UHM 2016, Vol. 43, No.

1 INACCURATE SpCO FROM DIGITAL CLUBBING: CASE REPORT

Inaccurate pulse CO-oximetry of carboxyhemoglobin due to digital clubbing:

case report
Nicole Harlan, M.D. 1, Lindell K. Weaver, M.D., FACP, FCCP, FCCM, FUHM 1,2,3,
Kayla Deru 2
1 Department

of Anesthesiology, Center for Hyperbaric Medicine and Environmental Physiology, Duke University
Medical Center, Durham, North Carolina U.S.
2 Division of Hyperbaric Medicine, Intermountain Medical Center, Murray, Utah and Intermountain LDS Hospital,
Salt Lake City, Utah U.S.
3 University of Utah School of Medicine, Salt Lake City, Utah U.S.
CORRESPONDING AUTHOR: Lindell K. Weaver Lindell.Weaver@imail.org
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ABSTRACT

Newer pulse CO-oximeters provide a non-invasive

and quick means of measuring oxyhemoglobin,
carboxyhemoglobin and methemoglobin. Clubbing
has been reported to cause inaccuracy in pulse oximeters. We present a case of inaccurate carboxyhemoglobin measurement by pulse CO-oximetry
due to digital clubbing.
An 18-year-old man with a history of cystic fibrosis
presented after a suicide attempt by inhalation of
exhaust. At the initial emergency department evaluation, his blood carboxyhemoglobin was 33%. He
was intubated, placed on 100% oxygen and transferred to our facility. Upon arrival, we placed three
different pulse CO-oximeters on different fingers

and toes. Carboxyhemoglobin levels measured by

these meters ranged from 9%-11%. A venous blood
gas drawn on arrival showed a carboxyhemoglobin
level of 2.3% after four hours on 100% oxygen by
endotracheal tube. Thirty minutes later, we checked
arterial blood gas, which revealed a COHb level of
0.9%. Again, non-invasive carboxyhemoglobin measurements read 10%. The patient was treated with
hyperbaric oxygen for carbon monoxide poisoning.
This case suggests that non-invasive measurements
of carboxyhemoglobin should be correlated with the
clinic history and with an arterial or venous blood
gas oximetry analysis.

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INTRODUCTION
Digital clubbing occurs in many syndromes, but is often related to chronic hypoxia [1]. Its pathophysiology
is related to fibrosis [1]. Cystic fibrosis and clubbing
can cause inaccurate pulse oximetry measurements
[2,3]; earlobe and forehead measurements are recommended in patients with these conditions.
The Masimo RAD-57 (Masimo Corporation, Irvine,
California) is a newer pulse CO-oximeter that can
measure carboxyhemoglobin (SpCO) and methemoglobin (SpMET). While this device can provide a rapid,
non-invasive measurement if carbon monoxide poison-

ing is suspected, the results should be confirmed by

arterial or venous carboxyhemoglobin (COHb) by blood
gas oximetry [4]. The RAD-57 should not be used to
rule out carbon monoxide poisoning [4]. We report a
case of incorrectly elevated SpCO in a patient with digital clubbing, which has not been reported previously.
CASE REPORT
An 18-year-old man with a history of mild cystic fibrosis (treated only with albuterol) and smoking was
discovered unconscious by his mother. The patient was
slumped halfway outside a motor vehicle in a closed

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KEYWORDS: clubbing, pulse oximetry, RAD-57, carbon monoxide poisoning

Copyright 2016 Undersea & Hyperbaric Medical Society, Inc.

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UHM 2016, Vol. 43, No. 1 INACCURATE SpCO FROM DIGITAL CLUBBING: CASE REPORT

Figure 1: The patients hand, showing

digital clubbing related to cystic fibrosis

Figure 2: RAD-57 (left) and Radical 7 (right) devices

one-car garage. Emergency medical services intubated
him and transported him to an outside hospital. On
arrival, his venous COHb was 33%. He was sedated
with propofol and fentanyl and was transported to our
facility while receiving 100% oxygen by endotracheal
tube.
When he arrived at our facility, after four hours of
100% oxygen, his venous COHb was 0.9%. On examination, he had digital clubbing (Figure 1). At the time
of the blood draw, we used three different Masimo
RAD-57 monitors to measure SpCO. The SpCO measurements were 11%, 9% and 9%; the SpMET, 1.5%,
1.1% and 1.1%; and the perfusion indices, 2.0, 1.6
and 2.0. We relocated the probe to alternate fingers,
and the SpCO measurements ranged from 9%-11%.

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Using four different probes, three RAD-57 devices

and one Radical 7 (Figure 2) (Masimo Corporation,
Irvine, California) (probes DCI-dc3), SpCO measurements were consistently elevated compared to COHb
values. Probe were placed in accordance with manufacturers recommendations, and clinicians had been
formally trained by the manufacturer on probe placement. We repeated the blood gas analysis, this time
with arterial blood, which showed pH 7.30, paCO2 45,
paO2 277 and COHb 2.3%. His methemoglobin was
1.5%, and the total bilirubin was 0.1 mg/dL. His
triglycerides were normal. When the probes were
placed on non-clubbed healthcare providers, SpCO
levels were undetectable.
The patient received three hyperbaric oxygen sessions in 24 hours [5]. After his first hyperbaric oxygen
treatment, his SpCO measurements remained elevated
at 10%.
After hyperbaric oxygen treatment, the patient was
discharged home with psychiatric follow-up. His neurologic examination at discharge was normal except
for slightly decreased light touch sensation over the
right forehead and decreased proprioception with the
right great toe.
DISCUSSION
To our knowledge, this is the first reported evidence
that non-invasive carbon monoxide monitoring (SpCO)
may be distorted by digital clubbing, just as regular
pulse oximetry readings may be [2,3]. The acceptable
perfusion index suggests that this inaccuracy was not
caused by poor fit between the probe and the patients
finger. We considered the hospital measurement of
COHb by CO-oximeter to be the gold standard [4]
because the measurement is from blood and adheres
to all federal and hospital-required guidelines for precision. The arterial and venous COHb measures were
different by 1.4 percentile points. The manufacturer of
our blood gas CO-oximeter states the 95% confidence
interval is 1.5 percentile points (e.g., a COHb level
of 5% should read 3.5%-6.5%). Touger, et al., found
differences of as much as 2.4 percentile points when
comparing simultaneous venous and arterial COHb [6].
Regardless, the falsely elevated SpCO in this patient
(9-11%) is much greater than the imprecision of the

Harlan N, Weaver LK, Deru K

UHM 2016, Vol. 43, No. 1 INACCURATE SpCO FROM DIGITAL CLUBBING: CASE REPORT
blood gas analyzer. The measures of SpCO and COHb
were not influenced by elevations in this patients
methemoglobin [7,8], total bilirubin [9-11], or hyperlipidemia [12].
Van Ginderdeuren, et al. suggested the pulse oximetry inaccuracy was a perfusion problem [3], but we
discount this because these monitors offered SpCO
numbers with good waveforms and acceptable perfusion indexes. We assume other RAD-57 monitors
would behave similarly. We speculate that this error in measurement is due to abnormalities induced
by the abnormal microvasculature in the light trans-

mission and its interpretation by the device, biasing

toward SpCO when carboxyhemoglobin is not present.
Without a detailed knowledge of the light transmission technology from this device, we cannot offer
a firm explanation for this observation. Nevertheless,
providers should be aware of the discrepancy between
non-invasive and invasive testing, and should rule
out elevated COHb levels with venous or arterial blood
gas [4,6].
Conflict of interest
The authors have declared that no conflict of interest exists
with this submission.


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Harlan N, Weaver LK, Deru K

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