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September 22, 1993, Vol 270, No. 12 >
ARTICLE | September 22, 1993

The Use of Pulse Oximetry During Conscious Sedation FREE

Yank D. Coble, Jr, MD; A. Bradley Eisenbrey, MD; E. Harvey Estes, Jr, MD; Mitchell S. Karlan, MD; William R. Kennedy, MD; Patricia Joy Numann, MD; William C. Scott, MD; W. Douglas Skelton, MD; Richard M. Steinhilber, MD; Jack P. Strong, MD; Christine C. Toevs; Henry N. Wagner, Jr, MD; Jerod M. Loeb, PhD; Robert C. Rinaldi, PhD; Joan B. Vatz, MD
[+] Author Affiliations

This report was submitted to the House of Delegates of the American Medical Association at the December 1991 Interim Meeting as Report E of the Council on Scientific Affairs. The recommendations of this report were adopted in lieu of Resolution 17 (1-90).

This report is not intended to be construed orto serve as a standard of medical care. Standards of medical care are determined on the basis of all the facts and circumstances involved in an individual case and are subject to change as scientific knowledge and technology advance and patterns of practice evolve. This report reflects the scientific literature as of March 1993.

Reprint requests to the Council on Scientific Affairs, American Medical Association, 515 N State St, Chicago IL 60610 (Jerod M. Loeb, PhD).


JAMA. 1993;270(12):1463-1468. doi:10.1001/jama.1993.03510120085036
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Article
References

SINCE its introduction in the early 1980s, pulse oximetry has been one of the most rapidly diffusing electronic monitoring technologies in medicine.1 Use of pulse oximetry during procedures requiring general anesthesia quickly became standard practice in the United States because it is noninvasive, requires no special training, gives continuous realtime estimates of arterial oxygen saturation (SaO2) in the range of 70% to 100%, and gives early warning of loss of pulse.1-3 This report provides background information concerning the development of oximetry technology and its use during "conscious sedation," a state of minimally depressed consciousness elicited by sedating agents used during certain procedures.

HISTORY  Oximetry originated in Germany in the 1930s with the work of Nicolai, Kramer, and Matthes.4 They studied the kinetics of tissue oxygenation and applied the Beer Lambert law, which relates the concentration of a solute to the intensity of light transmitted through the

REFERENCES

1 +
Barker SJ, Tremper KK.  Pulse oximetry: applications and limitations. Int Anesthesiol Clin . 1987;; 25:155-75.
2 +
Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG.  Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA . 1986;;256:1017-1020.
3 +
Standards for Basic Intra-Operative Monitoring . Park Ridge, Ill: American Society of Anesthesiologists; 1991;.
4 +
Cohen DE, Downes JJ, Raphaely RC.  What difference does pulse oximetry make? Anesthesiology . 1988;;68:181-183.
5 +
Schnapp LM, Cohen NH.  Pulse oximetry: uses and abuses. Chest . 1990;;98:1244-1250.
6 +
Aoyagi T, Kishi M, Yamaguchi K, Watanabe S.  Development of an earpiece oximeter [in Japanese].  In: Program and abstracts of the 13th annual meeting of the Japanese Society for Medical Electronics and Biological Engineering ; April 26, 1974;; Osaka, Japan; 90-91.
7 +
Severinghaus JW, Honda Y.  Pulse oximetry. Int Anesthesiol Clin . 1987;;25:205-214.
8 +
Kellerman AL, Cofer CA, Joseph S, Hackman BB.  Impact of pulse oximetry on arterial blood gas test ordering in an urban emergency department. Ann Emerg Med . 1991;;20:130-134.
9 +
Kidd JF, Vickers MD.  Pulse oximeters: essential monitors with limitations. Br J Anaesth . 1989;;62: 355-357.
10 +
Huch A, Huch R, Konig V, et al.  Limitations of pulse oximetry. Lancet . 1988;;1:357-358.
11 +
SeveringhausJW, Spellman MJJr.  Pulse oximeter failure thresholds in hypotension and ischemia. Anesthesiology . 1990;;73:532-537.
12 +
Severinghaus JW, Naifeh KH, Koh SO.  Errors during profound hypoxia in 14 pulse oximeters. J Clin Monit . 1989;;5:72-81.
13 +
Mihm FG, Halperin BD.  Noninvasive detection of profound arterial desaturation using a pulse oximetry device. Anesthesiology . 1985;;62:85-87.
14 +
Bowes WA, Corke BC, Hulka J.  Pulse oximetry: a review of the theory, accuracy, and clinical applications. Obstet Gynecol . 1989;;74:541-546.
15 +
Brooks TD, Paulus DA, Winkle WE.  Infrared heat lamps interfere with pulse oximeters. Anesthesiology . 1984;;61:630-631.
16 +
Barker SJ, Tremper FF.  The effect of carbon monoxide inhalation on pulse oximeter signal detection. Anesthesiology . 1987;;66:677-679.
17 +
Scheller MS, Unger RJ, Kelner MJ.  Effects of intravenously administered dyes on pulse oximetry readings. Anesthesiology . 1986;;65:550-552.
18 +
Severinghaus JW, Naifeh KH.  Accuracy of response of six pulse oximeters to profound hypoxia. Anesthesiology . 1987;;67:551-558.
19 +
Freeman ML, Hennessy JT, Cass OW.  Carbon dioxide retention and oxygen desaturation during conscious sedation for ERCP, colonoscopy, and upper GI endoscopy. Gastrointest Endosc . 1991;;37: 233.
20 +
Rosenberg MB, Campbell RL.  Guidelines for intraoperative monitoring of dental patients undergoing conscious sedation, deep sedation, and general anesthesia. Oral Surg Oral Med Oral Pathol . 1991;;71:2-8.
21 +
Accreditation Manualfor Hospitals . Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1991;:269.
22 +
Bartelsman JFNM, Sars PRA, Tytgat GNJ.  Flumazenil used for reversal of midazolam-induced sedation in endoscopy outpatients. Gastrointest Endosc . 1990;;36( (suppl) ):S9-S12.
23 +
Gross JB, Zebrowski ME, Carel WD, Gardner S, Smith TC.  Time course of ventilatory depression after thiopental and midazolam in normal subjects and in patients with chronic obstructive pulmonary disease. Anesthesiology . 1983;;58:540-544.
24 +
Forster A, Gardaz JP, Suter PM, Gemperle M.  Respiratory depression by midazolam and diazepam. Anesthesiology . 1980;;53:494-497.
25 +
Tyler IL, Tanisira B, Winter PM, Motoyama EK.  Oxygen monitoring of arterial oxygen saturation with pulse oximetry during transfer to the recovery room. Anesth Analg . 1985;;64:1108-1112.
26 +
Becker DE.  The respiratory effects of drugs used for conscious sedation and general anesthesia. J Am Dent Assoc . 1989;;119:153-156.
27 +
Goodman LS, Gilman A, Harvey SC.  Hypnotics and sedatives.  In: Rail TW, Murced F, eds. The Pharmacologic Basis of Therapeutics . 7th ed. New York, NY: Macmillan Publishing Co; 1985;:339-371.
28 +
Comroe JH, Bothelo S.  The unreliability of cyanosis in the recognition of arterial anoxemia. Am J Med Sci . 1947;;214:1-6.
29 +
Hayward SR, Sugawa C, Wilson RF.  Changes in oxygenation and pulse rate during endoscopy. Am Surg . 1989;;55:198-202.
30 +
Barkin JS, Krieger B, Blinder M, Bosch-Blinder L, Goldberg RI, Phillips RS.  Oxygen desaturation and changes in breathing pattern in patients undergoing colonoscopy and gastroscopy. Gastrointest Endosc . 1989;;35:526-530.
31 +
Woods SDS, Chung SCS, Leung JWC, Chan ACW, Li AKC.  Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: detection by pulse oximetry. Gastrointest Endosc . 1989;;35:523-525.
32 +
Visco DM, Tolpin E, StraughnJC, Fagraeus L.  Arterial oxygen saturation in sedated patients undergoing gastrointestinal endoscopy and a review of pulse oximetry. Del Med J . 1989;;61:533-542.
33 +
Murray AW, Morran CG, Kenny GNC, Anderson JR.  Arterial oxygen saturation during upper gastrointestinal endoscopy: the effects of a midazolan/pethidine combination. Gut . 1990;;31:270-273.
34 +
Bell GD, Morden A, Coady T, Bown S, Logan RFA.  Prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae. Lancet . 1987;;1:1022-1024.
35 +
Ghows MB, Rosen MJ, Chuang MT, Sacks HS, Teirstein AS.  Transcutaneous oxygen monitoring during fiberoptic bronchoscopy. Chest . 1989;;89:543-544.
36 +
Maranetra N, Pushpakom R, Bovornkitti S.  Oxygen desaturation during fiberoptic bronchoscopy. J Med Assoc Thai . 1990;;73:258-263.
37 +
Dodson SR, Hensley FAJr, Martin DE, Larach DR, Morris DL.  Continuous oxygen saturation monitoring during cardiac catheterization in adults. Chest . 1988;;94:28-31.
38 +
Hensley FA, Dodson DL, Martin DE, Stauffer RH, Larach DR.  Oxygen saturation during preinduction placement of monitoring catheters in the cardiac surgical patient. Anesthesiology .1987;;66:834-836.
39 +
Krenkel R, Liappis N, Redel D, Hildebrand G.  Non-invasive determination of oxygen saturation with the oxygen met pulse wave oximeter: comparison with the invasive reflectometric method. Klin Pediatr . 1981;;193:315-317.
40 +
Bucher HU, Menner K, Huch A, Huch R.  Transcutaneous Po2-measurement during heart catheterization in childhood. Z Kardiol . 1977;;66: 598-600.
41 +
Fleischer DE, Goldstein SA.  Transesophageal echocardiography: what the gastroenterologist thinks the cardiologist should know about endoscopy. J Am Soc Echocardiogr . 1990;;3:428-434.
42 +
Singer R, Thomas PE.  Pulse oximeter in the ambulatory aesthetic surgical facility. Plast Reconstr Surg . 1988;;82:111-114.
43 +
Raemer DB, Warren DL, Morris R.  Hypoxemia during ambulatory gynecologic surgery as evaluated by the pulse oximeter. J Clin Monit . 1987;;3:244-248.
44 +
Choi HJ, Little MS, Garber SZ, Tremper KK.  Pulse oximetry for monitoring during ward analgesia: epidural morphine versus parenteral narcotics. J Clin Monit . 1989;;5:87-89.
45 +
Wheatley RG, Somerville ID, Sapsford DJ.  Postoperative hypoxaemia: comparison of extradural, IM and patient-controlled opioid analgesia. Br J Anaesth . 1990;;64:267-275.
46 +
Hardeman JH, Sabol SR, Goldwasser MS.  Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery. J Oral Maxillofac Surg . 1990;;48:942-944.
47 +
Poiset M, Johnson R, Nakamura R.  Pulse rate and oxygen saturation in children during routine dental procedures. ASDC J Dent Child . 1990;;57: 279-283.
48 +
Coté CJ, Goldstein EA, Coté MA, Hoaglin DC, Ryan JF.  A single-blind study of pulse oximetry in children. Anesthesiology . 1988;;68:184-188.
49 +
Coté CJ, Rolf N, Liu LMP, et al.  A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology . 1991;;74:980-987.
50 +
Davis DA.  An analysis of anesthetic mishaps from medical liability claims. Int Anesthesiol Clin . 1984;;22:31-42.
51 +
Brunner EA.  The National Association of Insurance Commissioners' closed claim study. Int Anesthesiol Clin . 1984;;22:17-30.
52 +
Cooper JB, Newbower RS, Kitz RJ.  An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology . 1984;;60:34-42.
53 +
Paget NS, Lambert TF, Sridhar K.  Factors affecting an anaesthetist's work: some findings on vigilance and performance. Anaesth Intensive Care . 1981;;4:359-365.
54 +
Utting JE, Gray TC, Shelley FC.  Human misadventure in anaesthesia. Can Anaesth Soc J . 1982;; 26:472-478.
55 +
Rendell-Baker L.  Problems with anesthetic gas machines and their solutions. Int Anesthesiol Clin . 1982;;20:1-82.
56 +
Cooper JB, Newbower RS, Long CD, McPeek B.  Preventable anesthesia mishaps: a study of human factors. Anesthesiology . 1978;;49:399-406.
57 +
O'Connor KW, Jones S.  Oxygen desaturation is common and clinically underappreciated during elective endoscopic procedures. Gastrointest Endosc . 1990;;36( (suppl) ):S2-S4.
58 +
Carey WD.  Indications, contraindications, and complications of upper endoscopy.  In: Sivak MY Jr, ed. Gastroenterologic Endoscopy . Philadelphia, Pa: WB Saunders Co; 1987;:301-304.
59 +
Bell GD, Reeve PA, Moshiri M, et al.  Intravenous midazolam: a study of the degree of oxygen desaturation during UGI endoscopy. Br J Clin Pharmacol . 1987;;23:703-708.
60 +
Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB.  Results from the American Society for Gastrointestinal Endoscopy/US Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc . 1991;;37:421-427.
61 +
Coplans MP.  Mortality and morbidity studies.  In: Dionne RA, Laskin DM, eds. Anesthesia and Sedation in the Dental Office . New York, NY: Elsevier Science Publishing Co; 1986;:29-37.
62 +
Bilotta JJ, Floyd JL, Waye JD.  Arterial oxygen desaturation during ambulatory colonoscopy: predictability, incidence, and clinical insignificance. Gastrointest Endosc . 1990;;36( (suppl) ):S5-S8.
63 +
Keeffe EB, O'Connor KW.  1989 A/S/G/E survey of endoscopic sedation and monitoring practices. Gastrointest Endosc . 1990;;36( (suppl) ):S13-S18.
64 +
Block AJ, Boysen PG, Wynne JW, Hunt LA.  Sleep apnea, hypopnea and oxygen desaturation in normal subjects. N Engl J Med . 1979;;300:513-517.
65 +
AMA Commission on Emergency Medical Services.  Medical aspects of transportation aboard commercial aircraft. JAMA . 1982;;247:1007-1011.
66 +
McKenzie AJ.  Perioperative hypoxaemia detected by intermittent pulse oximetry. Anaesth Intensive Care . 1989;;17:412-417.
67 +
Fleischer D.  Monitoring the patient receiving conscious sedation for gastrointestinal endoscopy: issues and guidelines. Gastrointest Endosc . 1989;; 35:262-266.
68 +
Standards for Postanesthesia Care . Park Ridge, Ill: American Society of Anesthesiologists. 1990;.
69 +
Berman IR.  Monitoring and patient safety. Gastrointest Endosc . 1990;;36:160-161.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Barker SJ, Tremper KK.  Pulse oximetry: applications and limitations. Int Anesthesiol Clin . 1987;; 25:155-75.
2 +
Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG.  Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA . 1986;;256:1017-1020.
3 +
Standards for Basic Intra-Operative Monitoring . Park Ridge, Ill: American Society of Anesthesiologists; 1991;.
4 +
Cohen DE, Downes JJ, Raphaely RC.  What difference does pulse oximetry make? Anesthesiology . 1988;;68:181-183.
5 +
Schnapp LM, Cohen NH.  Pulse oximetry: uses and abuses. Chest . 1990;;98:1244-1250.
6 +
Aoyagi T, Kishi M, Yamaguchi K, Watanabe S.  Development of an earpiece oximeter [in Japanese].  In: Program and abstracts of the 13th annual meeting of the Japanese Society for Medical Electronics and Biological Engineering ; April 26, 1974;; Osaka, Japan; 90-91.
7 +
Severinghaus JW, Honda Y.  Pulse oximetry. Int Anesthesiol Clin . 1987;;25:205-214.
8 +
Kellerman AL, Cofer CA, Joseph S, Hackman BB.  Impact of pulse oximetry on arterial blood gas test ordering in an urban emergency department. Ann Emerg Med . 1991;;20:130-134.
9 +
Kidd JF, Vickers MD.  Pulse oximeters: essential monitors with limitations. Br J Anaesth . 1989;;62: 355-357.
10 +
Huch A, Huch R, Konig V, et al.  Limitations of pulse oximetry. Lancet . 1988;;1:357-358.
11 +
SeveringhausJW, Spellman MJJr.  Pulse oximeter failure thresholds in hypotension and ischemia. Anesthesiology . 1990;;73:532-537.
12 +
Severinghaus JW, Naifeh KH, Koh SO.  Errors during profound hypoxia in 14 pulse oximeters. J Clin Monit . 1989;;5:72-81.
13 +
Mihm FG, Halperin BD.  Noninvasive detection of profound arterial desaturation using a pulse oximetry device. Anesthesiology . 1985;;62:85-87.
14 +
Bowes WA, Corke BC, Hulka J.  Pulse oximetry: a review of the theory, accuracy, and clinical applications. Obstet Gynecol . 1989;;74:541-546.
15 +
Brooks TD, Paulus DA, Winkle WE.  Infrared heat lamps interfere with pulse oximeters. Anesthesiology . 1984;;61:630-631.
16 +
Barker SJ, Tremper FF.  The effect of carbon monoxide inhalation on pulse oximeter signal detection. Anesthesiology . 1987;;66:677-679.
17 +
Scheller MS, Unger RJ, Kelner MJ.  Effects of intravenously administered dyes on pulse oximetry readings. Anesthesiology . 1986;;65:550-552.
18 +
Severinghaus JW, Naifeh KH.  Accuracy of response of six pulse oximeters to profound hypoxia. Anesthesiology . 1987;;67:551-558.
19 +
Freeman ML, Hennessy JT, Cass OW.  Carbon dioxide retention and oxygen desaturation during conscious sedation for ERCP, colonoscopy, and upper GI endoscopy. Gastrointest Endosc . 1991;;37: 233.
20 +
Rosenberg MB, Campbell RL.  Guidelines for intraoperative monitoring of dental patients undergoing conscious sedation, deep sedation, and general anesthesia. Oral Surg Oral Med Oral Pathol . 1991;;71:2-8.
21 +
Accreditation Manualfor Hospitals . Oakbrook Terrace, Ill: Joint Commission on Accreditation of Healthcare Organizations; 1991;:269.
22 +
Bartelsman JFNM, Sars PRA, Tytgat GNJ.  Flumazenil used for reversal of midazolam-induced sedation in endoscopy outpatients. Gastrointest Endosc . 1990;;36( (suppl) ):S9-S12.
23 +
Gross JB, Zebrowski ME, Carel WD, Gardner S, Smith TC.  Time course of ventilatory depression after thiopental and midazolam in normal subjects and in patients with chronic obstructive pulmonary disease. Anesthesiology . 1983;;58:540-544.
24 +
Forster A, Gardaz JP, Suter PM, Gemperle M.  Respiratory depression by midazolam and diazepam. Anesthesiology . 1980;;53:494-497.
25 +
Tyler IL, Tanisira B, Winter PM, Motoyama EK.  Oxygen monitoring of arterial oxygen saturation with pulse oximetry during transfer to the recovery room. Anesth Analg . 1985;;64:1108-1112.
26 +
Becker DE.  The respiratory effects of drugs used for conscious sedation and general anesthesia. J Am Dent Assoc . 1989;;119:153-156.
27 +
Goodman LS, Gilman A, Harvey SC.  Hypnotics and sedatives.  In: Rail TW, Murced F, eds. The Pharmacologic Basis of Therapeutics . 7th ed. New York, NY: Macmillan Publishing Co; 1985;:339-371.
28 +
Comroe JH, Bothelo S.  The unreliability of cyanosis in the recognition of arterial anoxemia. Am J Med Sci . 1947;;214:1-6.
29 +
Hayward SR, Sugawa C, Wilson RF.  Changes in oxygenation and pulse rate during endoscopy. Am Surg . 1989;;55:198-202.
30 +
Barkin JS, Krieger B, Blinder M, Bosch-Blinder L, Goldberg RI, Phillips RS.  Oxygen desaturation and changes in breathing pattern in patients undergoing colonoscopy and gastroscopy. Gastrointest Endosc . 1989;;35:526-530.
31 +
Woods SDS, Chung SCS, Leung JWC, Chan ACW, Li AKC.  Hypoxia and tachycardia during endoscopic retrograde cholangiopancreatography: detection by pulse oximetry. Gastrointest Endosc . 1989;;35:523-525.
32 +
Visco DM, Tolpin E, StraughnJC, Fagraeus L.  Arterial oxygen saturation in sedated patients undergoing gastrointestinal endoscopy and a review of pulse oximetry. Del Med J . 1989;;61:533-542.
33 +
Murray AW, Morran CG, Kenny GNC, Anderson JR.  Arterial oxygen saturation during upper gastrointestinal endoscopy: the effects of a midazolan/pethidine combination. Gut . 1990;;31:270-273.
34 +
Bell GD, Morden A, Coady T, Bown S, Logan RFA.  Prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae. Lancet . 1987;;1:1022-1024.
35 +
Ghows MB, Rosen MJ, Chuang MT, Sacks HS, Teirstein AS.  Transcutaneous oxygen monitoring during fiberoptic bronchoscopy. Chest . 1989;;89:543-544.
36 +
Maranetra N, Pushpakom R, Bovornkitti S.  Oxygen desaturation during fiberoptic bronchoscopy. J Med Assoc Thai . 1990;;73:258-263.
37 +
Dodson SR, Hensley FAJr, Martin DE, Larach DR, Morris DL.  Continuous oxygen saturation monitoring during cardiac catheterization in adults. Chest . 1988;;94:28-31.
38 +
Hensley FA, Dodson DL, Martin DE, Stauffer RH, Larach DR.  Oxygen saturation during preinduction placement of monitoring catheters in the cardiac surgical patient. Anesthesiology .1987;;66:834-836.
39 +
Krenkel R, Liappis N, Redel D, Hildebrand G.  Non-invasive determination of oxygen saturation with the oxygen met pulse wave oximeter: comparison with the invasive reflectometric method. Klin Pediatr . 1981;;193:315-317.
40 +
Bucher HU, Menner K, Huch A, Huch R.  Transcutaneous Po2-measurement during heart catheterization in childhood. Z Kardiol . 1977;;66: 598-600.
41 +
Fleischer DE, Goldstein SA.  Transesophageal echocardiography: what the gastroenterologist thinks the cardiologist should know about endoscopy. J Am Soc Echocardiogr . 1990;;3:428-434.
42 +
Singer R, Thomas PE.  Pulse oximeter in the ambulatory aesthetic surgical facility. Plast Reconstr Surg . 1988;;82:111-114.
43 +
Raemer DB, Warren DL, Morris R.  Hypoxemia during ambulatory gynecologic surgery as evaluated by the pulse oximeter. J Clin Monit . 1987;;3:244-248.
44 +
Choi HJ, Little MS, Garber SZ, Tremper KK.  Pulse oximetry for monitoring during ward analgesia: epidural morphine versus parenteral narcotics. J Clin Monit . 1989;;5:87-89.
45 +
Wheatley RG, Somerville ID, Sapsford DJ.  Postoperative hypoxaemia: comparison of extradural, IM and patient-controlled opioid analgesia. Br J Anaesth . 1990;;64:267-275.
46 +
Hardeman JH, Sabol SR, Goldwasser MS.  Incidence of hypoxemia in the postanesthetic recovery room in patients having undergone intravenous sedation for outpatient oral surgery. J Oral Maxillofac Surg . 1990;;48:942-944.
47 +
Poiset M, Johnson R, Nakamura R.  Pulse rate and oxygen saturation in children during routine dental procedures. ASDC J Dent Child . 1990;;57: 279-283.
48 +
Coté CJ, Goldstein EA, Coté MA, Hoaglin DC, Ryan JF.  A single-blind study of pulse oximetry in children. Anesthesiology . 1988;;68:184-188.
49 +
Coté CJ, Rolf N, Liu LMP, et al.  A single-blind study of combined pulse oximetry and capnography in children. Anesthesiology . 1991;;74:980-987.
50 +
Davis DA.  An analysis of anesthetic mishaps from medical liability claims. Int Anesthesiol Clin . 1984;;22:31-42.
51 +
Brunner EA.  The National Association of Insurance Commissioners' closed claim study. Int Anesthesiol Clin . 1984;;22:17-30.
52 +
Cooper JB, Newbower RS, Kitz RJ.  An analysis of major errors and equipment failures in anesthesia management: considerations for prevention and detection. Anesthesiology . 1984;;60:34-42.
53 +
Paget NS, Lambert TF, Sridhar K.  Factors affecting an anaesthetist's work: some findings on vigilance and performance. Anaesth Intensive Care . 1981;;4:359-365.
54 +
Utting JE, Gray TC, Shelley FC.  Human misadventure in anaesthesia. Can Anaesth Soc J . 1982;; 26:472-478.
55 +
Rendell-Baker L.  Problems with anesthetic gas machines and their solutions. Int Anesthesiol Clin . 1982;;20:1-82.
56 +
Cooper JB, Newbower RS, Long CD, McPeek B.  Preventable anesthesia mishaps: a study of human factors. Anesthesiology . 1978;;49:399-406.
57 +
O'Connor KW, Jones S.  Oxygen desaturation is common and clinically underappreciated during elective endoscopic procedures. Gastrointest Endosc . 1990;;36( (suppl) ):S2-S4.
58 +
Carey WD.  Indications, contraindications, and complications of upper endoscopy.  In: Sivak MY Jr, ed. Gastroenterologic Endoscopy . Philadelphia, Pa: WB Saunders Co; 1987;:301-304.
59 +
Bell GD, Reeve PA, Moshiri M, et al.  Intravenous midazolam: a study of the degree of oxygen desaturation during UGI endoscopy. Br J Clin Pharmacol . 1987;;23:703-708.
60 +
Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB.  Results from the American Society for Gastrointestinal Endoscopy/US Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc . 1991;;37:421-427.
61 +
Coplans MP.  Mortality and morbidity studies.  In: Dionne RA, Laskin DM, eds. Anesthesia and Sedation in the Dental Office . New York, NY: Elsevier Science Publishing Co; 1986;:29-37.
62 +
Bilotta JJ, Floyd JL, Waye JD.  Arterial oxygen desaturation during ambulatory colonoscopy: predictability, incidence, and clinical insignificance. Gastrointest Endosc . 1990;;36( (suppl) ):S5-S8.
63 +
Keeffe EB, O'Connor KW.  1989 A/S/G/E survey of endoscopic sedation and monitoring practices. Gastrointest Endosc . 1990;;36( (suppl) ):S13-S18.
64 +
Block AJ, Boysen PG, Wynne JW, Hunt LA.  Sleep apnea, hypopnea and oxygen desaturation in normal subjects. N Engl J Med . 1979;;300:513-517.
65 +
AMA Commission on Emergency Medical Services.  Medical aspects of transportation aboard commercial aircraft. JAMA . 1982;;247:1007-1011.
66 +
McKenzie AJ.  Perioperative hypoxaemia detected by intermittent pulse oximetry. Anaesth Intensive Care . 1989;;17:412-417.
67 +
Fleischer D.  Monitoring the patient receiving conscious sedation for gastrointestinal endoscopy: issues and guidelines. Gastrointest Endosc . 1989;; 35:262-266.
68 +
Standards for Postanesthesia Care . Park Ridge, Ill: American Society of Anesthesiologists. 1990;.
69 +
Berman IR.  Monitoring and patient safety. Gastrointest Endosc . 1990;;36:160-161.

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For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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