1. Non-Invasive Oxygen Monitoring Pulse Oximetry & Conjunctival Oxygen Monitoring

2. OBJECTIVES At the end of this module, the student will be able to… define terms associated with pulse oximetry. explain the theory of operation of a pulse oximeter. differentiate between functional and fractional saturation. list the indications, limitations, advantages, disadvantages and contraindications for use of a pulse oximeter.

3. OBJECTIVES At the end of this module, the student should be able to… list some of the things that affect the accuracy of a pulse oximeter. explain when co-oximetry would be more appropriate than pulse oximetry. describe patient application for each of the noninvasive monitors.

4. ASSIGNMENTS Read: Egan Chapter 16, pgs. 377 – 383 AARC Clinical Practice Guidelines - Pulse Oximetry Articles on Pulse Oximetry (look on website)

5. Circle of Oxygenation Lungs Uptake P a O 2 Dissolved Oxygen Blood Carrying S a O 2 Carried Oxygen Heart Pumping DO 2 Oxygen Delivery Tissues Utilization O 2 Oxygen Consumption

6. Hypoxia Develops Rapidly SaO2%SaO2% P a O 2 mmHg 4 —> 2 L/min A Central Apnea Obstructive Apnea Hypoxia + Obstructive Apnea from Hanning,"Oximetry and Anaesthetic Practice", 1985 01234 0 20 40 60 80 100 120 98 97 96 95 90 80 70 50 30 10

7. Pulse Oximetry The Fifth Vital Sign

8. Oxygen Content The total amount of oxygen present in arterial blood. Dissolved oxygen (P a O 2 ) Attached to hemoglobin (S a O 2 ) Measured by co-oximeter Estimated by pulse oximeter Calculated by blood gas analyzer Actual amount of hemoglobin (Hb)

9. Oxygen Carrying Capacity

10. The Science behind Oximetry Spectrophotometry Lambert-Beer Law Light Transmission Spectra and Oximetry Light Emitting Diode (LED) technology Optical Plethysmography

11. Spectrophotometry Spectrophotometry is the measurement of the amount of light that is absorbed as it passes through a substance. Reflected Absorbed Transmitted Spectrophotometry is an application of Beer’s (Beer-Lambert) law.

12. Absorption Spectrum

13. Schematic block diagram of a pulse oximeter

14. Wavelength Selection Two wavelengths are selected for analysis. A red light at about 660 nanometers (nm). An infrared light at about 940 nanometers. So how do we get such specific measurements?

15. Light Emitting Diode Technology A pulse oximeter sensor is made up of two different parts: An light emitting diode A photodetector

16. Misalignment of the sensor by inserting finger too far.

17. Optical Plethysmography Plethysmography is the measurement of changes in volume in a particular part of the body. Originally designed to measure vascular perfusion. Changes in volume at a site is due to the pulsation of arterial blood.

18. Output signal generated by pulse oximeter. Saturation is based on the ratio of light absorption during pulsatile and baseline phases.

19. Functional vs. Fractional Saturation S p O 2  S a O 2 Functional Saturation (S p O 2 ) Fractional Saturation ( S a O 2 )

20. Measurement vs. Monitoring Measurement: A one time snapshot. Example: ABG sample or a “spot-check” S p O 2. Monitoring: Ongoing measurements. Example: Continuous pulse oximetry

21. Golden Rule For Safety Monitors SAFE ACCURATE RELIABLE CONVENIENT “Always detect danger” and “No false goodness” A Safety Monitor must be:A Safety Monitor must be:

22. Technical Limitations Calibration Assumptions Optical Interference Absorption Interference Signal Artifact

23. Calibration Assumptions Calibration curves Accuracy range

24. Optical Interference Ambient Light Optical Shunt Optical Cross-Talk Edema

25. Absorption Interference Anemia Skin Pigmentation Nail Polish Carbon Monoxide Methemoglobin Intravascular Dyes

26. Signal Artifact Artifact can cause errors in measurement. Artifact may obscure the signal Causes: Low perfusion Hypotension Cold Motion Artifact

28. The Solution? Improvements in technology that: Improve the signal to noise ratio present in low perfusion. Improve the ability of the oximeter to “read” through motion.

29. Sensor Application Properly place sensor. Single use sensor are meant for a single patient. Use sensor as designed.

30. Patient Application - Sites Adults & children Finger Toe Ear lobe Cheek Tongue Nose Small children & babies Wrist Upper arm Across foot

31. Pulse oximetry probes

33. Reporting Results Four things to verify prior to reporting results: Waveform Signal strength Heart rate Clinical Correlation

34. Plethysmograph – Pulse oximeter tracing

35. Oxyhemoglobin Dissociation Curve

36. Contraindications (relative) When arterial blood gases are indicated for measurement of pH or PaCO 2. When CO-oximetry is indicated for evaluation of total hemoglobin and abnormal hemoglobins HbCO% HbMet%

37. Maintenance Pulse oximeters usually do a self-check when they are first turned on. They do not require regular routine manual calibration. Wipe probe and monitor with an alcohol soaked cloth between patients.

38. Mini Clini - Egan: Page 363

39. Conjunctival Principles of Operation A sensor is inserted under the eyelid. It contains a Clark P O 2 electrode similar to a blood gas analyzer. It is used mainly in to OR for short-term application. Conjunctival P O 2 is reported and correlates to the arterial P a O 2.

40. Conjunctival P O 2 (P cj O 2 )