Accuracy and trending ability of hemoglobin measurement by the Pulse CO-Oximeter during vascular surgery

  • Rosanna Carmela De Rosa
  • Giovanni Marco RomanoEmail author
  • Roberta Abbate
  • Antonio Corcione
  • Edoardo De Robertis
Original Research


Real time information of Hb concentration can guide a tailored patient blood management. The study investigates the accuracy, precision and trending ability of the Pulse CO-Oximeter (SpHb) and blood gas analyzer in measuring the Hb concentration, compared to hematological analysis, in surgery at high risk of hemorrhage. We performed an observational study, involving 48 patients undergoing abdominal aortic open surgery. The primary endpoints of the study were to compare the accuracy in measuring the Hb concentration using non-invasive method (Masimo rainbow SET® Radical 7 Pulse CO-Oximetry™) compared to the values provided by invasive conventional blood gas analyzer and hematological analysis. The secondary endpoint was to compare the differences between the baseline and the final value of the Hb after surgery (Δ-values), as well as the trending ability. Bias (precision) for the SpHb was 1.63 g/dL (± 0.05) with 95% limits of agreement between 0.85 and + 2.4 g/dL, while for the blood gas analyzer was 0.69 g/dL (± 0.04) with 95% limits of agreement between 0.07 and 1.3 g/dL. Δ-values values were not statistically different from the reference values of ΔHb obtained with the hematological analysis. Trending ability was good for both Pulse CO-Oximeter and blood gas analysis. Our results have shown that the SpHb is not precise enough to replace an invasive approach, but the trending ability of SpHb is accurate and may provide important information on the changes in hemoglobin concentration to guide blood management.


Blood transfusion Hemoglobin Hemorrhage Point-of-care systems 


Author contributions

Rosanna Carmela De Rosa has designed the study, collected data, contributed to the statistical analysis and to the draft of the manuscript. Giovanni Marco Romano has designed the study, collected data, contributed to the statistical analysis and to the draft of the manuscript. Roberta Abbate has designed the study, collected data, and contributed to the draft of the manuscript. Edoardo De Robertis has designed the study, contributed to the statistical analysis and to the draft of the manuscript. Antonio Corcione has contributed to writing and reviewing the manuscript.

Compliance with ethical standards

Conflicts of interest

Rosanna Carmela De Rosa and Edoardo De Robertis were speakers in Masimo sponsored symposia.


  1. 1.
    Cecconi M, Corredor C, Arulkumaran N, Abuella G, Ball J, Grounds RM, et al. Clinical review: goal-directed therapy—what is the evidence in surgical patients? The effect on different risk groups. Crit Care. 2013;17:209.CrossRefGoogle Scholar
  2. 2.
    Gupta PK, Sundaram A, Mactaggart JN, Johanning JM, Gupta H, Fang X, et al. Preoperative anemia is an independent predictor of postoperative mortality and adverse cardiac events in elderly patients undergoing elective vascular operations. Ann Surg. 2013;258:1096–102.CrossRefGoogle Scholar
  3. 3.
    Berkow L. Factors affecting hemoglobin measurement. J Clin Monit Comput. 2013;27:499–508.CrossRefGoogle Scholar
  4. 4.
    Bourner G, Dhaliwal J, Sumner J. Performance evaluation of the latest fully automated hematology analyzers in a large, commercial laboratory setting: a 4-way, side-by-side study. Lab Hematol. 2005;11:285–97.CrossRefGoogle Scholar
  5. 5.
    Feiner JR, Bickler PE, Mannheimer PD. Accuracy of methemoglobin detection by pulse CO-oximetry during hypoxia. Anesth Analg. 2010;111:143–8.CrossRefGoogle Scholar
  6. 6.
    Butwick A, Hilton G, Carvalho B. Non-invasive haemoglobin measurement in patients undergoing elective Caesarean section. Br J Anaesth. 2012;108:271–7.CrossRefGoogle Scholar
  7. 7.
    Frasca D, Dahyot-Fizelier C, Catherine K, Levrat Q, Debaene B, Mimoz O. Accuracy of a continuous noninvasive hemoglobin monitor in intensive care unit patients. Crit Care Med. 2011;39:2277–82.CrossRefGoogle Scholar
  8. 8.
    Giraud B, Frasca D, Debaene B, Mimoz O. Comparison of haemoglobin measurement methods in the operating theatre. Br J Anaesth. 2013;111:946–54.CrossRefGoogle Scholar
  9. 9.
    Vos JJ, Kalmar AF, Struys MMRF, Porte RJ, Wietasch JKG, Scheeren TWL, et al. Accuracy of non-invasive measurement of haemoglobin concentration by pulse co-oximetry during steady-state and dynamic conditions in liver surgery. Br J Anaesth. 2012;109:522–8.CrossRefGoogle Scholar
  10. 10.
    Patino M, Schultz L, Hossain M, Moeller J, Mahmoud M, Gunter J, et al. Trending and accuracy of noninvasive hemoglobin monitoring in pediatric perioperative patients. Anesth Analg. 2014;119:920–5.CrossRefGoogle Scholar
  11. 11.
    Erdogan Kayhan G, Colak YZ, Sanli M, Ucar M, Toprak HI. Accuracy of non-invasive hemoglobin monitoring by pulse CO-oximeter during liver transplantation. Minerva Anestesiol. 2017;83:485–92.Google Scholar
  12. 12.
    Zeng R, Svensen CH, Li H, Xu X, Skoog Svanberg A, Liu H, et al. Can noninvasive hemoglobin measurement reduce the need for preoperative venipuncture in pediatric outpatient surgery? Paediatr Anaesth. 2017;27:1131–5.CrossRefGoogle Scholar
  13. 13.
    Khalafallah AA, Chilvers CR, Thomas M, Chilvers CM, Sexton M, Vialle M, et al. Usefulness of non-invasive spectrophotometric haemoglobin estimation for detecting low haemoglobin levels when compared with a standard laboratory assay for preoperative assessment. Br J Anaesth. 2015;114:669–76.CrossRefGoogle Scholar
  14. 14.
    Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet. 1986;1:307–10.CrossRefGoogle Scholar
  15. 15.
    Bland JM, Altman DG. Measurement error and correlation coefficients. BMJ. 1996;313:41–2.CrossRefGoogle Scholar
  16. 16.
    Myles PS, Cui J. Using the Bland-Altman method to measure agreement with repeated measures. Br J Anaesth. 2007;99:309–11.CrossRefGoogle Scholar
  17. 17.
    Morey TE, Gravenstein N, Rice MJ. Let’s think clinically instead of mathematically about device accuracy. Anesth Analg. 2011;113:89–91.CrossRefGoogle Scholar
  18. 18.
    Critchley LA, Lee A, Ho AMH. A critical review of the ability of continuous cardiac output monitors to measure trends in cardiac output. Anesth Analg. 2010;111:1180–92.CrossRefGoogle Scholar
  19. 19.
    Critchley LA, Yang XX, Lee A. Assessment of trending ability of cardiac output monitors by polar plot methodology. J Cardiothorac Vasc Anesth. 2011;25:536–46.CrossRefGoogle Scholar
  20. 20.
    Skelton VA, Wijayasinghe N, Sharafudeen S, Sange A, Parry NS, Junghans C. Evaluation of point-of-care haemoglobin measuring devices: a comparison of Radical-7™ pulse co-oximetry, HemoCue(®) and laboratory haemoglobin measurements in obstetric patients*. Anaesthesia. 2013;68:40–5.CrossRefGoogle Scholar
  21. 21.
    Miller RD, Ward TA, McCulloch CE, Cohen NH. Does a digital regional nerve block improve the accuracy of noninvasive hemoglobin monitoring? J Anesth. 2012;26:845–50.CrossRefGoogle Scholar
  22. 22.
    Mannheimer PD. The light-tissue interaction of pulse oximetry. Anesth Analg. 2007;105:S10–7.CrossRefGoogle Scholar
  23. 23.
    Severinghaus JW, Astrup PB. History of blood gas analysis. VI. Oximetry. J Clin Monit. 1986;2:270–88.CrossRefGoogle Scholar
  24. 24.
    Shamir MY, Avramovich A, Smaka T. The current status of continuous noninvasive measurement of total, carboxy, and methemoglobin concentration. Anesth Analg. 2012;114:972–8.CrossRefGoogle Scholar
  25. 25.
    Macknet MR, Allard M, Applegate RL, Rook J. The accuracy of noninvasive and continuous total hemoglobin measurement by pulse CO-Oximetry in human subjects undergoing hemodilution. Anesth Analg. 2010;111:1424–6.CrossRefGoogle Scholar
  26. 26.
    Berkow L, Rotolo S, Mirski E. Continuous noninvasive hemoglobin monitoring during complex spine surgery. Anesth Analg. 2011;113:1396–402.CrossRefGoogle Scholar
  27. 27.
    Hiscock R, Kumar D, Simmons SW. Systematic review and meta-analysis of method comparison studies of Masimo pulse co-oximeters (Radical-7™ or Pronto-7™) and HemoCue® absorption spectrometers (B-Hemoglobin or 201+) with laboratory haemoglobin estimation. Anaesth Intensive Care. 2015;43:341–50.CrossRefGoogle Scholar
  28. 28.
    Kim S-H, Lilot M, Murphy LS, Sidhu KS, Yu Z, Rinehart J, et al. Accuracy of continuous noninvasive hemoglobin monitoring: a systematic review and meta-analysis. Anesth Analg. 2014;119:332–46.CrossRefGoogle Scholar
  29. 29.
    Yang ZW, Yang SH, Chen L, Qu J, Zhu J, Tang Z. Comparison of blood counts in venous, fingertip and arterial blood and their measurement variation. Clin Lab Haematol. 2001;23:155–9.CrossRefGoogle Scholar
  30. 30.
    Gehring H, Duembgen L, Peterlein M, Hagelberg S, Dibbelt L. Hemoximetry as the “gold standard”? Error assessment based on differences among identical blood gas analyzer devices of five manufacturers. Anesth Analg. 2007;105:S24–30.CrossRefGoogle Scholar
  31. 31.
    Patel KP, Hay GW, Cheteri MK, Holt DW. Hemoglobin test result variability and cost analysis of eight different analyzers during open heart surgery. J Extra Corpor Technol. 2007;39:10–7.Google Scholar
  32. 32.
    Barker SJ, Shander A, Ramsay MA. Continuous noninvasive hemoglobin monitoring: a measured response to a critical review. Anesth Analg. 2016;122:565–72.CrossRefGoogle Scholar
  33. 33.
    Adel A, Awada W, Abdelhamid B, Omar H, Abd-El-Dayem O, Hasanin A, et al. Accuracy and trending of non-invasive hemoglobin measurement during different volume and perfusion statuses. J Clin Monit Comput. 2018;32(6):1025–31.CrossRefGoogle Scholar
  34. 34.
    Colquhoun DA, Forkin KT, Durieux ME, Thiele RH. Ability of the Masimo pulse CO-Oximeter to detect changes in hemoglobin. J Clin Monit Comput. 2012;26:69–73.CrossRefGoogle Scholar
  35. 35.
    Marques NR, Kramer GC, Voigt RB, Salter MG, Kinsky MP. Trending, accuracy, and precision of noninvasive hemoglobin monitoring during human hemorrhage and fixed crystalloid bolus. Shock. 2015;44(Suppl 1):45–9.CrossRefGoogle Scholar
  36. 36.
    Miller RD, Ward TA, Shiboski SC, Cohen NH. A comparison of three methods of hemoglobin monitoring in patients undergoing spine surgery. Anesth Analg. 2011;112:858–63.CrossRefGoogle Scholar
  37. 37.
    Applegate RL, Barr SJ, Collier CE, Rook JL, Mangus DB, Allard MW. Evaluation of pulse cooximetry in patients undergoing abdominal or pelvic surgery. Anesthesiology. 2012;116:65–72.CrossRefGoogle Scholar
  38. 38.
    Hinkelbein J, Genzwuerker HV, Fiedler F. Detection of a systolic pressure threshold for reliable readings in pulse oximetry. Resuscitation. 2005;64:315–9.CrossRefGoogle Scholar
  39. 39.
    Hinkelbein J, Genzwuerker HV, Sogl R, Fiedler F. Effect of nail polish on oxygen saturation determined by pulse oximetry in critically ill patients. Resuscitation. 2007;72:82–91.CrossRefGoogle Scholar
  40. 40.
    Hinkelbein J, Koehler H, Genzwuerker HV, Fiedler F. Artificial acrylic finger nails may alter pulse oximetry measurement. Resuscitation. 2007;74:75–82.CrossRefGoogle Scholar
  41. 41.
    Bergek C, Zdolsek JH, Hahn RG. Accuracy of noninvasive haemoglobin measurement by pulse oximetry depends on the type of infusion fluid. Eur J Anaesthesiol. 2012;29:586–92.Google Scholar
  42. 42.
    Park Y-H, Lee J-H, Song H-G, Byon H-J, Kim H-S, Kim J-T. The accuracy of noninvasive hemoglobin monitoring using the radical-7 pulse CO-Oximeter in children undergoing neurosurgery. Anesth Analg. 2012;115:1302–7.CrossRefGoogle Scholar
  43. 43.
    Awada WN, Mohmoued MF, Radwan TM, Hussien GZ, Elkady HW. Continuous and noninvasive hemoglobin monitoring reduces red blood cell transfusion during neurosurgery: a prospective cohort study. J Clin Monit Comput. 2015;29:733–40.CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  • Rosanna Carmela De Rosa
    • 1
  • Giovanni Marco Romano
    • 2
    Email author
  • Roberta Abbate
    • 1
  • Antonio Corcione
    • 1
  • Edoardo De Robertis
    • 3
  1. 1.Department of Anesthesia, and Postoperative Intensive Care UnitAORN dei Colli – MonaldiNaplesItaly
  2. 2.Department of Anesthesia and Intensive Care UnitAORN CardarelliNaplesItaly
  3. 3.Department of Surgical and Biomedical SciencesUniversity of PerugiaPerugiaItaly

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