines for
use and suitable sta training are in place [42]. Because

pulse oximetry can easily indicate whether a patient
needs oxygen therapy or not, prophylactic and thera-
peutic oxygen use can be rationalized and minimized.
In addition, use of oximetry can reduce the number of
diagnostic blood gas analyses performed [55]. Further,
telemetric pulse oximetry systems can aid in the ecient
utilization of nursing resources. By identifying the con-
tribution of hypoxemia to the disruptive and distressing
eects of postoperative delirium, oximetry monitoring
can also improve patient care and even patients' quality
of life.
Perhaps more signicantly, oximetry use in late post-
operative patients could potentially decrease the risk of
catastrophic late sequellae of anesthesia and surgery as
well as the specic dangers of ventilatory depresssion
from pain therapy opiates, whether administered intra-
venously, epidurally, or intrathecally, with virtually no
added risk of its own. Furthermore, this potential bene-
t appears to be available at a favorable cost. One early
cost-benet analysis estimated that one fatal hypoxemic
episode in 40,000 moderately hypoxemic patients
would justify the cost of the oximetry [56].
CONCLUSION
The combination of constant and episodic hypoxemia
in the late postoperative period may represent a poten-
tially serious risk for postsurgical patients. Given increas-
ing cost pressures to accelerate transfer of patients from
intensive care areas of the hospital to the general care
oor, it is valid to maximize methods of patient mon-
itoring to guard against the potential complications of
late postoperative hypoxemia.
Pulse oximetry became a standard of care in the
operating room and postanesthesia care unit because it
warns very early in the development of desaturation
and also detects clinically inapparent episodes of arterial
hypoxemia. Its nearly unanimous acceptance and sup-
port by the anesthesiology community its testimony to
its clinical utility. Current evidence suggests that hypo-
xemia may play a role in postoperative morbidity and
possibly even mortality in the late postoperative period
as well. Given recent advances in the technological reli-
ability of pulse oximetry, as well as its incorporation of
telemetry features, further clinical and scal study of
the problem of hypoxemia on the general care oor is
warranted to identify patients at risk, assess its eect on
patient outcomes, develop methods of problem preven-
tion and treatment, and determine more fully the e-
cacy and resource-eectiveness of pulse oximetry mon-
itoring in this setting.
Eichhorn: Hypoxemia on the General Care Floor 53
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