The recent article by Wilder et al.  1presents a concerning correlation between multiple episodes of anesthesia in childhood and later learning disabilities. In the discussion of possible causes for this correlation, they focus on the known neurotoxicity of various anesthetic agents in vitro  and in animal studies. They identify some possible sources of bias in their study but neglect to mention one of the most significant changes in anesthetic practice, which occurred after the children in the study received their anesthesia.

Pulse oximetry was developed in the 1970s2but only became commonly used in anesthesia at the end of the 1980s and was made a part of the American Society of Anesthesiologists standards for basic anesthetic monitoring. The introduction of a standard for monitoring and the availability of pulse oximetry coincided with a great reduction in the incidence of undetected hypoxia and resultant injury as demonstrated at Harvard at the time.3Because the children in this study received their anesthesia in the period 1976 through 1986, the possibility that their increased incidence of learning difficulties might have resulted partly from undetected hypoxia brief or mild enough not to have caused injury that was immediately obvious should not be discounted. A comparison with children who received a more current standard of monitoring after 1990 would be helpful in determining the likely magnitude of this effect.

St Vincent's Hospital, Fitzroy, Victoria, Australia.

Wilder RT, Flick RP, Sprung J, Katusic SK, Barbaresi WJ, Mickelson C, Gleich SJ, Schroeder DR, Weaver AL, Warner DO: Early exposure to anesthesia and learning disabilities in a population-based birth cohort. Anesthesiology 2009; 110:796–804
Severinghaus JW, Honda Y: History of blood gas analysis, VII: Pulse oximetry. J Clin Monit 1987; 3:135–8
Eichhorn JH: Prevention of intraoperative anesthesia accidents and related severe injury through safety monitoring. Anesthesiology 1989; 70:572–7