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Doumat G, Mehta GD, Espinola JA, Gallegos C, Zhu Z, Mansbach JM, Hasegawa K, Camargo CA. Race-Neutral Equations and Pulmonary Function Test Interpretation in Two Pediatric Cohorts. J Pediatr 2024; 273:114124. [PMID: 38815738 DOI: 10.1016/j.jpeds.2024.114124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/01/2024]
Abstract
OBJECTIVE To investigate the changes in predicted lung function measurements when using race-neutral equations in children, based upon the new Global Lung Initiative (GLI) reference equations, utilizing a race-neutral approach in interpreting spirometry results compared with the 2012 race-specific GLI equations. STUDY DESIGN We analyzed data from 2 multicenter prospective cohorts comprised of healthy children and children with history of severe (requiring hospitalization) bronchiolitis. Spirometry testing was done at the 6-year physical exam, and 677 tests were analyzed using new GLI Global and 2012 GLI equations. We used multivariable logistic regression, adjusted for age, height, and sex, to examine the association of race with the development of new impairment or increased severity (forced expiratory volume in the first second (FEV1) z-score ≤ -1.645) as per 2022 American Thoracic Society (ATS) guidelines. RESULTS Compared with the race-specific GLI, the race-neutral equation yielded increases in the median forced expiratory volume in the first second and forced vital capacity (FVC) percent predicted in White children but decreases in these two measures in Black children. The prevalence of obstruction increased in White children by 21%, and the prevalence of possible restriction increased in Black children by 222%. Compared with White race, Black race was associated with increased prevalence of new impairments (aOR 7.59; 95%CI, 3.00-19.67; P < .001) and increased severity (aOR 35.40; 95%CI, 4.70-266.40; P = .001). Results were similar across both cohorts. CONCLUSIONS As there are no biological justifications for the inclusion of race in spirometry interpretation, use of race-neutral spirometry reference equations led to an increase in both the prevalence and severity of respiratory impairments among Black children.
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Affiliation(s)
- George Doumat
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Geneva D Mehta
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Massachusetts Chan Medical School, Worcester, MA
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Catalina Gallegos
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Zhaozhong Zhu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | | | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
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Martin D, Johns C, Sorrell L, Healy E, Phull M, Olusanya S, Peters M, Fabes J. Effect of skin tone on the accuracy of the estimation of arterial oxygen saturation by pulse oximetry: a systematic review. Br J Anaesth 2024; 132:945-956. [PMID: 38368234 PMCID: PMC11103098 DOI: 10.1016/j.bja.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Pulse oximetry-derived oxygen saturation (SpO2) is an estimate of true arterial oxygen saturation (SaO2). The aim of this review was to evaluate available evidence determining the effect of skin tone on the ability of pulse oximeters to accurately estimate SaO2. METHODS Published literature was screened to identify clinical and non-clinical studies enrolling adults and children when SpO2 was compared with a paired co-oximetry SaO2 value. We searched literature databases from their inception to March 20, 2023. Risk of bias (RoB) was assessed using the QUADAS-2 tool. Certainty of assessment was evaluated using the GRADE tool. RESULTS Forty-four studies were selected reporting on at least 222 644 participants (6121 of whom were children) and 733 722 paired SpO2-SaO2 measurements. Methodologies included laboratory studies, prospective clinical, and retrospective clinical studies. A high RoB was detected in 64% of studies and there was considerable heterogeneity in study design, data analysis, and reporting metrics. Only 11 (25%) studies measured skin tone in 2353 (1.1%) participants; the remainder reported participant ethnicity: 68 930 (31.0%) participants were of non-White ethnicity or had non-light skin tones. The majority of studies reported overestimation of SaO2 by pulse oximetry in participants with darker skin tones or from ethnicities assumed to have darker skin tones. Several studies reported no inaccuracy related to skin tone. Meta-analysis of the data was not possible. CONCLUSIONS Pulse oximetry can overestimate true SaO2 in people with darker skin tones. The clinical relevance of this bias remains unclear, but its magnitude is likely to be greater when SaO2 is lower. SYSTEMATIC REVIEW PROTOCOL International Prospective Register of Systematic Reviews (PROSPERO): CRD42023390723.
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Affiliation(s)
- Daniel Martin
- Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, UK; Intensive Care Unit, University Hospitals Plymouth, Plymouth, UK.
| | - Chris Johns
- Library & Digital Support, University of Plymouth, Drake Circus, Plymouth, UK
| | - Lexy Sorrell
- Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, UK
| | - Eugene Healy
- Dermatopharmacology, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Dermatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Mandeep Phull
- Barking, Havering and Redbridge University Trust, Romford, UK; William Harvey Research Institute, Queen Mary University London, London, UK
| | | | - Mark Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK; University College London Great Ormond St Institute of Child Health, London, UK
| | - Jeremy Fabes
- Peninsula Medical School, University of Plymouth, John Bull Building, Plymouth, UK; Anaesthetic Department, University Hospitals Plymouth, Plymouth, UK
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Chen QC, Shen JJ, Huang YL, Kong R, Xie YM, Wang SS. Discrepancy between arterial oxygen saturation and pulse oximetry measurement in a Chinese pediatric patient cohort. Heliyon 2024; 10:e28336. [PMID: 38560171 PMCID: PMC10981058 DOI: 10.1016/j.heliyon.2024.e28336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 03/14/2024] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Background Increasing evidence suggest a racial bias in pulse oximetry measurement, but this was under investigated in Asian pediatric populations. Methods Via the Pediatric Intensive Care database, this retrospective study included pediatric patient records of arterial oxygen saturation (SaO2) and oxygen saturation on pulse oximetry (SpO2) measured within 10 min. Discrepancy was examined, and potential predictors of occult hypoxemia (defined as SaO2 <88% with the paired SpO2 ≥92%) as well as its association with outcomes were explored by logistic regression. Results A total of 390 patients were included with 454 pairs of SaO2-SpO2 readings. The study population consisted of Han Chinese (99.0%) and 43.6% were female. Occult hypoxemia was observed in 20.0% of the patients, with a mean SaO2 of 71.4 ± 15.8%. Potential predictors of occult hypoxemia included female, being first admitted to cardiac ICU, congenital heart disease, increased heart rate, while patients with prior surgery records were less likely to experience occult hypoxemia. Patients with occult hypoxemia had numerically higher in-ICU mortality (16.7% versus 10.9%) and in-hospital mortality (17.9% versus 10.9%), but the associations were not statistically significant. Conclusions There was a substantial proportion of hypoxemia that was not detected by pulse oximetry in the Chinese pediatric patients, which might be predicted by several characteristics and seemed to associate with mortality.
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Affiliation(s)
| | | | | | - Ran Kong
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, China
| | - Yu-mei Xie
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, China
| | - Shu-shui Wang
- Department of Pediatric Cardiology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, 510000, China
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Sharma V, Barker SJ, Sorci R, Park L, Wilson WC. Racial effects on masimo pulse oximetry: impact of low perfusion index. J Clin Monit Comput 2024; 38:347-354. [PMID: 38238634 PMCID: PMC10995008 DOI: 10.1007/s10877-023-01113-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/21/2023] [Indexed: 04/06/2024]
Abstract
PURPOSE Evaluate the SpO2-SaO2 difference between Black and White volunteer subjects having a low perfusion index (Pi) compared to those having a normal Pi. METHODS The Pi data were abstracted from electronic files collected on 7183 paired SpO2-SaO2 samples (3201 Black and 3982 White) from a recently reported desaturation study of 75 subjects (39 Black and 36 White) where SaO2 values were sequentially decreased from 100 to 70%. The Pi values from that dataset were divided into two groups (Pi ≤ 1 or Pi > 1) for analysis. A Pi value ≤ 1 was considered "low perfusion" and a Pi value > 1 was considered "normal perfusion". Statistical calculations included values of bias (mean difference of SpO2-SaO2), precision (standard deviation of the difference), and accuracy (root-mean-square error [ARMS]). During conditions of low perfusion (Pi ≤ 1, range [0.1 to 1]), overall bias and precision were + 0.48% ± 1.59%, while bias and precision were + 0.19 ± 1.53%, and + 0.91 ± 1.57%, for Black and White subjects, respectively. RESULTS During normal perfusion (Pi > 1, range [1 to 12]), overall bias and precision were + 0.18% ± 1.34%, while bias and precision were -0.26 ± 1.37%, and - 0.12 ± 1.31%, for Black and White subjects, respectively. ARMS was 1.37% in all subjects with normal perfusion and 1.64% in all subjects with low perfusion. CONCLUSION Masimo SET® pulse oximeters with RD SET® sensors are accurate for individuals of both Black and White races when Pi is normal, as well as during conditions when Pi is low. The ARMS for all conditions studied is well within FDA standards. This study was conducted in healthy volunteers during well-controlled laboratory desaturations, and results could vary under certain challenging clinical conditions.
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Affiliation(s)
- Vikrant Sharma
- Vice President, Optical Sciences, Masimo Corp, Irvine, CA, USA
| | | | - Rebecca Sorci
- Director, Clinical Publication Review and Communications, Masimo Corp, Irvine, CA, USA
| | - Linus Park
- Vice President Regulatory Affairs, Masimo Corp, Irvine, CA, USA
| | - William C Wilson
- Executive Vice President, Clinical Research Operations and Medical Affairs, Masimo Corp, Irvine, CA, USA.
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Mills M, Gleason M, Lin M, Braykov N, Smith S, Fundora M, Aljiffry A. Race and Pulse Oximetry in Infants With Single Ventricles Undergoing Stage 1 Palliation. JAMA Netw Open 2024; 7:e245369. [PMID: 38578643 PMCID: PMC10998150 DOI: 10.1001/jamanetworkopen.2024.5369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024] Open
Abstract
This cross-sectional study investigates perioperative oxygen saturation differences in Black and White infants with single ventricles undergoing stage 1 palliation.
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Affiliation(s)
- Marcos Mills
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michelle Gleason
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael Lin
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Nikolay Braykov
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Sherry Smith
- Information Services and Technology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Michael Fundora
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Alaa Aljiffry
- Division of Cardiology, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Fischer M, Ngendahimana DK, Watson RS, Schwarz AJ, Shein SL. Cognitive, Functional, and Quality of Life Outcomes 6 Months After Mechanical Ventilation for Bronchiolitis: A Secondary Analysis of Data From the Randomized Evaluation of Sedation Titration for Respiratory Failure Trial ( RESTORE ). Pediatr Crit Care Med 2024; 25:e129-e139. [PMID: 38038620 DOI: 10.1097/pcc.0000000000003405] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVES To describe rates and associated risk factors for functional decline 6 months after critical bronchiolitis in a large, multicenter dataset. DESIGN Nonprespecified secondary analysis of existing 6-month follow-up data of patients in the Randomized Evaluation of Sedation Titration for Respiratory Failure trial ( RESTORE , NCT00814099). SETTING Patients recruited to RESTORE in any of 31 PICUs in the United States, 2009-2013. PATIENTS Mechanically ventilated PICU patients under 2 years at admission with a primary diagnosis of bronchiolitis. INTERVENTIONS There were no interventions in this secondary analysis; in the RESTORE trial, PICUs were randomized to protocolized sedation versus usual care. MEASUREMENTS AND MAIN RESULTS "Functional decline," defined as worsened Pediatric Overall Performance Category and/or Pediatric Cerebral Performance Category (PCPC) scores at 6 months post-PICU discharge as compared with preillness baseline. Quality of life was assessed using Infant Toddler Quality of Life Questionnaire (ITQOL; children < 2 yr old at follow-up) or Pediatric Quality of Life Inventory (PedsQL) at 6 months post-PICU discharge. In a cohort of 232 bronchiolitis patients, 28 (12%) had functional decline 6 months postdischarge, which was associated with unfavorable quality of life in several ITQOL and PedsQL domains. Among 209 patients with normal baseline functional status, 19 (9%) had functional decline. In a multivariable model including all subjects, decline was associated with greater odds of worse baseline PCPC score and longer PICU length of stay (LOS). In patients with normal baseline status, decline was also associated with greater odds of longer PICU LOS. CONCLUSIONS In a random sampling of RESTORE subjects, 12% of bronchiolitis patients had functional decline at 6 months. Given the high volume of mechanically ventilated patients with bronchiolitis, this observation suggests many young children may be at risk of new morbidities after PICU admission, including functional and/or cognitive morbidity and reduced quality of life.
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Affiliation(s)
- Meredith Fischer
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | | | - R Scott Watson
- Department of Pediatrics, University of Washington, Seattle, WA
| | - Adam J Schwarz
- Department of Pediatrics, Critical Care Division, CHOC Children's Hospital, Orange, CA
| | - Steven L Shein
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
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Webb LV, Evans J, Smith V, Pettibone E, Tofil J, Hicks JF, Green S, Nassel A, Loberger JM. Sociodemographic Factors are Associated with Care Delivery and Outcomes in Pediatric Severe Sepsis. Crit Care Explor 2024; 6:e1056. [PMID: 38415020 PMCID: PMC10896474 DOI: 10.1097/cce.0000000000001056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
IMPORTANCE Sepsis is a leading cause of morbidity and mortality in the United States and disparate outcomes exist between racial/ethnic groups despite improvements in sepsis management. These observed differences are often related to social determinants of health (SDoH). Little is known about the role of SDoH on outcomes in pediatric sepsis. OBJECTIVE This study examined the differences in care delivery and outcomes in children with severe sepsis based on race/ethnicity and neighborhood context (as measured by the social vulnerability index). DESIGN SETTING AND PARTICIPANTS This retrospective, cross-sectional study was completed in a quaternary care children's hospital. Patients 18 years old or younger who were admitted between May 1, 2018, and February 28, 2022, met the improving pediatric sepsis outcomes (IPSO) collaborative definition for severe sepsis. Composite measures of social vulnerability, care delivery, and clinical outcomes were stratified by race/ethnicity. MAIN OUTCOMES AND MEASURES The primary outcome of interest was admission to the PICU. Secondary outcomes were sepsis recognition and early goal-directed therapy (EGDT). RESULTS A total of 967 children met the criteria for IPSO-defined severe sepsis, of whom 53.4% were White/non-Hispanic. Nearly half of the cohort (48.7%) required PICU admission. There was no difference in illness severity at PICU admission by race (1.01 vs. 1.1, p = 0.18). Non-White race/Hispanic ethnicity was independently associated with PICU admission (odds ratio [OR] 1.35 [1.01-1.8], p = 0.04). Although social vulnerability was not independently associated with PICU admission (OR 0.95 [0.59-1.53], p = 0.83), non-White children were significantly more likely to reside in vulnerable neighborhoods (0.66 vs. 0.38, p < 0.001). Non-White race was associated with lower sepsis recognition (87.8% vs. 93.6%, p = 0.002) and less EGDT compliance (35.7% vs. 42.8%, p = 0.024). CONCLUSIONS AND RELEVANCE Non-White race/ethnicity was independently associated with PICU admission. Differences in care delivery were also identified. Prospective studies are needed to further investigate these findings.
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Affiliation(s)
- Lece V Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Jakob Evans
- Department of Pediatrics, Pediatrics Residency Program, University of Alabama at Birmingham, Birmingham, AL
| | - Veronica Smith
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Elisabeth Pettibone
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Jessica Floyd Hicks
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Sherry Green
- Performance Improvement and Accreditation Department, Children's of Alabama, Birmingham, AL
| | - Ariann Nassel
- Lister Hill Center for Health Policy, School of Public Health, University of Alabama at Birmingham, AL
| | - Jeremy M Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
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Lakshminrusimha S, Abman SH. Oxygen Targets in Neonatal Pulmonary Hypertension: Individualized, "Precision-Medicine" Approach. Clin Perinatol 2024; 51:77-94. [PMID: 38325948 PMCID: PMC10857735 DOI: 10.1016/j.clp.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Oxygen is a specific pulmonary vasodilator. Hypoxemia causes pulmonary vasoconstriction, and normoxia leads to pulmonary vasodilation. However, hyperoxia does not enhance pulmonary vasodilation but causes oxidative stress. There are no clinical trials evaluating optimal oxygen saturation or Pao2 in pulmonary hypertension. Data from translational studies and case series suggest that oxygen saturation of 90% to 97% or Pao2 between 50 and 80 mm Hg is associated with the lowest pulmonary vascular resistance.
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Affiliation(s)
- Satyan Lakshminrusimha
- Department of Pediatrics, University of California, UC Davis Children's Hospital, 2516 Stockton Boulevard, Sacramento, CA 95817, USA.
| | - Steven H Abman
- Department of Pediatrics, The Pediatric Heart Lung Center, University of Colorado Anschutz Medical Campus, Mail Stop B395, 13123 East 16th Avenue, Aurora, CO 80045, USA
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Gudelunas MK, Lipnick M, Hendrickson C, Vanderburg S, Okunlola B, Auchus I, Feiner JR, Bickler PE. Low Perfusion and Missed Diagnosis of Hypoxemia by Pulse Oximetry in Darkly Pigmented Skin: A Prospective Study. Anesth Analg 2024; 138:552-561. [PMID: 38109495 DOI: 10.1213/ane.0000000000006755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
BACKGROUND Retrospective clinical trials of pulse oximeter accuracy report more frequent missed diagnoses of hypoxemia in hospitalized Black patients than White patients, differences that may contribute to racial disparities in health and health care. Retrospective studies have limitations including mistiming of blood samples and oximeter readings, inconsistent use of functional versus fractional saturation, and self-reported race used as a surrogate for skin color. Our objective was to prospectively measure the contributions of skin pigmentation, perfusion index (PI), sex, and age on pulse oximeter errors in a laboratory setting. METHODS We enrolled 146 healthy subjects, including 25 with light skin (Fitzpatrick class I and II), 78 with medium (class III and IV), and 43 with dark (class V and VI) skin. We studied 2 pulse oximeters (Nellcor N-595 and Masimo Radical 7) in prevalent clinical use. We analyzed 9763 matched pulse oximeter readings (pulse oximeter measured functional saturation [Sp o2 ]) and arterial oxygen saturation (hemoximetry arterial functional oxygen saturation [Sa o2 ]) during stable hypoxemia (Sa o2 68%-100%). PI was measured as percent infrared light modulation by the pulse detected by the pulse oximeter probe, with low perfusion categorized as PI < 1%. The primary analysis was to assess the relationship between pulse oximeter bias (difference between Sa o2 and Sp o2 ) by skin pigment category in a multivariable mixed-effects model incorporating repeated-measures and different levels of Sa o2 and perfusion. RESULTS Skin pigment, PI, and degree of hypoxemia significantly contributed to errors (bias) in both pulse oximeters. For PI values of 1.0% to 1.5%, 0.5% to 1.0%, and <0.5%, the P value of the relationship to mean bias or median absolute bias was <.00001. In lightly pigmented subjects, only PI was associated with positive bias, whereas in medium and dark subjects bias increased with both low perfusion and degree of hypoxemia. Sex and age was not related to pulse oximeter bias. The combined frequency of missed diagnosis of hypoxemia (pulse oximeter readings 92%-96% when arterial oxygen saturation was <88%) in low perfusion conditions was 1.1% for light, 8.2% for medium, and 21.1% for dark skin. CONCLUSIONS Low peripheral perfusion combined with darker skin pigmentation leads to clinically significant high-reading pulse oximeter errors and missed diagnoses of hypoxemia. Darkly pigmented skin and low perfusion states are likely the cause of racial differences in pulse oximeter performance in retrospective studies.
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Affiliation(s)
- M Koa Gudelunas
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
| | - Michael Lipnick
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
- School of Medicine
- UCSF Center for Health Equity in Surgery and Anesthesia (CHESA), University of California San Francisco, San Francisco, California
| | - Carolyn Hendrickson
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
| | - Sky Vanderburg
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
| | - Bunmi Okunlola
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- Division of Critical Care Medicine, Zuckerberg San Francisco General Hospital
- Department of Anesthesiology and Critical Care, New York University School of Medicine, New York, New York
| | - Isabella Auchus
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
- School of Medicine
- UCSF Center for Health Equity in Surgery and Anesthesia (CHESA), University of California San Francisco, San Francisco, California
| | - John R Feiner
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
| | - Philip E Bickler
- From the Hypoxia Research Laboratory, Department of Anesthesia and Perioperative Care
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Eposse Ekoube C, Heles Nsang E, Épée P, Mandeng Ma Linwa E, Djike Puepi Y, Mbono Betoko R, Noukeu Njinkui D, Enyama D, Mbonjo Bitsie D, Disso Massako J, Abba S, Ngo Linwa EE, Ida Penda C. Predictors of prolonged length of hospital stay and in-hospital mortality in patients aged 1-24 months with acute bronchiolitis in Douala, Cameroon. BMC Pediatr 2024; 24:150. [PMID: 38424505 PMCID: PMC10903055 DOI: 10.1186/s12887-024-04653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 02/17/2024] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION In Cameroon, acute bronchiolitis has been reported as the third commonest lower respiratory infection and is usually associated with low mortality. Nonetheless, respiratory distress associated with non-adherence to management guidelines can prolong hospital stay. This study aimed to explore predictors of prolonged hospital stay (≥ 5 days) and mortality in patients aged < 2years hospitalised for acute bronchiolitis. METHODOLOGY We conducted a retrospective cohort study at three paediatric units in the city of Douala, Cameroon. Factors associated with prolonged hospital stay and mortality were determined using multivariable linear regression model. Threshold for significance was set at p ≤ 0.05. RESULTS A total of 215 patients with bronchiolitis were included with mean age of 6.94 ± 5.71 months and M/F sex ratio of 1.39/1. Prolonged hospital stay was reported in 46.98% and mortality in 10.70% of patients hospitalised for bronchiolitis. Factors independently associated with prolonged hospital duration were oxygen administration [b = 0.36, OR = 2.35 (95% CI:1.16-4.74), p = 0.017], abnormal respiratory rate [b = 0.38, OR = 2.13 (1.00-4.55), p = 0.050] and patients presenting with cough [b = 0.33, OR = 2.35 (95% CI: 1.22-4.51), p = 0.011], and diarrhoea [b = 0.71, OR = 6.44 (95% CI: 1.6-25.86), p = 0.009] on admission. On the other hand, factors independently associated with mortality were age of the patient [b= -0.07, OR = 0.84 (95% CI: 0.74-0.97), p = 0.014] and oxygen administration [b = 1.08, OR = 9.64 (95% CI:1.16-79.85), p = 0.036] CONCLUSION: Acute bronchiolitis represented 1.24% of admissions and was common in the rainy season, in males and 3-11-month-old patients. Management guidelines were poorly respected. Prolonged length of stay was reported in half of the patients hospitalized and mortality was high, especially in younger patients and in patients receiving oxygen.
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Affiliation(s)
- Charlotte Eposse Ekoube
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon.
- Paediatric unit, Douala Laquintinie Hospital, Douala, Cameroon.
| | - Emmanuel Heles Nsang
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Patricia Épée
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | | | - Ritha Mbono Betoko
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | - Diomède Noukeu Njinkui
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Dominique Enyama
- Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Dschang, Cameroon
| | - Dora Mbonjo Bitsie
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | - Soumaiyatou Abba
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
| | | | - Calixte Ida Penda
- Faculty of Medicine and Pharmaceutical Sciences, University of Douala, Douala, Cameroon
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Orr CJ, Leslie LK, Schaechter J, Williams XJ, Montez KG, Deen JF, Evans YN, Russell CJ, Webb J, Gaona AR, Mendoza FS. Diversity, Equity, and Inclusion, Child Health, and the Pediatric Subspecialty Workforce. Pediatrics 2024; 153:e2023063678S. [PMID: 38300010 PMCID: PMC10852199 DOI: 10.1542/peds.2023-063678s] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
Using multiple metrics, the diversity of the pediatric population in the United States is increasing. However, recent data suggest significant disparities in both the prevalence and management of child health conditions cared for by pediatric subspecialists. These inequities occur across multiple dimensions of diversity, including race and ethnicity, country of origin, socioeconomic status, sex and gender, and disability. Research also suggests that attending to diversity, equity, and inclusion in the medical workforce may positively affect health outcomes. High-quality pediatric subspecialty care thus requires knowledge of these data, attention to the effects of social drivers, including racism and discrimination, on health and wellbeing, and interventions to improve pediatric health equity through educational, practice, policy, and research innovations. In this article, we review data on the diversity of the pediatric population and pediatric subspecialty workforce, suggest potential strengths, weaknesses, opportunities, and threats of current diversity, equity, and inclusion initiatives in academic pediatrics, and provide recommendations across 4 domains: education and training, practice, policy, and future research. The ultimate goal of pediatrics is to improve health equity for all infants, children, adolescents, and young adults cared for in the United States by pediatric subspecialists.
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Affiliation(s)
- Colin J. Orr
- Department of Pediatrics
- Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | | | | | - Kimberly G. Montez
- Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Jason F. Deen
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Yolanda N. Evans
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | - Jonathan Webb
- American Board of Pediatrics, Chapel Hill, North Carolina
- Association of Women’s Health Obstetric and Neonatal Nurses, Washington, District of Columbia
| | | | - Fernando S. Mendoza
- Department of Pediatrics, Stanford School of Medicine, Palo Alto, California
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12
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Rogerson CM, Hogan AH, Waldo B, White BR, Carroll CL, Shein SL. Wide Institutional Variability in the Treatment of Pediatric Critical Asthma: A Multicenter Retrospective Study. Pediatr Crit Care Med 2024; 25:37-46. [PMID: 37615529 DOI: 10.1097/pcc.0000000000003347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVES Children with status asthmaticus refractory to first-line therapies of systemic corticosteroids and inhaled beta-agonists often receive additional treatments. Because there are no national guidelines on the use of asthma therapies in the PICU, we sought to evaluate institutional variability in the use of adjunctive asthma treatments and associations with length of stay (LOS) and PICU use. DESIGN Multicenter retrospective cohort study. SETTING Administrative data from the Pediatric Health Information Systems (PHIS) database. PATIENTS All inpatients 2-18 years old were admitted to a PHIS hospital between 2013 and 2021 with a diagnostic code for asthma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS This study included 213,506 inpatient encounters for asthma, of which 29,026 patient encounters included care in a PICU from 39 institutions. Among these PICU encounters, large variability was seen across institutions in both the number of adjunctive asthma therapies used per encounter (min: 0.6, median: 1.7, max: 2.5, p < 0.01) and types of adjunctive asthma therapies (aminophylline, ipratropium, magnesium, epinephrine, and terbutaline) used. The center-level median hospital LOS ranged from 1 (interquartile range [IQR]: 1, 3) to 4 (3, 6) days. Among all the 213,506 inpatient encounters for asthma, the range of asthma admissions that resulted in PICU admission varied between centers from 5.2% to 47.3%. The average number of adjunctive therapies used per institution was not significantly associated with hospital LOS ( p = 0.81) nor the percentage of encounters with PICU admission ( p = 0.47). CONCLUSIONS Use of adjunctive therapies for status asthmaticus varies widely among large children's hospitals and was not associated with hospital LOS or the percentage of encounters with PICU admission. Wide variance presents an opportunity for standardizing care with evidence-based guidelines to optimize outcomes and decrease adverse treatment effects and hospital costs.
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Affiliation(s)
- Colin M Rogerson
- Division of Pediatric Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Alexander H Hogan
- Division of Hospital Medicine, Connecticut Children's Medical Center, Hartford, CT
| | - Briana Waldo
- Department of Respiratory Therapy, Rainbow Babies and Children's Hospital, Cleveland, OH
| | - Benjamin R White
- Division of Pediatric Critical Care Medicine, University of Utah, Salt Lake City, UT
| | - Christopher L Carroll
- Department of Pediatrics, Wolfson Children's, University of Florida, Jacksonville, FL
| | - Steven L Shein
- Division of Pediatric Critical Care Medicine, Rainbow Babies and Children's Hospital, Cleveland, OH
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13
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Grunwell JR. So, You Say You Want a Revolution? You Tell Me That It's Evolution: Associating Temporal Changes in Pediatric Acute Respiratory Distress Syndrome Plasma Biomarkers With Lung Injury Severity. Pediatr Crit Care Med 2024; 25:80-83. [PMID: 38169340 PMCID: PMC10783528 DOI: 10.1097/pcc.0000000000003328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, GA
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14
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Williams JG, Jones RL, Yunger TL, Lahni PM, Yehya N, Varisco BM. Comparison of 16 Pediatric Acute Respiratory Distress Syndrome-Associated Plasma Biomarkers With Changing Lung Injury Severity. Pediatr Crit Care Med 2024; 25:e31-e40. [PMID: 37382480 PMCID: PMC10755079 DOI: 10.1097/pcc.0000000000003311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
OBJECTIVES Pediatric acute respiratory distress syndrome (PARDS) is a source of substantial morbidity and mortality in the PICU, and different plasma biomarkers have identified different PARDS and ARDS subgroups. We have a poor understanding of how these biomarkers change over time and with changing lung injuries. We sought to determine how biomarker levels change over PARDS course, whether they are correlated, and whether they are different in critically ill non-PARDS patients. DESIGN Two-center prospective observational study. SETTING Two quaternary care academic children's hospitals. PATIENTS Subjects under 18 years of age admitted to the PICU who were intubated and met the Second Pediatric Acute Lung Injury Consensus Conference-2 PARDS diagnostic criteria and nonintubated critically ill subjects without apparent lung disease. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Plasma samples were obtained on study days 1, 3, 7, and 14. The levels of 16 biomarkers were measured using a fluorometric bead-based assay. Compared with non-PARDS subjects, on day 1 PARDS subjects had increased concentrations of tumor necrosis factor-alpha, interleukin (IL)-8, interferon-γ, IL17, granzyme B, soluble intercellular adhesion molecule-1 (sICAM1), surfactant protein D, and IL18 but reduced matrix metalloproteinase 9 (MMP-9) concentrations (all p < 0.05). Day 1 biomarker concentrations and PARDS severity were not correlated. Over PARDS course, changes in 11 of the 16 biomarkers positively correlated with changing lung injury with sICAM1 ( R = 0.69, p = 2.2 × 10 -16 ) having the strongest correlation. By Spearman rank correlation of biomarker concentrations in PARDS subjects, we identified two patterns. One had elevations of plasminogen activator inhibitor-1, MMP-9, and myeloperoxidase, and the other had higher inflammatory cytokines. CONCLUSIONS sICAM1 had the strongest positive correlation with worsening lung injury across all study time points suggesting that it is perhaps the most biologically relevant of the 16 analytes. There was no correlation between biomarker concentration on day 1 and day 1 PARDS severity; however, changes in most biomarkers over time positively correlated with changing lung injury. Finally, in day 1 samples, 7 of the 16 biomarkers were not significantly different between PARDS and critically ill non-PARDS subjects. These data highlight the difficulty of using plasma biomarkers to identify organ-specific pathology in critically ill patients.
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Affiliation(s)
- James G Williams
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rhonda L Jones
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Toni L Yunger
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Patrick M Lahni
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Nadir Yehya
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Brian M Varisco
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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15
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Leland SB, Staffa SJ, Newhams MM, Khemani RG, Marshall JC, Young CC, Maddux AB, Hall MW, Weiss SL, Schwarz AJ, Coates BM, Sanders RC, Kong M, Thomas NJ, Nofziger RA, Cullimore ML, Halasa NB, Loftis LL, Cvijanovich NZ, Schuster JE, Flori H, Gertz SJ, Hume JR, Olson SM, Patel MM, Zurakowski D, Randolph AG. The Modified Clinical Progression Scale for Pediatric Patients: Evaluation as a Severity Metric and Outcome Measure in Severe Acute Viral Respiratory Illness. Pediatr Crit Care Med 2023; 24:998-1009. [PMID: 37539964 PMCID: PMC10688559 DOI: 10.1097/pcc.0000000000003331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVES To develop, evaluate, and explore the use of a pediatric ordinal score as a potential clinical trial outcome metric in children hospitalized with acute hypoxic respiratory failure caused by viral respiratory infections. DESIGN We modified the World Health Organization Clinical Progression Scale for pediatric patients (CPS-Ped) and assigned CPS-Ped at admission, days 2-4, 7, and 14. We identified predictors of clinical improvement (day 14 CPS-Ped ≤ 2 or a three-point decrease) using competing risks regression and compared clinical improvement to hospital length of stay (LOS) and ventilator-free days. We estimated sample sizes (80% power) to detect a 15% clinical improvement. SETTING North American pediatric hospitals. PATIENTS Three cohorts of pediatric patients with acute hypoxic respiratory failure receiving intensive care: two influenza (pediatric intensive care influenza [PICFLU], n = 263, 31 sites; PICFLU vaccine effectiveness [PICFLU-VE], n = 143, 17 sites) and one COVID-19 ( n = 237, 47 sites). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive mechanical ventilation rates were 71.4%, 32.9%, and 37.1% for PICFLU, PICFLU-VE, and COVID-19 with less than 5% mortality for all three cohorts. Maximum CPS-Ped (0 = home at respiratory baseline to 8 = death) was positively associated with hospital LOS ( p < 0.001, all cohorts). Across the three cohorts, many patients' CPS-Ped worsened after admission (39%, 18%, and 49%), with some patients progressing to invasive mechanical ventilation or death (19%, 11%, and 17%). Despite this, greater than 76% of patients across cohorts clinically improved by day 14. Estimated sample sizes per group using CPS-Ped to detect a percentage increase in clinical improvement were feasible (influenza 15%, n = 142; 10%, n = 225; COVID-19, 15% n = 208) compared with mortality ( n > 21,000, all), and ventilator-free days (influenza 15%, n = 167). CONCLUSIONS The CPS-Ped can be used to describe the time course of illness and threshold for clinical improvement in hospitalized children and adolescents with acute respiratory failure from viral infections. This outcome measure could feasibly be used in clinical trials to evaluate in-hospital recovery.
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Affiliation(s)
- Shannon B Leland
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Margaret M Newhams
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
- Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA
| | - John C Marshall
- Department of Surgery, Li Ka Shing Knowledge Institute, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Cameron C Young
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Aline B Maddux
- Department of Pediatrics, Section of Critical Care Medicine, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH
| | - Scott L Weiss
- Division of Critical Care, Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Adam J Schwarz
- Division of Critical Care Medicine, Children's Hospital Orange County (CHOC), Orange, CA
| | - Bria M Coates
- Division of Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ronald C Sanders
- Section of Pediatric Critical Care, Department of Pediatrics, Arkansas Children's Hospital, Little Rock, AR
| | - Michele Kong
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Neal J Thomas
- Department of Pediatrics, Penn State Hershey Children's Hospital, Penn State University College of Medicine, Hershey, PA
| | - Ryan A Nofziger
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH
| | - Melissa L Cullimore
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital and Medical Center, Omaha, NE
| | - Natasha B Halasa
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Laura L Loftis
- Section of Critical Care Medicine, Department of Pediatrics, Texas Children's Hospital, Houston, TX
| | - Natalie Z Cvijanovich
- Division of Critical Care Medicine, UCSF Benioff Children's Hospital Oakland, Oakland, CA
| | - Jennifer E Schuster
- Division of Pediatric Infectious Disease, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Heidi Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Mott Children's Hospital and University of Michigan, Ann Arbor, MI
| | - Shira J Gertz
- Division of Pediatric Critical Care, Department of Pediatrics, Cooperman Barnabas Medical Center, Livingston, NJ
| | - Janet R Hume
- Division of Pediatric Critical Care, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Samantha M Olson
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - Manish M Patel
- Influenza Division and CDC COVID-19 Response Team, Centers for Disease Control of Prevention, National Center for Immunization and Respiratory Diseases (NCIRD), Atlanta, GA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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16
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Halm MA. Skin Pigmentation and Accuracy of Pulse Oximetry Values. Am J Crit Care 2023; 32:459-462. [PMID: 37907368 DOI: 10.4037/ajcc2023292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Affiliation(s)
- Margo A Halm
- Margo A. Halm is a nurse scientist consultant in Portland, Oregon
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17
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Gandhi HA, Olson G, Lee H, Zouaidi K, Yansane A, Walji M, Kalenderian E, Tokede B. Assessing the safety of deep sedation in outpatient pediatric oral health care. J Am Dent Assoc 2023; 154:975-983.e1. [PMID: 37676186 DOI: 10.1016/j.adaj.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/12/2023] [Accepted: 07/24/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Children are the patient subgroup with the lowest error tolerance regarding deep sedation (DS)-supported care. This study assessed the safety of DS-supported pediatric dental treatment carried out in an outpatient setting through retrospective review of patient charts. METHODS An automated script was developed to identify charts of pediatric patients who underwent DS-supported dental procedures from 2017 through 2019 at a dental clinic. Charts were assessed for the presence of sedation-related adverse events (AEs). A panel of experts performed a second review and confirmed or refuted the designation of AE (by the first reviewer). AEs were classified with the Tracking and Reporting Outcomes of Procedural Sedation system. RESULTS Of the 175 DS cases, 19 AEs were identified in 15 cases (8.60%). Using the Tracking and Reporting Outcomes of Procedural Sedation classification system, 7 (36.84%) events were related to the airway and breathing category, 9 (47.37%) were related to sedation quality (including a dizzy patient who fell at the checkout desk and sustained a head laceration), and 3 (15.79%) were classified as an allergy. CONCLUSION This study suggests an AE (whether relatively minor or of potentially major consequence) occurs in 1 of every 12 DS cases involving pediatric patients, performed at an outpatient dental clinic. Larger studies are needed, in addition to root cause analyses. PRACTICAL IMPLICATIONS As dentists increasingly pivot in the use of DS services from in-hospital to outpatient settings, patients expect comparable levels of safety. This work helps generate evidence to drive targeted efforts to improve the safety and reliability of pediatric outpatient sedation.
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18
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Blank JA, Armstrong-Hough M, Valley TS. Disparities among patients with respiratory failure. Curr Opin Crit Care 2023; 29:493-504. [PMID: 37641499 PMCID: PMC10599128 DOI: 10.1097/mcc.0000000000001079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Disparities are common within healthcare, and critical illness is no exception. This review summarizes recent literature on health disparities within respiratory failure, focusing on race, ethnicity, socioeconomic status, and sex. RECENT FINDINGS Current evidence indicates that Black patients have higher incidence of respiratory failure, while the relationships among race, ethnicity, and mortality remains unclear. There has been renewed interest in medical device bias, specifically pulse oximetry, for which data demonstrate patients with darker skin tones may be at risk for undetected hypoxemia and worse outcomes. Lower socioeconomic status is associated with higher mortality, and respiratory failure can potentiate socioeconomic inequities via illness-related financial toxicity. Literature on sex-based disparities is limited; however, evidence suggests males receive more invasive care, including mechanical ventilation. SUMMARY Most studies focused on disparities in incidence and mortality associated with respiratory failure, but few relied on granular clinical data of patients from diverse backgrounds. Future studies should evaluate processes of care for respiratory failure that may mechanistically contribute to disparities in order to develop interventions that improve outcomes.
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Affiliation(s)
| | - Mari Armstrong-Hough
- New York University School of Global Public Health, Department of Social & Behavioral Sciences, Department of Epidemiology
| | - Thomas S. Valley
- University of Michigan, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine
- VA Center for Clinical Management Research, Ann Arbor, Michigan
- Institute for Healthcare Policy and Innovation, University of Michigan
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19
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Cabanas AM, Martín-Escudero P, Shelley KH. Improving pulse oximetry accuracy in dark-skinned patients: technical aspects and current regulations. Br J Anaesth 2023; 131:640-644. [PMID: 37544838 DOI: 10.1016/j.bja.2023.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/15/2023] [Accepted: 07/08/2023] [Indexed: 08/08/2023] Open
Abstract
Recent concerns regarding the clinical accuracy of pulse oximetry in dark-skinned patients, specifically in detecting occult hypoxaemia, have motivated research on this topic and recently reported in this journal. We provide an overview of the technical aspects of the issue, the sources of inaccuracy, and the current regulations and limitations. These insights offer perspectives on how pulse oximetry can be improved to address these potential limitations.
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Affiliation(s)
- Ana M Cabanas
- Department of Physics, Universidad de Tarapacá, Arica, Chile.
| | - Pilar Martín-Escudero
- Medical School of Sport Medicine, Faculty of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Kirk H Shelley
- Department of Anesthesiology, Yale University, New Haven, CT, USA
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20
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Geva A, Akhondi-Asl A, Mehta NM. Validation and Extension of the Association Between Potentially Excess Oxygen Exposure and Death in Mechanically Ventilated Children. Pediatr Crit Care Med 2023; 24:e434-e440. [PMID: 37668503 DOI: 10.1097/pcc.0000000000003261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
OBJECTIVES "Cumulative excess oxygen exposure" (CEOE)-previously defined as the mean hourly administered Fio2 above 0.21 when the corresponding hourly Spo2 was 95% or above-was previously shown to be associated with mortality. The objective of this study was to examine the relationship among Fio2, Spo2, and mortality in an independent cohort of mechanically ventilated children. DESIGN Retrospective cross-sectional study. SETTING Quaternary-care PICU. PATIENTS All patients admitted to the PICU between 2012 and 2021 and mechanically ventilated via endotracheal tube for at least 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among 3,354 patients, 260 (8%) died. Higher CEOE quartile was associated with increased mortality (p = 0.001). The highest CEOE quartile had an 87% increased risk of mortality (95% CI, 7-236) compared with the first CEOE quartile. The hazard ratio for extended CEOE exposure, which included mechanical ventilation data from throughout the patients' mechanical ventilation time rather than only from the first 24 hours of mechanical ventilation, was 1.03 (95% CI, 1.02-1.03). CONCLUSIONS Potentially excess oxygen exposure in patients whose oxygen saturation was at least 95% was associated with increased mortality.
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Affiliation(s)
- Alon Geva
- Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Computational Health Informatics Program, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Alireza Akhondi-Asl
- Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
| | - Nilesh M Mehta
- Perioperative and Critical Care Center for Outcomes Research and Evaluation (PC-CORE), Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, MA
- Department of Anaesthesia, Harvard Medical School, Boston, MA
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21
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Shapiro I, Stein J, MacRae C, O'Reilly M. Pulse oximetry values from 33,080 participants in the Apple Heart & Movement Study. NPJ Digit Med 2023; 6:134. [PMID: 37500721 PMCID: PMC10374661 DOI: 10.1038/s41746-023-00851-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 05/24/2023] [Indexed: 07/29/2023] Open
Abstract
Wearable devices that include pulse oximetry (SpO2) sensing afford the opportunity to capture oxygen saturation measurements from large cohorts under naturalistic conditions. We report here a cross-sectional analysis of 72 million SpO2 values collected from 33,080 individual participants in the Apple Heart and Movement Study, stratified by age, sex, body mass index (BMI), home altitude, and other demographic variables. Measurements aggregated by hour of day into 24-h SpO2 profiles exhibit similar circadian patterns for all demographic groups, being approximately sinusoidal with nadir near midnight local time, zenith near noon local time, and mean 0.8% lower saturation during overnight hours. Using SpO2 measurements averaged for each subject into mean nocturnal and daytime SpO2 values, we employ multivariate ordinary least squares regression to quantify population-level trends according to demographic factors. For the full cohort, regression coefficients obtained from models fit to daytime SpO2 are in close quantitative agreement with the corresponding values from published reference models for awake arterial oxygen saturation measured under controlled laboratory conditions. Regression models stratified by sex reveal significantly different age- and BMI-dependent SpO2 trends for females compared with males, although constant terms and regression coefficients for altitude do not differ between sexes. Incorporating categorical variables encoding self-reported race/ethnicity into the full-cohort regression models identifies small but statistically significant differences in daytime SpO2 (largest coefficient corresponding to 0.13% lower SpO2, for Hispanic study participants compared to White participants), but no significant differences between groups for nocturnal SpO2. Additional stratified analysis comparing regression models fit independently to subjects in each race/ethnicity group is suggestive of small differences in age- and sex-dependent trends, but indicates no significant difference in constant terms between any race/ethnicity groups for either daytime or nocturnal SpO2. The large diverse study population and study design employing automated background SpO2 measurements spanning the full 24-h circadian cycle enables the establishment of healthy population reference trends outside of clinical settings.
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Affiliation(s)
| | | | - Calum MacRae
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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22
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Savorgnan F, Hassan A, Borges N, Acosta S. Pulse Oximetry and Arterial Saturation Difference in Pediatric COVID-19 Patients: Retrospective Analysis by Race. Pediatr Crit Care Med 2023; 24:458-462. [PMID: 36825900 PMCID: PMC10226388 DOI: 10.1097/pcc.0000000000003208] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
OBJECTIVES Pulse oximetry (Sp o2 ) may overestimate arterial oxygen saturation (Sa o2 ) in blood laboratory testing. This study aimed to assess Sp o2 -Sa o2 difference in relation to race (i.e., patient self-reporting as Black or White), occult hypoxemia, and length of stay (LOS) in pediatric patients with COVID-19. DESIGN Single-center retrospective study in pediatric COVID-19 patients. We used multivariable linear regressions to examine the association between race and oximetry measurements and between occult hypoxemia and LOS. Oximetry bias was defined using Sp o2 and Sa o2 data according to approved comparisons. Occult hypoxemia was defined as Sp o2 greater than 92% and Sa o2 less than 88%. SETTING Quaternary pediatric hospital. PATIENTS Pediatric COVID-19 patients admitted to Texas Children's Hospital between May 2020 and December 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 2713 patients with complete physiological data in the analysis. Of the total, 61% were Black, and 39% were White. Oximetry bias was greater in Black compared with White patients ( p < 0.001), and this bias increased as the oxygen saturations decreased ( p < 0.001). Black and White patients had a 12% and 4% prevalence of occult hypoxemia, respectively ( p < 0.001). LOS was not associated with oximetry bias or occult hypoxemia once controlled for the level of support (intensive care, respiratory, circulatory). CONCLUSIONS We found an oximetry bias in the measurement of Sp o2 with respect to Sa o2 in symptomatic hospitalized pediatric patients with the diagnosis of COVID-19. Furthermore, race is related to an increased oximetry bias. However, we did not find a relationship between oximetry bias and the LOS in the hospital in this cohort of patients.
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Affiliation(s)
- Fabio Savorgnan
- Divisions of Critical Care and Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | | | - Nirica Borges
- Divisions of Critical Care and Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Sebastian Acosta
- Divisions of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
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Barreto JA, Moynihan KM. Discrimination by Design: Is It Time to Recalibrate Interpretation of Pulse Oximetry? Pediatr Crit Care Med 2023; 24:517-521. [PMID: 37260336 DOI: 10.1097/pcc.0000000000003229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Jessica A Barreto
- Department of Pediatrics, Harvard Medical School, Boston, MA
- Department of Cardiology, Boston Children's Hospital, Boston, MA
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24
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Ruppel H, Makeneni S, Faerber JA, Lane-Fall MB, Foglia EE, O’Byrne ML, Bonafide CP. Evaluating the Accuracy of Pulse Oximetry in Children According to Race. JAMA Pediatr 2023; 177:540-543. [PMID: 36939727 PMCID: PMC10028535 DOI: 10.1001/jamapediatrics.2023.0071] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 12/07/2022] [Indexed: 03/21/2023]
Abstract
This cross-sectional study investigates the association between race and pulse oximeter accuracy in children in the US.
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Affiliation(s)
- Halley Ruppel
- School of Nursing, Department of Family and Community Health, University of Pennsylvania, Philadelphia
| | - Spandana Makeneni
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Jennifer A. Faerber
- Data Science and Biostatistics Unit, Children’s Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
| | - Meghan B. Lane-Fall
- Perelman School of Medicine, Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia
| | | | - Michael L. O’Byrne
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia
| | - Christopher P. Bonafide
- Section of Hospital Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
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25
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Kaltsogianni O, Zaidi S, Bhat R, Greenough A, Dassios T. Race, hypoxaemia and oxidative stress in prematurely-born infants. Early Hum Dev 2023; 182:105778. [PMID: 37127019 DOI: 10.1016/j.earlhumdev.2023.105778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/18/2023] [Accepted: 04/18/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Disparities in neonatal respiratory outcomes in prematurely-born infants might be partially explained by racial differences and the relationship of hypoxia and oxidative stress. AIMS To determine if Black, preterm infants were exposed more frequently to hypoxaemia compared to White infants and had a higher level of oxidative damage. STUDY DESIGN Single-centre retrospective cohort study at King's College Hospital, London, UK between 2018 and 2021. SUBJECTS Infants born before 32 completed weeks of gestational age. OUTCOME MEASURES The median arterial oxygen saturation (SaO2) over the first seven days was measured. The maximum carboxyhaemoglobin (COHb) level for the first three days was also recorded as an index of oxidative stress. RESULTS Two thousand and sixty blood gases from 87 infants (38 Black) with a median (IQR) gestational age of 26.4 (24.6-28.3) weeks were analysed. The median (IQR) SaO2 was not significantly different in Black [96.1 (95.2-96.8) %] compared to White infants [96.7 (95.6-97.7) %, p = 0.24]. The median (IQR) COHb was not significantly different in Black infants [1.9 (1.7-2.4) %] compared to White infants [1.9 (1.7-2.3) %, p = 0.77]. The highest COHb was significantly related to the median SaO2 in all infants (r = -0.51, p < 0.001) and separately in Black (r = -0.50, p = 0.002) and White (r = -0.56, p < 0.001) infants. CONCLUSIONS Preterm, Black infants were not exposed more frequently to hypoxaemia compared to White infants. Lower saturation levels were associated with higher maximum carboxyhaemoglobin levels indicating a higher risk of oxidative stress, irrespective of racial background.
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Affiliation(s)
- Ourania Kaltsogianni
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK.
| | - Sara Zaidi
- School of Medicine, Faculty of Life Sciences and Medicine, King's College London, UK.
| | - Ravindra Bhat
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.
| | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK.
| | - Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK; Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK.
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26
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Sjoding MW, Iwashyna TJ, Valley TS. Change the Framework for Pulse Oximeter Regulation to Ensure Clinicians Can Give Patients the Oxygen They Need. Am J Respir Crit Care Med 2023; 207:661-664. [PMID: 36260769 PMCID: PMC10037469 DOI: 10.1164/rccm.202209-1773ed] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Michael W Sjoding
- Department of Internal Medicine and Center for Computational Medicine and Bioinformatics University of Michigan Medical School Ann Arbor, Michigan and Max Harry Weil Institute for Critical Care Research and Innovation University of Michigan Ann Arbor, Michigan and Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor, Michigan
| | - Theodore J Iwashyna
- Department of Medicine and Department of Health Policy and Management Johns Hopkins University Baltimore, Maryland
| | - Thomas S Valley
- Department of Internal Medicine University of Michigan Medical School Ann Arbor, Michigan and Institute for Healthcare Policy and Innovation and Center for Bioethics and Social Sciences in Medicine University of Michigan Ann Arbor, Michigan and Veterans Affairs Center for Clinical Management Research Ann Arbor, Michigan
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27
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Ryals S, Chiang A, Schutte-Rodin S, Chandrakantan A, Verma N, Holfinger S, Abbasi-Feinberg F, Bandyopadhyay A, Baron K, Bhargava S, He K, Kern J, Miller J, Patel R, Ratnasoma D, Deak MC. Photoplethysmography-new applications for an old technology: a sleep technology review. J Clin Sleep Med 2023; 19:189-195. [PMID: 36123954 PMCID: PMC9806792 DOI: 10.5664/jcsm.10300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/14/2022] [Accepted: 09/15/2022] [Indexed: 01/07/2023]
Abstract
Education is integral to the American Academy of Sleep Medicine (AASM) mission. The AASM Emerging Technology Committee identified an important and evolving piece of technology that is present in many of the consumer and clinical technologies that we review on the AASM #SleepTechnology (https://aasm.org/consumer-clinical-sleep-technology/) resource-photoplethysmography. As more patients with sleep tracking devices ask clinicians to view their data, it is important for sleep providers to have a general understanding of the technology, its sensors, how it works, targeted users, evidence for the claimed uses, and its strengths and weaknesses. The focus in this review is photoplethysmography-a sensor type used in the familiar pulse oximeter that is being developed for additional utilities and data outputs in both consumer and clinical sleep technologies. CITATION Ryals S, Chang A, Schutte-Rodin S, et al. Photoplethysmography-new applications for an old technology: a sleep technology review. J Clin Sleep Med. 2023;19(1):189-195.
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Affiliation(s)
- Scott Ryals
- Atrium Health Sleep Medicine, Charlotte, North Carolina
| | - Ambrose Chiang
- Louis Stokes Cleveland VA Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sharon Schutte-Rodin
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | | | | | | | | | - Anuja Bandyopadhyay
- Section of Pediatric Pulmonology, Allergy, and Sleep Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kelly Baron
- University of Utah Sleep-Wake Center, Salt Lake City, Utah
| | - Sumit Bhargava
- Lucille Packard Children’s Hospital at Stanford, Palo Alto, California
| | - Ken He
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington
| | - Joseph Kern
- New Mexico VA Health Care System, Albuquerque, New Mexico
| | | | - Ruchir Patel
- The Insomnia and Sleep Institute of Arizona, Scottsdale, Arizona
| | - Dulip Ratnasoma
- Sleep Medicine, Sentara Martha Jefferson Medical & Surgical Associates, Charlottesville, Virginia
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28
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Sullivan BA, Kausch SL, Fairchild KD. Artificial and human intelligence for early identification of neonatal sepsis. Pediatr Res 2023; 93:350-356. [PMID: 36127407 DOI: 10.1038/s41390-022-02274-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 07/29/2022] [Accepted: 08/05/2022] [Indexed: 11/09/2022]
Abstract
Artificial intelligence may have a role in the early detection of sepsis in neonates. Machine learning can identify patterns that predict high or increasing risk for clinical deterioration from a sepsis-like illness. In developing this potential addition to NICU care, careful consideration should be given to the data and methods used to develop, validate, and evaluate prediction models. When an AI system alerts clinicians to a change in a patient's condition that warrants a bedside evaluation, human intelligence and experience come into play to determine an appropriate course of action: evaluate and treat or wait and watch closely. With intelligently developed, validated, and implemented AI sepsis systems, both clinicians and patients stand to benefit. IMPACT: This narrative review highlights the application of AI in neonatal sepsis prediction. It describes issues in clinical prediction model development specific to this population. This article reviews the methods, considerations, and literature on neonatal sepsis model development and validation. Challenges of AI technology and potential barriers to using sepsis AI systems in the NICU are discussed.
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Affiliation(s)
- Brynne A Sullivan
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Sherry L Kausch
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Karen D Fairchild
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
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29
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Patterson S, Sandercock N, Verhovsek M. Understanding pulse oximetry in hematology patients: Hemoglobinopathies, racial differences, and beyond. Am J Hematol 2022; 97:1659-1663. [PMID: 36074079 DOI: 10.1002/ajh.26721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/27/2022] [Accepted: 08/30/2022] [Indexed: 01/31/2023]
Abstract
Pulse oximetry (SpO2 ) is a widely used, non-invasive method of estimating arterial oxygen saturation. Measurement of SpO2 relies on comparing the relative absorption of light in the red and infrared regions with the expected absorption pattern of oxygenated and deoxygenation adult hemoglobin. As this screening tool has entered common clinical use, test limitations have emerged, including concern about the risk of overestimation of oxygen saturation by pulse oximetry in a disproportionate number of people with dark skin pigment, leading to potential for underdiagnosis of true hypoxemia. In addition, a range of challenges may arise in patients with increased levels of methemoglobin - whether acquired or inherited - carboxyhemoglobin, or in patients with a subset of inherited variant hemoglobins. It is important for Hematologists, and indeed all clinicians who rely on pulse oximetry, to understand the principles and limitations of this ubiquitous test.
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Affiliation(s)
- Sarah Patterson
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nick Sandercock
- Molecular Hematology, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Madeleine Verhovsek
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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30
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Racial effects on Masimo pulse oximetry: a laboratory study. J Clin Monit Comput 2022; 37:567-574. [PMID: 36370242 PMCID: PMC9652601 DOI: 10.1007/s10877-022-00927-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/03/2022] [Indexed: 11/13/2022]
Abstract
AbstractRecent publications have suggested that pulse oximeters exhibit reduced accuracy in dark-skinned patients during periods of hypoxemia. Masimo SET® (Signal Extraction Technology®) has been designed, calibrated, and validated using nearly equal numbers of dark and light skinned subjects, with the goal of eliminating differences between pulse oximetry saturation (SpO2) and arterial oxygen saturation (SaO2) values due to skin pigmentation. The accuracy concerns reported in dark-skinned patients led us to perform a retrospective analysis of healthy Black and White volunteers. Seventy-five subjects who self-identified as being racially Black or White underwent a desaturation protocol where SaO2 values were decreased from 100 to 70%, while simultaneous SpO2 values were recorded using Masimo RD SET® sensors. Statistical bias (mean difference) and precision (standard deviation of difference) were − 0.20 ± 1.40% for Black and − 0.05 ± 1.35% for White subjects. Plots of SpO2 versus SaO2 show no significant visible differences between races throughout the saturation range from 70 to 100%. Box plots grouped in 1% saturation bins, from 89–96%, and plotted against concomitant SaO2 values, show that occult hypoxemia (SaO2 < 88% when SpO2 = 92–96%) occurred in only 0.2% of White subject data pairs, but not in any Black subjects. There were no clinically significant differences in bias (mean difference of SpO2-SaO2) found between healthy Black and White subjects. Occult hypoxemia was rare and did not occur in Black subjects. Masimo RD SET® can be used with equal assurance in people with dark or light skin. These laboratory results were obtained in well-controlled experimental conditions in healthy volunteers—not reflecting actual clinical conditions/patients.
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31
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Gottlieb ER, Ziegler J, Morley K, Rush B, Celi LA. Assessment of Racial and Ethnic Differences in Oxygen Supplementation Among Patients in the Intensive Care Unit. JAMA Intern Med 2022; 182:849-858. [PMID: 35816344 PMCID: PMC9274443 DOI: 10.1001/jamainternmed.2022.2587] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Pulse oximetry (SpO2) is routinely used for transcutaneous monitoring of blood oxygenation, but it can overestimate actual oxygenation. This is more common in patients of racial and ethnic minority groups. The extent to which these discrepancies are associated with variations in treatment is not known. OBJECTIVE To determine if there are racial and ethnic disparities in supplemental oxygen administration associated with inconsistent pulse oximeter performance. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study was based on the Medical Information Mart for Intensive Care (MIMIC)-IV critical care data set. Included patients were documented with a race and ethnicity as Asian, Black, Hispanic, or White and were admitted to the intensive care unit (ICU) for at least 12 hours before needing advanced respiratory support, if any. Oxygenation levels and nasal cannula flow rates for up to 5 days from ICU admission or until the time of intubation, noninvasive positive pressure ventilation, high-flow nasal cannula, or tracheostomy were analyzed. MAIN OUTCOMES AND MEASURES The primary outcome was time-weighted average supplemental oxygen rate. Covariates included race and ethnicity, sex, SpO2-hemoglobin oxygen saturation discrepancy, data duration, number and timing of blood gas tests on ICU days 1 to 3, partial pressure of carbon dioxide, hemoglobin level, average respiratory rate, Elixhauser comorbidity scores, and need for vasopressors or inotropes. RESULTS This cohort included 3069 patients (mean [SD] age, 66.9 [13.5] years; 83 were Asian, 207 were Black, 112 were Hispanic, 2667 were White). In a multivariable linear regression, Asian (coefficient, 0.602; 95% CI, 0.263 to 0.941; P = .001), Black (coefficient, 0.919; 95% CI, 0.698 to 1.140; P < .001), and Hispanic (coefficient, 0.622; 95% CI, 0.329 to 0.915; P < .001) race and ethnicity were all associated with a higher SpO2 for a given hemoglobin oxygen saturation. Asian (coefficient, -0.291; 95% CI, -0.546 to -0.035; P = .03), Black (coefficient, -0.294; 95% CI, -0.460 to -0.128; P = .001), and Hispanic (coefficient, -0.242; 95% CI, -0.463 to -0.020; P = .03) race and ethnicity were associated with lower average oxygen delivery rates. When controlling for the discrepancy between average SpO2 and average hemoglobin oxygen saturation, race and ethnicity were not associated with oxygen delivery rate. This discrepancy mediated the effect of race and ethnicity (-0.157; 95% CI, -0.250 to -0.057; P = .002). CONCLUSIONS AND RELEVANCE In this cohort study, Asian, Black, and Hispanic patients received less supplemental oxygen than White patients, and this was associated with differences in pulse oximeter performance, which may contribute to known race and ethnicity-based disparities in care.
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Affiliation(s)
- Eric Raphael Gottlieb
- Division of Renal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge
| | - Jennifer Ziegler
- Department of Internal Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Katharine Morley
- Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Barret Rush
- Department of Internal Medicine, Section of Critical Care Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leo Anthony Celi
- Harvard Medical School, Boston, Massachusetts.,Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge.,Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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32
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Valbuena VSM, Seelye S, Sjoding MW, Valley TS, Dickson RP, Gay SE, Claar D, Prescott HC, Iwashyna TJ. Racial bias and reproducibility in pulse oximetry among medical and surgical inpatients in general care in the Veterans Health Administration 2013-19: multicenter, retrospective cohort study. BMJ 2022; 378:e069775. [PMID: 35793817 PMCID: PMC9254870 DOI: 10.1136/bmj-2021-069775] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate measurement discrepancies by race between pulse oximetry and arterial oxygen saturation (as measured in arterial blood gas) among inpatients not in intensive care. DESIGN Multicenter, retrospective cohort study using electronic medical records from general care medical and surgical inpatients. SETTING Veteran Health Administration, a national and racially diverse integrated health system in the United States, from 2013 to 2019. PARTICIPANTS Adult inpatients in general care (medical and surgical), in Veteran Health Administration medical centers. MAIN OUTCOMES MEASURES Occult hypoxemia (defined as arterial blood oxygen saturation (SaO2) of <88% despite a pulse oximetry (SpO2) reading of ≥92%), and whether rates of occult hypoxemia varied by race and ethnic origin. RESULTS A total of 30 039 pairs of SpO2-SaO2 readings made within 10 minutes of each other were identified during the study. These pairs were predominantly among non-Hispanic white (21 918 (73.0%)) patients; non-Hispanic black patients and Hispanic or Latino patients accounted for 6498 (21.6%) and 1623 (5.4%) pairs in the sample, respectively. Among SpO2 values greater or equal to 92%, unadjusted probabilities of occult hypoxemia were 15.6% (95% confidence interval 15.0% to 16.1%) in white patients, 19.6% (18.6% to 20.6%) in black patients (P<0.001 v white patients, with similar P values in adjusted models), and 16.2% (14.4% to 18.1%) in Hispanic or Latino patients (P=0.53 v white patients, P<0.05 in adjusted models). This result was consistent in SpO2-SaO2 pairs restricted to occur within 5 minutes and 2 minutes. In white patients, an initial SpO2-SaO2 pair with little difference in saturation was associated with a 2.7% (95% confidence interval -0.1% to 5.5%) probability of SaO2 <88% on a later paired SpO2-SaO2 reading showing an SpO2 of 92%, but black patients had a higher probability (12.9% (-3.3% to 29.0%)). CONCLUSIONS In general care inpatient settings across the Veterans Health Administration where paired readings of arterial blood gas (SaO2) and pulse oximetry (SpO2) were obtained, black patients had higher odds than white patients of having occult hypoxemia noted on arterial blood gas but not detected by pulse oximetry. This difference could limit access to supplemental oxygen and other more intensive support and treatments for black patients.
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Affiliation(s)
- Valeria S M Valbuena
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA
| | - Sarah Seelye
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Thomas S Valley
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Robert P Dickson
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven E Gay
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Dru Claar
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Hallie C Prescott
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theodore J Iwashyna
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI, USA
- National Clinician Scholars Program, University of Michigan, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
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