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PULSE OXIMETRY

HISTORY
• MATHEES- father of oximetry
• 20 papers in1934 –1944
• HERTZMAN 1937 –use of photoelectric finger
plethsmography
• 1975 –concept of pulse oximetry –Japan
• YELDERMAN &NEW -1983 –Nellcor pulse
oximeter
INTRODUCTION
• The maintenance of optimal O2 delivery is the
core concern during anaesthesia

• “Oxygen lack not only stops the machine but


wrecks the machinery ”– J.S. Haldane.

• Monitoring of oxygenation using


pulseoximeter avoids many catastrophies
• Fifth vital sign
• Non invasive method of Hb saturation (SpO₂)
• Older version – Required arterialisation, large
and expensive.
• Latest – LEDs, miniaturised photodetectors,
microprocessors. Smaller, less expensive, easy to
use.
• ASA has made it a standard and mandatory for
intra op and PACU (Post Anaesthetic Care
Unit)monitoring
DEFINITION
• A NON INVASIVE TECHNOLGY TO MONITOR
OXYGEN SATURATION OF THE HAEMOGLOBIN
OPERATING PRINCIPLES
1.ABSORBTION SPECTRO PHOTOMETRY
2.BEER LAMBERT LAW
• LAMBERT’S LAW states that when a light falls on
a homogenous substance,intensity of transmitted
light decreases as the distance through the
substance increase
• BEER’S LAW states that when a light is
transmitted through a clear substance with a
dissolved solute ,the intensity of transmitted light
decreases as the concentration of the solute
increases
• Absorbance of the medium is the ratio of
intensity of incident light (Iin) to the intensity of
transmitted light ( Itrans)
• Absorbance = Iin / I trans

• Optical density is the log to the base 10 of


absorbance

• Optical density (OD)=log 10 Iin/Itrans


1.Beer’s law states that the intensity of transmitted
light decreases exponentially as the concentration
of substance increases.

.log ₁₀ Iin/Itrans α concentration C


2.Lambert’s law states that the intensity of transmitted
light decreases exponentially as distance travelled
through the substance increases
.log ₁₀ Iin/Itrans α distance d
Combining equations 1 & 2,
log ₁₀ Iin/Itrans α c Χ d
or
log ₁₀ Iin/Itrans = Єcd
This is Beer Lambert’s equation. It is also
expressed as Itrans = Iin e -Єcd
C – concentration of the solute
Є – extinction coeffecient. It is a known
constant for a specific solute at a specified
wavelength
e - base of natural logarithm
Єcd – absorbance or optical density
Hb-light absorption
• Reduced Hb – absorbs more light in red
band(660 nm)
• Oxy Hb – absorbs more light in Infra Red
band(940nm).
Components of absorption signal
PHYSIOLOGY

• Saturation is defined as ratio of O2 content to


oxygen capacity of Hb expressed as a
percentage.
• Desaturation leads to Hypoxemia – a relative
deficiency of O2 in arterial blood. PaO2 <
80mmHg – hypoxemia
• Oxygen saturation will not decrease until
PaO2 is below 85mmHg.
• At SaO2 of 90% PaO2 is already 60mmHg.
• Rough guide for PaO2 between saturation of
90%-75% is PaO2 = SaO2 - 30.
• SaO2< than 76% is life threatening
Types of hypoxemia
• 1.Hypoxic hypoxemia
•  PaO2  SaO2 – Normal Hb

• 2.Anaemic hypoxemia
• Hb , Normal PaO2 & SaO2

• 3.Toxic hypoxemia
• SaO2,Normal PaO2
PaO2 [mmHg] SaO2 [%]

• Normal 97 to ≥80 97 to ≥95

• Hypoxia < 80 < 95


• Mild 60-79 90-94
• Moderate 40 – 59 75 – 89
• Severe <40 < 75
Oxy Hb dissociation curve
TYPES OF PULSE OXIMETRY
Transmitted light is absorbed by photodetector &
generates a proportional voltage
Pulse oximetry – two types.
1)Transmission pulse oximetry – commonest type
• Light beam is transmitted through vascular bed & is
detected on the opposite side of that bed.
2)Reflectance pulse oximetry – Relies on light that is
reflected to same side.
• Probe has an LED and a photodiode (photodecetor
).
• Reflection depends upon the different reflective
indices of the materials which interfaces between
them.
COMPONENTS OF PULSE OXIMETRY
1)Probe: contains two LEDS ( that emits light &
detects the light)
2)Cable : Connects oximeter to the probe
3)Microprocessor : Analyses DC & AC
components at 660 & 940 nm.
4)Console / monitor :
two type – .free standing unit
.Hand held unit
5)Miniatured photodetcters
Console / monitor displays-
1. Percentage of Hb saturation
2. Pulse rate
3. Alarm limits
4. Plethysmograph (waveform)
- Operated by –
Electricity,battery charged,rechargeable units.
Available as reusable/disposable forms and in
various sizes
SITES OF APPLICATION
1. Finger 9. Laryngeal
2. Toe 10.Palm
3. Nose 11. Foot
4. Ear 12.Penis
5. Tongue 13.Ankle
6. Cheek 14. Arm
7. Oesophagus 15. Calf
8. Forehead
Its fixed by-
headband,glove,wrapping,clips,adhes
ive band,metal strip,probe,velcro
1)Finger : Most Commonly used.
Lower failure rates
More accurate.
.Thumb – preferred.
. Index finger- avoided,(Injury to eye/cornea)
Disadvantages-
-Performance is improved by improveing circulation
e.g) Finger block, digital pulp space infiltration,
vasodilator, vigorous rubbing can improve circulation
• Relative sensitivity to sympathetic vasoconstriction
• Dark nail polish / synthetic finger nails- probe oriented
from side to side of finger, that allows transmission of
light.
• Exception is clear acrylic nails (i.e –centrally placed)
• Detection of desaturation slower than with a centrally
placed probe.

Toe : late detection of desaturation- 1 to 2min


• Reliable parameter for the success of epidural
block,resulting in increase of amplitude
2)Nose-sites : bridge,wings of nostrils, septum.
• Early detection of saturation changes.
• Recommended in hypothermia
hypotension
infusion of vasoconstrictor drugs
• Trendelenburg position – venous congestion –
low sat. levels.( SPo₂)
3)Tongue: Reflectance oximetry used
• In extensive burns
• Quicker detection of saturation changes
• Resistant to signal interference from
electrosurgery.
Disadvantages :
• Tongue quivering mimics tachycardia
• venous congestion – head down position
• Oral secretions
4)Cheek : more accurate than finger.
Applied over the cheek or lips.
Metal strip /clip is applied particularly on
the buccal surface.

• Effective in Hypothermia
Decreased cardiac output
Increased SVR
Low pulse pressure
In burns
Disadvantages : Difficult placement
Poor acceptance in the awake
Artifacts during airway-
manuouvers
5)Esophagus: use of reflectance oximetry
used in – Hemodynamic instability
Extensive burns
Disadvantages: placement requires practice
difficulty in obtaining a reliable signal
6)Forehead :- flat reflectance oximetry
- Placed just above the eye brows after
cleaning the site with alcohol.
- easily accessible
- Resistant to vasoconstriction
- Signals improved with headband/pressure
dressing.
Disadvantages: supine- venous pooling- low sat. reading.
Others:
• Pharyngeal pulse oximetry – probe is attached to
LMA in patients with poor peripheral perfusion.
• Flexible probes used on palm, foot, penis, ankle,
lower calf, arm in infants
• TESTING OF PULSE OXIMETRY
Done by-
1. Appearance of reliable wave patterns.
2. SPo₂ readings must be correlated with other
pulse oximetry.
3. Confirmation of reliable PR/HR values.
4. Compare PR/HR values with that of ECG
monitor
APPLICATIONS OF PULSE OXIMETRY
1. Monitoring O₂ Saturation -
Anaesthetising areas:
• During induction,emergence,maintanance
• To detect bronchial intubation.Not always reliable when high
Fio2 is used.
• Managing one lung ventilation.Effectively with pulse oximetry.
• Under regional anaesthesia,MAC.Restless is due hypoxia or
inadequate regional block ( RA ).
• To Confirm tracheal tube placement,i.e) by ↑ SPo₂ levels
.
Other areas Transport of the patient
• Post Anaesthetic CareUnit
• ICU – to wean ventilators
• During CPR
• Reflectance oximetry to monitor fetal
oxygenation ( fetal SPo₂ ).
2. Monitoring peripheral circulation :
• During different arm positions
• During lithotomy positon
• During Shoulder arthroscopy – brachial artery
compression
• Blood flow to fracture areas, to know circulation
compromised or not distal to it.
• Mediastinoscopy – risk for brachiocephalic artery and
aortic arch compression.
• To know the effect of sympathetic block.
• To know the effect of angiography,to know the
existence of the collateral circulation or not.
• To determine site of amputation or arterial bypass
surgery.
• To monitor reimplanted or revascularised digits.
• To measure palmar collateral circulation.
3. Determining systolic BP- cuff applied to same arm
as the pulse oximeter,SBP correspond to the
absence of reading
4.Locating arteries –
• Axillary artery- keep the pulse oximetry on same side
press the axilla or groin ,and observe the pulse wave
form disappears or not.
• Femoral or dorsalis pedis
5.Avoiding hyperoxemia – devpt of retinopathy & other
pathological conditions, if Spo₂ is >98% for a
pronlonged period in neonates.
6.Monitoring vascular volume & symp tone:
• skipped beats suggests-Hypovolemia .
• Amplitude changes- indicates -vascular distensibility
7.Other uses: To know the effectiveness of ;
• High frequency jet ventilation
• Effectiveness of therapeutic bronchoscopy
ADVANTAGES
1. Accuracy
2. Independance from gases/ vapours
3. Fast response time
4. Noninvasive
5. Continuous measurements
6. Separate respiratory and circulatory variables
CVS –Perfusion is indicated by the pulse signal strenght.
Resp.- Oxygenation is indicated by % of saturation ( SPo₂).
7. Convenient, for arterilisation of skin ,pulse oximetry is
not essential except an ear lobe is the monitoring site.
8. Pulse Tone modulation-To detect hypoxic episodes,by
hearing the change in the pitch of pulse oximetry tone.
9. Light weight & compact
10. Probe variability
11.No heating required
12.Battery operated
13.Economy
14.Needs minimal training
DISADVANTAGES & LIMITATIONS
1.Failure to determine O₂ saturation due to Poor
function with poor perfusion ( SPo₂)
2.Difficulty in detecting high oxygen partial pressures
(Pao₂) beyond 100% saturation
3.Hypoxic event detection delayed due to time lag
4.Erratic performance with dysrhythmias
5.Inaccuracy readings in the following conditions
a) Different Hbs-
Methaemoglobinaemia –
 normal levels < 1%
 Drugs responsible – nitrobenzene, benzocaine,
prilocaine, dapsone
 Absorbs light equally at red and infra red
wavelengths
 Saturation is around 85%
Carboxyhaemoglobin – has absorbtion spectrum
similar to that of oxy Hb.
• SpO₂is over read.
Fetal Hb – more absorbtion of o₂ & less delivery
.so, false low levels of SPO₂.
HbS – inaccurate readings
Sulfhaemoglobin- causative drugs are
metaclopramide, phenacetin, dapsone,
sulfonamides.
• Displays low saturation levels
Other haemoglobinopathies –
.Hb H – high readings
-Hb koln
- Hb constant springs - low readings
-α thalassemia 2
- Heinz body hemolytic
anaemia
. Hb Hammersmith
.Hb Milwaukee - not useful
b) Low saturations- oximetry is less accurate when SpO₂ is
less than 75-80% because of dark skin ,cyanotic
heart diseases.
c) Malpositioned probe – penumbra effect (light from the
emitter to the detector grazes the tissue instead of
passing through it .)
-Causes false low readings due to signal to noise ratio is
decreased results in spurious SPo₂.
d) venous pulsations – High airway pressures during
artificial ventilation causes phasic venous congestion,
interpreted as pulse wave
e) mixing probes i.e) probe & console are of different
companies.
f) severe anaemia - overestimates SpO₂ at low sats
g)Dyes – methylene blue, indocyanine green,
lymphazurin, indigocarmine, nitrobenzene, patent
blue – low readings
• Used to confirm IV catheter placement ( either in vein
or in artery by measuring SPO₂ levels ).
• Used to assess C-output by dye dilution method
h) Optical interference – lights flickering at
frequencies similar to that of LEDs

i)Nail polish & coverings- low SPo₂ levels seen -with


brown,black, blue,green nail polish ,but not with red
or purples.
-synthetic nails,onycomycosis,dirty nails,blood stained
finger,taking docetaxel drug except Acrylic nails ( hear
normal/ high Spo₂).
j) Electrical interference-
• Prevented by- locating the ElectroSurgical ground
plate as close to surgical field as possible.
• Routing the cable & console as far from surgical
field as possible
• Electro Surgical apparatus & pulse oximeter not
to be plugged to the same circuit
K) Motion artifacts- mistaken for pulsations.
COMPLICATIONS
1.Corneal abrasions.
2.Pressure and ischaemic injuries.
3.Burns – due to
○ Incompatibility between probe and monitor
○ Damaged probe
4. Electric shock
MASIMO SET PULSE OXIMETRY
SPECIAL FEATURES ARE
1 It is not bounded by conventional red over
infra red ratio approach
2 To sense even at low signal states/conditions
3 To sense even at low perfusion conditions
4 To sense even at noise intensive environments
5 It is superior to conventional methods
6 It is clinically validated one
-Signal processing differs from the conventional types
-Adaptive digital filtering
-Able to adapt the varaying physiological signals/
noise and separate them into fractional components
-Processing algorithm DST(discrete saturation
transform)
-It identifies noise,isolate it and by using adaptive
filters cancels it
REFERENCES:
• DORSCH & DORSCH – 5th Edition
• IJA August 2002
• PULSE OXIMETRY by JOHN TB
MOYLE – 2nd Edition