Managing Perioperative Hypoxia: Nursing Strategies for Safer Surgical Outcomes

The hidden risks of perioperative hypoxia are more common than many surgical teams anticipate. Risk factors like moderate obesity or undiagnosed sleep apnea can go unnoticed until surgery, when they become critical red flags. Hypoxia—when tissues are deprived of adequate oxygen—can compromise healing and threaten organ function.

All surgical patients are at risk due to the respiratory effects of anesthesia. That’s why Yvette Martin McGrew, MD, PhD, anesthesiologist at Mayo Clinic in Rochester, Minn., emphasizes a coordinated, team-based approach to maintaining oxygenation across every phase of perioperative care.

Recognizing Hidden Risk Factors for Hypoxia in Surgical Patients

“Preoperative nurses play an important role in predicting and monitoring patients who may be at risk for hypoxia,” said Dr. McGrew, referring to the condition in which blood oxygenation levels fall below the safe range—typically defined as 90% or higher.

Hypoxia can occur intraoperatively or postoperatively. Risk factors include advanced age, obstructive sleep apnea, obesity, opioid or sedative use, and comorbidities such as severe COPD or congestive heart failure.

Because anesthetics and sedatives are known respiratory depressants—and can exacerbate conditions like obstructive sleep apnea—Dr. McGrew recommends using a screening tool such as STOP-BANG during preoperative assessment to help identify patients at risk.

STOP-BANG stands for:

S: Snoring loudly 

T: Tiredness during the day 

O: Observed apneas (breathing stops) during sleep 

P: Pressure (high blood pressure) 

B: BMI (Body Mass Index) 

A: Age (over 50) 

N: Neck circumference (over 40 cm for men, 38 cm for women) 

G: Gender (male) 

This tool is becoming more commonly applied in perioperative care to proactively address hypoxia risk.

Monitor Oxygenation Throughout Surgical Care and Use Supplemental Oxygen

Perioperative nurses involved in moderate sedation support patient oxygenation when administering moderate sedation. In this setting, Dr. Martin McGrew says periop nurses should monitor for hypoxia with a pulse oximeter and use supplemental oxygen to keep patients safe.

Use Pulse Oximetry

Monitoring oxygenation is a core component of the ASA standards for basic anesthetic monitoring. Pulse oximetry is typically used and has proven effective in detecting hypoxemia. “It is essential for patients receiving anesthetics, opioids, and sedatives,” Dr. McGrew notes.

Oxygenation should be continuously monitored during all types of anesthesia, including general, regional, and monitored anesthesia care.

Provide Supplemental Oxygen

All patients receiving moderate sedation or analgesia should receive supplemental oxygen unless contraindicated. Patients with a history of obstructive sleep apnea who use noninvasive positive airway pressure (PAP) therapy should be encouraged to bring their own equipment to the hospital.

If hypoxia persists during surgery despite escalating oxygen therapy, Dr. McGrew recommends that the anesthesiologist or CRNA evaluate any patient—not just those identified as high-risk—for pharmacologic interventions or advanced oxygen delivery methods such as PAP therapy or intubation.

Regulate Oxygen Before Discharge

The postoperative phase presents a heightened risk for hypoxia. For this reason, “pulse oximetry monitoring should continue in the postoperative environment, titrating oxygen administration to maintain SpO₂ levels at 90 percent or higher,” says Dr. McGrew

If a patient requires prolonged or increasing oxygen support, perioperative nurses should collaborate with anesthesiologists and CRNAs to recommend continuous pulse oximetry for high-risk patients receiving postoperative analgesia beyond the PACU.

“Early notification of hypoxemia by the perioperative nurse assists the anesthesiologist and CRNA in identifying underlying causes of hypoxia and facilitates decisions regarding pharmacologic treatment, escalation of monitoring, or adjustments to oxygen delivery methods,” Dr. McGrew said.

What are the Effects of Hypoxia During Surgery

The short-term effects of hypoxia during surgery can increase heartrate and cause shortness of breath, health effects that can delay surgery and risk patient harm if symptoms worsen and cause emergency response.

Long term patient outcomes caused by perioperative hypoxia are still being investigated. One possible result is increased risk of surgical site infection. Dr. Martin McGrew cautions that, “while high oxygen administration has been considered for reducing surgical site infections, more studies are needed to strengthen the evidence for this practice as well as to study potential risks associated with high oxygen therapy.”

What is well established in research and practice is that optimizing oxygenation as a team across preop, intraop and postop phases of care, particularly in high-risk surgical patients, can improve outcomes by keeping patients safe.

Trusted Tools for Safer Sedation—from Preop to Discharge

• The Guideline Essential for Moderate Sedation/Analgesia help nurses recognize and respond to hypoxia risks during sedation—and includes key takeaways, clinical FAQs, webinars and more.
• You can also sign up for the Safe Administration of Moderate Sedation online course. It offers an overview of the RN’s role in safely administering moderate sedation, including scope of practice, patient eligibility, monitoring and discharge criteria, medication administration, and strategies for managing emergencies.