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What’s New in the Patient Safety World

August 2020

Pulse Oximetry in Children



Anything we can do to reduce the risk of alarm fatigue is welcome. The most obvious one we’ve discussed is eliminating unnecessary telemetry monitoring. But, perhaps the next most obvious one is reducing pulse oximetry alarms that are not clinically important.


Continuous pulse oximetry monitoring is commonly performed in hospitalized children. An expert panel, utilizing the best evidence in the literature plus their own experience, recently utilized a modified Delphi Method to evaluate the need for continuous vs. intermittent pulse oximetry monitoring in a variety of conditions in hospitalized children outside the ICU (Schondelmeyer 2020).


For children with mild or moderate asthma, croup, pneumonia, and bronchiolitis, the panel recommended intermittent vital sign or oximetry measurement only. For those with severe disease in each respiratory condition as well as for a new or increased dose of intravenous opiate or benzodiazepine, the panel recommended continuous monitoring.


Children receiving supplemental oxygen should have continuous oximetry monitoring, but they should be transitioned from continuous monitoring to intermittent monitoring within 1 hour of achieving stable oxygen saturation levels of at least 90%.


We’ve, of course, done many columns on the dangers of respiratory depression by opioids or sedating agents. The panel recommends that intravenous opioid or benzodiazepine therapy requires continuous cardiorespiratory and oximetry monitoring only when there is a new medication or an increased dose of a current medication. Intermittent monitoring is otherwise sufficient.


We’re not so sure about the latter recommendation. Hypoxemia is a relatively late manifestation of drug-induced respiratory depression. Hypercapnia occurs before there is a significant reduction in oxygen saturation in most instances. It’s probably more appropriate to be using capnography to monitor patients receiving drugs that may depress respiration, such as opioids and benzodiazepines. We’ve certainly seen patients become obtunded while they still had good oxygen saturations, even on continuous pulse oximetry monitoring. If capnography is not available in such circumstances, we’d still feel more comfortable using continuous rather than intermittent pulse oximetry.


The panel did acknowledge there is a relative dearth of high quality evidence in the literature, which consists primarily of observational study designs, and that there was little or no evidence for some of the respiratory conditions.


Overall, the panel recommended that intermittent vital sign assessment is appropriate for most mild-moderate forms of childhood respiratory illnesses. For patients weaned from oxygen, transitioning to intermittent oximetry within one hour is appropriate.


There’s no question these new guidelines would significantly reduce alarms on pediatric units and, thus, reduce the risk of alarm fatigue.



Some of our previous columns on opioid safety issues in children:


Prior Patient Safety Tips of the Week pertaining to alarm-related issues:



Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:









Schondelmeyer AC, Dewan ML, Brady PW, et al. Cardiorespiratory and Pulse Oximetry Monitoring in Hospitalized Children: A Delphi Process. Pediatrics 2020; e20193336






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