Extending the WHO ‘Safe Surgery Saves Lives’ project through Global Oximetry

Pulse oximetry is widely accepted as essential during anaesthesia and its use is considered mandatory in the UK, Canada and the USA, Australia and New Zealand, much of Europe and South America, and many other countries around the world. At present, however, there are still places where oximeters are simply not available [1, 2]. At the World Congress of Anaesthesiologists in Paris in 2004, the Quality and Safety of Practice Committee of the World Federation of Societies of Anaesthesiologists (WFSA) identified the provision of pulse oximeters for use on every patient undergoing anaesthesia in the world as a priority for patient safety. From this grew the Global Oximetry (GO) initiative [3, 4]. Pilot projects have been underway in regions of Uganda, Vietnam, the Philippines and India. The World Health Organization (WHO) has now adopted this mission as a significant component of its Second Global Patient Safety Challenge. This challenge, Safe Surgery Saves Lives (SSSL) [5], launched in 2007, recognised the rising importance of surgery to public health. With increasing urbanisation and longevity, diseases characteristic of industrialised nations are becoming more prevalent even in resource-challenged low income nations and access to safe and effective surgery is increasingly essential for the health of populations worldwide. In 2008, Weiser et al. estimated the number of operations performed annually around the world as in the order of 230 million – double the number of births [6]. Global distribution is uneven: only 3.5% of surgery is undertaken in the poorest third of the world’s population, and this inadequacy of surgical services in many countries leads to the loss of 164 million disability-adjusted life years annually [7]. Even in industrialised countries, where there is generally good access to surgical services, major complication rates (estimated between 3% and 17%) are unacceptably high. Some of these complications are attributable to anaesthesia; many of them are avoidable. Safe surgery depends on (amongst other things) safe anaesthesia. The WHO SSSL initiative intends to improve safety in surgery and anaesthesia on a global scale. Anaesthesia today is typically very safe in high-income countries, where mortality solely attributable to anaesthetic complications has fallen to rates between 1 in 50 000 and 1 in 200 000 [8]. Unfortunately, there are still places where the anaesthesia mortality rate is probably 1000 times higher than this [9]; in such areas most anaesthesia providers tend to have little training and appallingly inadequate resources [10]. Furthermore, these colleagues are often very disempowered, and poorly placed to address the serious deficiencies in the services they are asked to provide for the large numbers of patients in need of surgery. If adequate access to surgery is important for a nation’s health, then so is adequate access to anaesthesia. However, surgery (and particularly elective surgery) is only worthwhile at acceptable limits of safety. No surgeon would attempt to provide an elective surgical service without a basic set of sterile instruments and sutures; safe anaesthesia is just as important and, in the same way, safety requires trained anaesthesia providers in adequate numbers with access to essential equipment and drugs. In the Safe Surgery Saves Lives project [5], the WHO brought together experts in surgery, anaesthesia, perioperative nursing and related disciplines. The task was to develop a strategy for safer surgery globally. The participants met face to face on several occasions during 2007 and 2008, corresponded between meetings, reviewed the relevant evidence, and iteratively developed consensus guidelines, captured in a substantial technical document. A key output was the WHO Surgical Safety Checklist [11]. As part of the development of this work, the International Standards for a Safe Practice of Anaesthesia, developed in the early 1990s, were revised to reflect advances in anaesthesia over the intervening years [12]. A key revision was the recommendation that pulse oximetry should be used in all anaesthetics worldwide. On the basis of this recommendation, oximetry was included as an essential item on the ‘Sign-In’ of the WHO surgical safety checklist. For some, this endorsement of oximetry by the WHO may seem controversial. In this era of evidence-based medicine (EBM), the fact is that hard evidence to support the routine use of pulse oximetry is limited. In fact, a 2002 Cochrane review concluded: ‘... we have found no evidence that pulse oximetry affects the outcome of anaesthesia. The conflicting subjective and objective results of the studies, despite an intense, methodical collection of data from a relatively large population, indicate that the value of peri-operative monitoring with pulse oximetry is questionable in relation to improved reliable outcomes, effectiveness and efficiency.’ [13] It is tempting to ignore this review or, as with the value of parachute use [14], simply to discount it as flying in the face of the obvious. However, a close analysis of this Cochrane review is quite illuminating. The starting point of such an analysis must be an appreciation that ‘evidence’ does not only come from randomised controlled trials. Sackett has defined EBM as ‘the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research’ [15]. We think the 2002 Cochrane review of Pedersen et al. fails Anaesthesia, 2009, 64, pages 1045–1050