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Pulse - Oximetery

Dr Prashant S Agarwal Dr Ashok Jadon Deptt. Of Anaesthesia

Why ?
• Cyanosis - poor guide to the detection of arterial hypoxemia
• Comroe JH, Botelho S. The unreliability of cyanosis in the recognition of arterial anoxemia. Am J Med Sci 1947;214:1–6.

• 5 g reduced hemoglobin per 100 ml capillary blood must be present to produce visible cyanosis
• Lundsgaard C, Van Slyke DD. Cyanosis. Medicine 1923;2:1.

Necessity is the mother of invention
• “Oxygen lack not only stops the machine but wrecks the machinery”
• JS Haldane;1921

• Anoxia - how long :- damage to cerebral cortex - 1 min heart - 5 min liver and kidney -10 minutes skeletal muscle - 2 hours.

HISTORY
• Glenn Millikan (1942) – First oximeter – For pilots of World War II – halogen incandescent lamp

• Hewlett-Packard ear oximeter
– fibreoptic light guide, eight wavelengths – considered to be the “gold standard” for first pulse oximeters calibration – No separation of the absorption due to arterial blood from the veins – large and cumbersome – frequent calibration

Current Pulse Oximetry
• Continuous noninvasive method for measuring
– Arterial oxygen saturation – Pulse rate

Optical principles
Beer–Lambert law A = log (Io/I) = εlc

Principle of operation

• Use of 2 different wavelengths (Oxyhemoglobin
absorbs more infrared light Reduced hemoglobin absorbs more red light)

Comparison’s are made between peak and trough of the cardiac cycle

Difference in absorptions is read by the computer and displayed on the screen

Plethysmogram

What to look for ?
• Signal Strength • Wave form • PR • SpO2 • Tone ( Pitch changes with decrease in saturation - Nellcor Pulse Oximeter 1983 ) • Rhythm (with expertise)

Indications
• • • • • • • • Oxygen lack Acute hypoxia Chronic hypoxia Respiratory failure Asthma Chronic obstructive pulmonary disease Adult respiratory distress syndrome Pulse oximetry for screening

Uses
• • • • • • • Operation Theater Recovery Room Intensive Care Unit Emergency Room High-dependency units Prehospital care Transportation

Applications
• • • • • • • • Avoidance of Hypoxemia Monitoring Oxygenation Controlling Oxygen Administration Monitoring Circulation Determining Systolic Blood Pressure Locating Vessels Monitoring Vascular Volume Monitoring of Peripheral Blood Flow

Sites
• • • • • • • • • Finger Ear lobule Nose Tongue Lips Forehead Scalp Foot Miscellaneous

Conditions Affecting Accuracy
• Ambient light • Electronic interferences • Patient conditions
– – – – – Carboxyhemoglobin Methmoglobinemia Hypovolemia/Hypotension Hypothermia Nail Polish (blue, black and green affects accuracy) – Patient movement – Peripheral shut down – Saturation < 75%

Anemia
• The lower limit of hemoglobin in vivo at which the pulse oximeter becomes totally unreliable has not yet been determined • Jay et al., have shown good performance at Hemoglobin as low as 2.3 g/dL

Advantages
• • • • • • • • • Accuracy Dependability Convenience Fast Response Time Non-Invasiveness Continuous Monitoring User Friendly Economical Ecological

Limitations
• neither indicates functional nor fractional saturation. • indicates a value, SpO2, which is best defined as
oxygen saturation as measured by a pulse oximeter

• only measures oxygenation not ventilation • no indication of PaO2, pH or PaCO2 levels

Cautions
• Hypoventilation (hypercarbia) may precede decrease in saturations by many minutes. • Supplemental oxygen may mask hypoventilation and CO2 retention.

Complications
• Ocular Injury • Pressure & Ischemic Injuries • Burns • Electric Shock

Review Literature
• The 88%-SAT may be more effective than spirometry for identifying reactive airways disease
• Wagner et al.

• Pulse oximetry is a sensitive indicator of perfusion in patients suffering peripheral vascular disease.
• Joyce WP, Walsh K, Gough JB et al. Br J Surg 1990; 77:115–7.

• Pulse oximetry as a means of assessing bowel viability at surgery.
• DeNobile J, Guzzetta P, J Surg Res 1990;48:21–3. • Tollefson DF, Wright DJ, Reddy DJ, Ann Vasc Surg 1995;9:357–60.

• Plastic surgery - Viability of skin flaps which have been “swung” around, and also of “free” flaps.

Newer advances
• Fetal pulse oximetery • Reflection pulse oximetry
– Can be placed on more proximal sites – Viability of visceras can be detected

• For MRI • has all of its electronic components in the main unit and the light energy is transmitted to and from the patient by optical fibers. • must be kept at least 3 m away from the bore of the MRI magnet

Reflectance Pl-Ox

Take Home Message
• Pulse oximetry is NOT intended to replace any part of the patient assessment! • Treat carboxyhemoglobinemia with high flow oxygen regardless of the pulse oximetry reading!

• Always administer oxygen to patients with poor perfusion!

Finally……….

Assess and treat the PATIENT not the oximeter!

THANK YOU