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Pulse oximetry and high-dose vasopressors: a comparison between forehead reflectance and finger transmission sensors

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Pulse oximetry (SpO2) measured at finger site via transmission mode may fail in situations of hypoperfusion. Forehead sensors using reflectance technology might be useful in these circumstances. We hypothesized that reflectance SpO2 would be more accurate than finger SpO2 in patients with severe shock.


A prospective observational study was conducted in an intensive care unit of a university hospital of patients in shock who were treated with high norepinephrine and/or epinephrine doses (≥0.1 μg kg−1 min−1). When blood gas determinations were requested, forehead SpO2 and finger SpO2 values were simultaneous recorded. Agreement between SpO2 measurements with arterial saturation (SaO2), obtained by blood analysis with a co-oximeter, was assessed using the Bland–Altman method. The number of outliers, defined by the formula SaO2 − SpO2 > ±3 %, indicated the proportion of measurements considered to be clinically unacceptable.


Thirty-two patients were enrolled in the study. With the forehead sensor no reading failure occurred, and 140 paired data sets (forehead SpO2 vs. SaO2) were obtained. Bias and precision were +1.0 and +2.5 %, respectively, and the limits of agreement ranged from −4.0 to 6.0 %. The finger sensor failed to give a value in four cases, thus providing 136 paired data sets (finger SpO2 vs. SaO2) for analysis. Bias and precision were +1.4 and +4.8 %, respectively, and the limits of agreement ranged from −8.0 to 10.9 %. There were 21 (15 %) outliers for the forehead sensor and 43 (32 %) for the finger sensor (P < 0.001).


Forehead SpO2 measurements were more accurate than finger SpO2 when compared with SaO2 in critically ill patients requiring high-dose vasopressor therapy and should therefore be the preferred method considered.

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  1. Seguin P, Le Rouzo A, Tanguy M, Guillou YM, Feuillu A, Malledant Y (2000) Evidence for the need of bedside accuracy of pulse oximetry in an intensive care unit. Crit Care Med 28:703–706

    Article  PubMed  CAS  Google Scholar 

  2. Jubran A (2004) Pulse oximetry. Intensive Care Med 30:2017–2020

    Article  PubMed  Google Scholar 

  3. Severinghaus JW, Kelleher JF (1992) Recent developments in pulse oximetry. Anesthesiology 76:1018–1038

    Article  PubMed  CAS  Google Scholar 

  4. Sinex JE (1999) Pulse oximetry: principles and limitations. Am J Emerg Med 17:59–67

    Article  PubMed  CAS  Google Scholar 

  5. Eisenkraft JB (2006) Forehead pulse oximetry: friend and foe. Anesthesiology 105:1075–1077

    Article  PubMed  Google Scholar 

  6. Palve H (1992) Reflection and transmission pulse oximetry during compromised peripheral perfusion. J Clin Monit 8:12–15

    Article  PubMed  CAS  Google Scholar 

  7. Casati A, Squicciarini G, Baciarello M, Putzu M, Salvadori A, Fanelli G (2007) Forehead reflectance oximetry: a clinical comparison with conventional digit sensors during laparotomic and laparoscopic abdominal surgery. J Clin Monit Comput 21:271–276

    Article  PubMed  Google Scholar 

  8. Sugino S, Kanaya N, Mizuuchi M, Nakayama M, Namiki A (2004) Forehead is as sensitive as finger pulse oximetry during general anesthesia. Can J Anaesth 51:432–436

    Article  PubMed  Google Scholar 

  9. Wax DB, Rubin P, Neustein S (2009) A comparison of transmittance and reflectance pulse oximetry during vascular surgery. Anesth Analg 109:1847–1849

    Article  PubMed  Google Scholar 

  10. MacLeod DB, Cortinez LI, Keifer JC, Cameron D, Wright DR, White WD, Moretti EW, Radulescu LR, Somma J (2005) The desaturation response time of finger pulse oximeters during mild hypothermia. Anaesthesia 60:65–71

    Article  PubMed  CAS  Google Scholar 

  11. Fernandez M, Burns K, Calhoun B, George S, Martin B, Weaver C (2007) Evaluation of a new pulse oximeter sensor. Am J Crit Care 16:146–152

    PubMed  Google Scholar 

  12. Schallom L, Sona C, McSweeney M, Mazuski J (2007) Comparison of forehead and digit oximetry in surgical/trauma patients at risk for decreased peripheral perfusion. Heart Lung 36:188–194

    Article  PubMed  Google Scholar 

  13. Agashe GS, Coakley J, Mannheimer PD (2006) Forehead pulse oximetry: headband use helps alleviate false low readings likely related to venous pulsation artifact. Anesthesiology 105:1111–1116

    Article  PubMed  Google Scholar 

  14. Carstensen B (2004) Comparing and predicting between several methods of measurement. Biostatistics 5:399–413

    Article  PubMed  Google Scholar 

  15. Ibanez J, Velasco J, Raurich JM (1991) The accuracy of the Biox 3700 pulse oximeter in patients receiving vasoactive therapy. Intensive Care Med 17:484–486

    Article  PubMed  CAS  Google Scholar 

  16. Van de Louw A, Cracco C, Cerf C, Harf A, Duvaldestin P, Lemaire F, Brochard L (2001) Accuracy of pulse oximetry in the intensive care unit. Intensive Care Med 27:1606–1613

    Article  PubMed  Google Scholar 

  17. Wilson BJ, Cowan HJ, Lord JA, Zuege DJ, Zygun DA (2010) The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock: a retrospective cohort study. BMC Emerg Med 10:9

    Article  PubMed  Google Scholar 

  18. Smithline HA, Rudnitzky N, Macomber S (2010) Blank FS Pulse oximetry using a disposable finger sensor placed on the forehead in hypoxic patients. J Emerg Med 39:121–125

    Article  PubMed  Google Scholar 

  19. Landry DW, Oliver JA (2001) The pathogenesis of vasodilatory shock. N Engl J Med 345:588–595

    Article  PubMed  CAS  Google Scholar 

  20. Secker C, Spiers P (1997) Accuracy of pulse oximetry in patients with low systemic vascular resistance. Anaesthesia 52:127–130

    Article  PubMed  CAS  Google Scholar 

  21. Lamhaut L, Apriotesei R, Combes X, Lejay M, Carli P, Vivien B (2011) Comparison of the accuracy of noninvasive hemoglobin monitoring by spectrophotometry (SpHb) and HemoCue®) with automated laboratory hemoglobin measurement. Anesthesiology 115:548–554

    Article  PubMed  CAS  Google Scholar 

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The authors thank Véronique Sébille, PhD (Biostatistics Unit, EA 4275, Pharmacy University of Nantes, Nantes, France), for statistical support. Financial support was obtained from institutional and/or departmental sources. Devices (forehead pulse oximetry sensors) were donated by Covidien, Tyco/Healthcare France.

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Correspondence to Nicolas Nesseler.

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Nesseler, N., Frénel, JV., Launey, Y. et al. Pulse oximetry and high-dose vasopressors: a comparison between forehead reflectance and finger transmission sensors. Intensive Care Med 38, 1718–1722 (2012).

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