Neurocirugía
2008 19: 121-126

Preliminary report on surgical mask induced deoxygenation during major
surgery*
A. Beder; *Ü. Büyükkoçak; **H. Sabuncuoğlu; ***Z.A. Keskil and ****S. KeskilBaşkent University. Faculty of Health Sciences. Department of Nursing and Health Services. Ankara, Turkey; *Kirikkale University. Faculty ofMedicine. Departments of Anaesthesiology and Pharmacology***. Kirikkale. Turkey. **Ufuk University, Faculty of Medicine, Department ofNeurosurgery. Ankara, Turkey. ****Bayindir Medical Center, Department of Neurosurgery. Ankara. Turkey.

Summary
Objectives. This study was undertaken to evaluate
whether the surgeons' oxygen saturation of hemoglobin
was affected by the surgical mask or not during major
operations.
Methods. Repeated measures, longitudinal and prospective observational study was performed on 53 surgeons using a pulse oximeter pre and postoperatively.
Results. Our study revealed a decrease in the oxygen
saturation of arterial pulsations (SpO2) and a slightincrease in pulse rates compared to preoperative values
in all surgeon groups. The decrease was more prominent in the surgeons aged over 35.
Conclusions. Considering our findings, pulse ratesof the surgeon's increase and SpO2 decrease after thefirst hour. This early change in SpO2 may be either due
to the facial mask or the operational stress. Since a verysmall decrease in saturation at this level, reflects a large
decrease in PaO2, our findings may have a clinical value
for the health workers and the surgeons.
KEY WORDS: Surgery. Surgical Mask. Oxygenation.
Operation. Oxygen saturation. Facemask.
Comunicación preliminar sobre desoxigenación inducida por la mascarilla quirúrgica durante la cirugía delarga duración
ResumenObjetivos. Este estudio se realizó para determinar sila saturación de oxígeno del cirujano se afectaba porel uso de la mascarilla, durante intervenciones de larga
duración.
Métodos. Se hizo un estudio longitudinal y prospectivo en 53 cirujanos con medidas de la hemoglogina realizadas con un oxímetro para medir la saturación del pulso arterial. Se hicieron estudios antes yRecibido: 13-03-07. Aceptado: 6-06-07

después de la operación.
Resultados. Nuestro estudio puso de manifiesto una
disminución de la saturación de oxígeno de las pulsaciones arteriales (SpO2) y un ligero aumento de las pulsaciones en comparación con el estado preoperatorio
en todos los grupos de cirujanos. La disminución era
mayor en el grupo de edad superior a los 35 años.
Conclusiones. Según nuestros hallazgos, el ritmodel pulso aumenta y la concentración de SpO2 disminuye después de la primera hora de la operación. Estecambio temprano de SpO2 puede deberse a la mascarilla o al estrés de la intervención. Puesto que un ligero
descenso en la saturación a este nivel refleja una mayor
disminución de la PaO2, nuestros datos pueden tener unvalor clínico para la salud del personal sanitario y paralos cirujanos.
PALABRAS CLAVE: Cirugía. Oxigenación. Operación.
Saturación de oxígeno. Mascarilla.
Introduction
Soon after the introduction of surgical masks by Mikulicz5 in 1897, their usage in the operating theatre became astandard practice. Although there appears to be a shift froma patient-protective standpoint to a healthcare worker-protective standpoint in recent years, it is generally acceptedthat operating theatre staff has to wear surgical masks
and change it partway through long procedures (4 hr ormore)6.
Surgeons in the operating room frequently experience
physical discomfort, fatigue, and possibly even deterioration of surgical judgment and performance. Although considerable information exists about the effects of ambientenvironment on both mental and physical performance,
the final "personal" environment for the surgeon beneaththe surgical mask is often very inadequately conditioned*The work was done in the surgical theaters of Kirikkale University, Faculty of Medicine and Fatih University, Faculty ofMedicine

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2008; 19: 121-126

Beder and coldespite the universal air-conditioning standard of operating
theaters. Thus they either wear masks improperly or refrainfrom using them altogether. As it is known that heat andmoisture trapping occur beneath surgical masks, it seems
reasonable that some of the exhaled CO2 may also be trapped beneath them, inducing a decrease in blood oxygenation.
“Normal blood O2 saturation” is usually defined as afractional saturation of 90 to 97.5%, which corresponds
to an arterial oxygen partial pressure of 13.3 to 13.7 kPa,
if there are no other hemoglobin species, apart from oxyand reduced hemoglobin. A pulse oximeter can detect theoxygen saturation of hemoglobin quickly, in an accurate,
and reliable way. Pulse oximeters combine oximetry andplethysmography to measure arterial oxygen saturation,noninvasively. According to Lambert Beer Law, oxygenated and reduced hemoglobin absorb red and infrared lightdifferently. Oxyhemoglobin absorbs more infrared light,
while reduced hemoglobin absorbs more red light. Theratio of absorptions at the red and infrared wavelengths
is analyzed by oximetry to give the oxygen saturation ofarterial pulsations4.
The primary focus of this study was to measure the surgeons’ oxygenation status while they were engaged in their
daily routine activities of major operations.
Materials and methods
53 surgeons from both sexes, employed at university
hospitals, 24 to 54 years old, non-smokers and without any
chronic lung disease were studied by pulse oximetry before
and after the course of an operation. They were hemodynamically stable, breathing room air and standing throughout
the operations.
The groups were formed according to the duration of
the operations:
I. Duration of the operations was up to 60 minutes,
Ia: group wearing mask (n=5)
Ib: group of surgeons who did not wear mask
during primary care operations with duration ofless than 30 minutes (n=9)
II. Duration of the operations was in between 60-120
minutes (n=25).
III. Duration of the operations was in between 120-180
minutes (n=23).
IV. Duration of the operations was in between 180-240
minutes (n=20).
In order to estimate whether age has any effect on
oxygen saturation of hemoglobin and pulse rate, surgeons
were also divided into two age groups according to themedian age: Surgeons under the age of 35 (n=25) and surgeons over the age of 35 (n=28). The surgeon age could not
be used as a covariate in regression analysis due to sparsity
122of the data.
Disposable sterile one-way surgical paper masks (Surgical Face Mask SLM/B, Sterilife, Yozgat, Turkey) wereused and the mask position did not vary during the procedures (never below the nose). The same pulse oximeterwith a reusable clip type finger probe (Cardiocap/5, DatexOhmeda, Helsinki, Finland) was used to measure the blood
O2 saturation during the study. Participants were encouraged to speak and behave in their usual manner throughout
the operation. To eliminate the effect of dehydration overa several hour case on both pulse rate and O2 saturation,
the surgeons were allowed after every hour to drink water
through a straw. For all measurements, finger probe wasapplied to the second finger of the right hand. The study
was performed for over a 3-month period extending fromMarch to May, while the operating room ambient temperature varied from 18 to 20°C, and the relative humidity from35 to 40%.
Just before the operation, oxygen saturation and pulse
rate values were recorded. At the end of the operation,pulse oximeter was applied again and the values wererecorded. As the sham group, same surgeons were individually reassessed in the following days before and after
exactly the same periods (between preoperational and post
operational measurements) while they were standing in theoperating room with their sterile gowns as an observer, notperforming surgery and not wearing masks to obtain the precontrol and post control values.
Paired and unpaired Student's t test were employedwhen comparing two groups such as pre and post operational values. The differences between the groups -morethan two- were statistically evaluated using Kruskal-Wallis
analysis of variance and than post hoc Dunn's test. Data areexpressed as mean ± standard error of mean (S.E.M.). Conditions were considered to be statistically significant whenp<0.05.
Results
When the values for oxygen saturation of hemoglobin
were compared, there were statistically significant differences only between preoperational and post operational
values (Fig. 1). As the duration of the operation increases,
oxygen saturation of hemoglobin decreases significantly.
Neither preoperational values, nor the post operational
values in themselves were different among the groups. In
the group of surgeons who did not wear masks during primary care operations with duration of less than 30 minutes,
preoperational saturation values were 97.6±0.2 while post
operational values decreased to 96.3±0.3 (p=0.0006).
When preoperational and post operational pulse rates
were compared, it was observed that pulse rate increased
after the operations, and there was a statistically significant

Preliminary report on surgical mask induced deoxygenation during major surgery

Neurocirugía
2008; 19: 121-126

Figure 1. The changes in the oxygen saturation of hemoglobin by the duration of surgical operations. Data are expressed as mean ± S.E.M.of n surgical operations. There were statistically significant differences only between preoperational and post
operational values. ** p<0.01, *** p<0.0001

Figure 2: The changes in pulse rates by the duration of surgical operations. Data are expressed as mean ± S.E.M. of n surgical ope-rations. There was a statistica-lly significant difference only in the group in which operation duration was 180-240
minutes. * p<0.05.
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2008; 19: 121-126

Beder and col

Figure 3. a: Effect of age on oxygen saturation of hemoglobin. ** p<0.01, * * * p<0.0001.
b: Effect of age on pulse rates. * p<0.05.
difference only in the group in which operation duration
was 180-240 minutes (p=0.02) (Fig. 2). Neither preoperational values, nor post operational values in themselves
were different in the groups.
There was not any statistically significant difference
between pre control and post control values of pulse rates
and oxygen saturations (SpO2) of the same surgeons,
without facial masks while not performing surgery (Fig 1).
124

Oxygen saturation of hemoglobin decreased significantly after the operations in both age groups (p<0.0001).
The post operational decrease was more prominent in surgeons over 35 when compared to the surgeons under 35(p=0.0073) (Fig. 3 a).
It was observed that pulse rate decreases by age. Bothpreoperational and post operational pulse rates were significantly different between the two age groups (p=0.0287Preliminary report on surgical mask induced deoxygenation during major surgery

and p=0.0124 respectively) (Fig 3 b). Under the age of35, pulse rate increases significantly after the operations(p=0.0207).
Discussion
Although decrease in both mental - physical performance and accuracy may sometimes be overcome by themotivation of the surgeon, increased fatigue is common inlengthy operations. The increased endogenous heat production of the surgeon, as well as many aspects of the operating room situation -even the close environment beneaththe surgical mask- may also negatively affect the working
condition of the surgeon. Surgical masks may impose somemeasurable airway resistance, but it seems doubtful if thissignificantly increases the process of breathing. Although
it might have appeared to be likely that hypoxemia resultsfrom the increased CO2 content of the inspired air1 due tothe exhaled CO2 getting trapped beneath the surgical facemask; there has been no controlled study concerning withthe effect of surgical masks on the level of blood oxygenation. In this study we have measured the oxygen saturationof arterial pulsations (SpO2) by a pulse oximeter and founda statistically significant decrease in the blood O2 saturationlevel of the surgeons post operationally, which is not due toprolonged standing or stress.
Pulse oximetry, nowadays considered as a standard ofclinical care, is a non-invasive method used to measurearterial oxygen saturation with a clinically acceptableaccuracy. Since pulse oximeters cannot be calibrated by
the user, their performances had been evaluated underboth normal (good perfusion, saturation within a normal
range and no interfering substances or extraneous factors)
and adverse conditions. Despite some performance limitations in the settings of carboxyhemoglobinemia, motion
artifact, presence of intravascular dyes, change in systemic
vascular resistance, hypotension, nail polish, vasoconstriction, and anemia2,7, it has been shown that age, gender,
weight, body temperature, hemoglobin concentration andpulse pressure have little effect on the accuracy of pulse
oximeters in detecting hypoxemia8. The majority of pulse
oximeters have an absolute mean error of less than 1.0%
when compared to in vitro saturation measurements3,9.
Pulse oximeters are limited by their software so as not togive a saturation reading greater than 100%, and this limits
the potential for positive errors and makes bias and precision calculations difficult to interpret in this high range.
As the sigmoid shape of the blood oxygen dissociation
curve flattens out at this high saturation levels (>90%) andsince even a very small decrease in saturation at this levelreflects a large decrease in PaO2; our findings may have aclinical value for the health worker-surgeon: The surgeon's
post operational blood O2 saturation level is decreased

Neurocirugía
2008; 19: 121-126

more than 1% although the variability of the saturation
sensors is less than 1%. It is thought that after a very
short time the barrier function of the surgical face mask
is gone6. Thus it is hard to believe that these masks serve
as a reducer of oxygen uptake, but they may be acting asa psychological restriction over spontaneous breathing of
the active surgeon.
Considering our findings, this is the first clinical investigation reporting a decrease in blood O2 saturation and anincrease in pulse rates of the surgeons after the operations
due to surgical mask usage. This change in SpO2 may beeither due to the facial mask or the operational stress, sincesimilar changes were observed in the group performing
surgery without a mask. However, it cannot be decided
whether stress plays any role on the late changes, namely
pulse rate increase and SpO2 level decrease; since surgeons
are not allowed to perform major surgery without a facialmask in most institutions. In order to better elucidate theeffects of stress, a randomized control study should havebeen conducted in a more controlled environment withdifferent sorts of workers from different gender who areor are not used to wearing face masks on (such as anesthesiologists, nurses) also working the same durations. Thus,
it is important not to generalize the results of this preliminary study, and further studies involving measurement ofgas tensions over time, both from blood and from samples
obtained under the mask (in order to show a presumedbuild-up of CO2 under the mask) have to be carried out toelucidate this issue.
References
1. Beck, W.C.: The air permeability of surgical masks.
Guthrie Clin Bull 1964; 34: 26.
2. Jensen, L.A., Onyskiw, J.E., Prasad, N.G.: Meta-analysis of arterial oxygen saturation monitoring by pulse oximetryin adults. Heart Lung 1998; 27: 387-408.
3. Kagle, D.M., Alexander, C.M., Berko, R.S., et al.: Evaluation of the Ohmeda 3700 pulse oximeter: steady state andtransient response characteristics. Anaesthesiology 1987; 66:376-380.
4. Mayers, J.R.: Patient Monitors. In: Morgan EG, MikhailMS, Murray MJ, Larson CP (eds). Clinical Anesthesiology. 3rded, Lange; Mc Graw Hill, 2002; pp.86-126
5. Mikulicz, J.: Das Operieren in sterilisierten Zwirnhandschuhen und mit Mundbinde. Centralblatt für Chirurgie
1897; 26: 714-717. (cited in ref. No. 6).
6. Romney, M.G.: Surgical face masks in the operating
theatre: re-examining the evidence. Journal of Hospital Infection 2001; 47: 251-256.
7. Sinex, J.E.: Pulse oximetry: principles and limitations.
Am J Emerg Med 1999; 17: 59-67.
8. Villanueva, R., Bell, C., Kain, Z.N., et al.: Effect of peri-125

Beder and colpheral perfusion on accuracy of pulse oximetry in children. J
Clin Anesth 1999; 11: 317-322.
9. Webb, R.K., Ralston, A.C., Runciman, W.B.: Potential errors in pulse oximetry. Anaesthesia 1991; 46: 207212.

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2008; 19: 121-126

Beder, A.; Büyükkoçak, Ü.; Sabuncuoğlu, H.; Keskil, Z.A.;
Keskil, S.: Preliminary report on surgical mask induced
deoxygenation during major surgery. Neurocirugía 2008;
19: 121-126.
Corresponding author: Prof. Dr. Semih Keskil, M.D., Ph.D.
Fethiye Sokak No: 4/6. Gazi Osman Pasa. 06700 Ankara Turkey.