# Is Pulse Co-Oximetry a Reliable Alternative to Invasive Hemoglobin Measurement in Pediatric Neurosurgical Procedures?

## TL;DR

Non-invasive hemoglobin monitoring overestimates lab values in children during neurosurgery, especially during severe acidosis and low blood pressure, requiring invasive checks for accuracy.

## Contribution

This study evaluates the reliability of non-invasive hemoglobin monitoring in pediatric neurosurgery under extreme physiological conditions.

## Key findings

- Non-invasive hemoglobin monitoring overestimates lab values with significant error during severe metabolic acidosis.
- Hemodynamic instability during hypotension reduces measurement accuracy despite normal perfusion index readings.
- SpHb has 0% sensitivity for detecting critical anemia and should not be used alone to trigger transfusions.

## Abstract

What are the main findings?
•Non-invasive hemoglobin monitoring systematically overestimates laboratory values, with error margins significantly widening during severe metabolic acidosis (Base Excess < −10 mEq/L).•Hemodynamic autoregulation is compromised during hypotensive episodes, creating a pressure-dependent perfusion state that degrades measurement precision even when the Perfusion Index appears clinically normal.

Non-invasive hemoglobin monitoring systematically overestimates laboratory values, with error margins significantly widening during severe metabolic acidosis (Base Excess < −10 mEq/L).

Hemodynamic autoregulation is compromised during hypotensive episodes, creating a pressure-dependent perfusion state that degrades measurement precision even when the Perfusion Index appears clinically normal.

What are the implications of the main findings?
•Clinicians should prioritize SpHb for continuous trend monitoring rather than as a sole trigger for transfusion, particularly in patients with hemodynamic or metabolic instability.•Since “normal” perfusion index values can persist during hypotension and mask instability, non-invasive monitoring must be cross-validated with invasive sampling and metabolic markers.

Clinicians should prioritize SpHb for continuous trend monitoring rather than as a sole trigger for transfusion, particularly in patients with hemodynamic or metabolic instability.

Since “normal” perfusion index values can persist during hypotension and mask instability, non-invasive monitoring must be cross-validated with invasive sampling and metabolic markers.

Background/Objectives: Pediatric neurosurgical procedures often involve significant blood loss and rapid hemodynamic shifts, necessitating accurate hemoglobin (Hb) monitoring. While continuous non-invasive Hb (SpHb) monitoring offers real-time trending, its accuracy in high-risk pediatric populations remains debated. We aimed to evaluate the diagnostic accuracy and clinical utility of SpHb compared to invasive arterial blood gas (ABG) analysis in pediatric patients undergoing cranial and spinal surgeries. Methods: This prospective, observational study enrolled 60 pediatric patients (aged 0–16 years) scheduled for high-risk neurosurgery. SpHb was measured continuously and compared with intermittent ABG-Hb values. Statistical analysis included Bland–Altman agreement, Pearson’s correlation, and Error Grid Analysis. Subgroup analyses assessed the impact of the Perfusion Index (PI), hypotension, and metabolic acidosis on device performance. Results: Data from 57 patients (median age: 12 months, interquartile range: 6–42 months; 70.2% aged <24 months) were analyzed. SpHb demonstrated a moderate correlation with ABG-Hb (r = 0.567, p < 0.001) but exhibited systematic overestimation with a mean bias of +1.60 ± 1.54 g/dL. Crucially, SpHb showed 0% sensitivity for detecting critical anemia (Hb < 8.0 g/dL). Device performance was significantly compromised by physiological extremes: severe metabolic acidosis significantly increased bias to +2.27 g/dL (p = 0.038), and intraoperative hypotension significantly widened the limits of agreement (SD of bias: 1.79 g/dL vs. 1.45 g/dL in normotension). Furthermore, hemodynamic analysis revealed a loss of autoregulation during hypotension, where the pressure-perfusion coupling strengthened (r = 0.44) compared to the normotensive state (r = 0.15). Conclusions: SpHb monitoring provides fair Hb trending but is limited by systematic overestimation and poor sensitivity for critical anemia. Accuracy worsens during severe acidosis and hemodynamic instability. Therefore, SpHb should function as a complementary “early warning” trend monitor rather than a sole transfusion trigger, with invasive validation remaining essential for intraoperative decision-making.