Send to:

Choose Destination
See comment in PubMed Commons below
J Anesth. 2005;19(2):164-6.

Undisrupted pulse wave on pulse oximeter display monitor at cardiac arrest in a surgical patient.

Author information

  • 1Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.


We have encountered a case of cardiac arrest during anesthesia care in which an application of a new-generation pulse oximetry technology led to a misleading interpretation of the patient's true condition. Just after manipulation of the peritoneum, the heart rhythm suddenly became asystole, while the ECG showed a standstill and an arterial pressure wave was absent. However, the Datex-Ohmeda AS/3 Patient Monitor connected to the Masimo SatShare Waveform Generator feature continued to display a pulse wave with a reading of 99%. Because we assumed the reading to be reliable, we took no immediate action. However, the ECG standstill and flattened arterial wave lasted for about 10 s, with no pulse at the common carotid artery; thus, 0.5 mg atropine and 4 mg ephedrine were given and chest compression performed using ventilation with oxygen. About 20 s later, the heart rhythm reappeared, which was monitored by the ECG and arterial pulse wave. This incident demonstrates the importance of becoming familiar with a new technology; otherwise, we will fall into medical errors.

[PubMed - indexed for MEDLINE]
PubMed Commons home

PubMed Commons

How to join PubMed Commons

    Supplemental Content

    Full text links

    Icon for Springer
    Loading ...
    Write to the Help Desk