• Masahiko Kuroda, Masashi Kawamoto, and Osafumi Yuge.
• Department of Anesthesiology and Critical Care, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan.
• J Anesth. 2005 Jan 1;19(2):164-6.

AbstractWe 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.

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