Chapter 24

Pulse Oximetry
P. 776


Introduction
Pul se oxi met ry, someti mes cal l ed the fi ft h vi tal si gn, i s a noni nvasive method of
measuri ng hemogl obi n saturati on (SpO
2
) by usi ng a li ght si gnal t ransmi tt ed t hrough
t i ssue. A l ow SpO
2
can provide warni ng of hypoxemi a bef ore ot her si gns such as
cyanosis or a change i n heart rat e are observed.
Unt i l the 1980s, noninvasi ve oximeters, known as ear oxi meters, were l arge,
expensive, and cumbersome. They requi red arteri al i zati on by heat or chemical
t reatment, and thei r uti l i t y was l i mi ted by dif f i cul ti es i n di ff erent iati ng l ight
absorbance of arteri al bl ood f rom that of venous bl ood and tissues.
Techni cal advances, i ncl udi ng l ight-emi tt i ng diodes (LEDs), miniaturi zed
photodetectors, and mi croprocessors, al l owed the creat ion of a new generat i on of
oximet ers, whi ch were smal l er, l ess expensi ve, and easi er to use. These
di ff erenti ate t he absorpti on of l ight by the pul sati le art eri al component f rom the
stat ic components, so t hey are cal led pul se oxi met ers.
A pul se oxi met er may be a stand-alone device or i ncorporated i nto anot her devi ce
such as a mul t i paramet er moni tori ng system. A rel ativel y new development i s a
combi ned pul se oxi met ry and transcutaneous carbon di oxi de tension ear sensor
(1,2,3,4).
The Ameri can Society of Anest hesi ol ogists (ASA) and Ameri can Associ at i on of
Nurse Anestheti sts have made assessment of oxygenati on a standard for
i ntraoperati ve and postoperative moni tori ng. I n 2005, an audi bl e al arm f or the pul se
oximet er was added to the ASA moni t oring standard (5). Internat i onal standards f or
saf e practice endorsed by the Worl d Federati on of Soci et ies of Anesthesi ol ogi sts
hi ghl y recommend cont inuous use of a quanti t ati ve moni tor of oxygenat i on such as
pulse oxi metry (6). I n some st ates, t he use of pul se oxi met ry i s mandat ory. A st udy
of closed cl ai ms of anesthet ic-related malpract i ce cases determined that a
combi nati on of pul se oxi met ry and capnography coul d have prevented 93% of
avoidabl e mishaps (7). One study determined that pul se oximet ry provided the f i rst
warni ng of an i nci dent i n 27% of si tuati ons (8). The number of unant icipated
i ntensi ve care uni t admissions decreased af ter the i nt roduct i on of the pul se
oximet ry (9).
Operating Principles
The pulse oxi meter esti mates SpO
2
f rom the di f ferent i al absorpt ion of red and
i nf rared li ght in t issue (10,11, 12,13,14, 15,16). The t wo wavelengths al low
di ff erenti ati on of reduced hemogl obi n and oxyhemoglobin. Reduced hemoglobi n
absorbs more l i ght i n the red band t han oxyhemogl obi n (Fi g. 24.1). Oxyhemoglobin
absorbs more l i ght i n the i nf rared band. The pulse oxi meter computes the rati o
bet ween t hese two si gnals and rel ates this rat io t o the arteri al oxygen saturat i on,
using an empi ri cal algori thm.
Pul se oxi meters di scri mi nat e bet ween art eri al blood and ot her components by
determining t he change i n transmi t ted l ight caused by t he f low of art eri al blood. The
oximet er pulses the red and i nf rared LEDs ON and OFF several hundred ti mes per
second. The rapi d sampl ing rat e al l ows recogni ti on of t he peak and t rough of each
pulse wave. At the t rough, the l ight i s t ransmi tt ed through a vascul ar bed t hat
contai ns mainl y capi l l ary and venous bl ood as wel l as i nterveni ng t issue. At the
peak, i t shines through al l thi s pl us arteri al bl ood. A phot odi ode col l ects the
t ransmi t t ed li ght and converts i t i nto el ectrical si gnals. The emi t ted si gnals are then
ampl i f i ed, processed, and di spl ayed on the moni tor. Oxi meters have a phase wi th
both LEDs OFF t o al l ow detect i on of and compensat ion for ext raneous l i ght. Li ght
readi ngs duri ng the OFF period are subtracted f rom the next sequence.
Fract ional oxygen saturati on (% HbO
2
) is t he rati o of oxyhemoglobi n to the sum of
al l hemogl obi n species present , whether avai l abl e f or reversi bl e bi ndi ng t o oxygen
or not (17). Functi onal oxygen saturat ion (SaO
2
) i s def i ned as t he rati o of
oxyhemoglobi n to al l functi onal hemogl obi ns. These must be determi ned by usi ng
an
P. 777

i n vi t ro oxi meter. For pat ients wi t h l ow dyshemoglobin l evels, the dif f erence
bet ween f ract ional and f uncti onal saturati on i s very smal l . However, when
dyshemoglobi n l evels are el evated, the t wo val ues can vary great ly, and pul se
oximet er readi ngs may not agree wi t h ei ther t he t rue f racti onal or f uncti onal
saturat ion val ues (18).

View Figure

Figure 24.1 Absorbance of light as a function of
wavelength. The extinction coefficient is a measure of the
tendency of a substance to absorb light. At the red
wavelengths (650 to 750 nm), reduced hemoglobin absorbs
more light than does oxyhemoglobin. In the infrared region
(900 to 1000 nm), the reverse is true.

Transmission Pulse Oximetry
The most common t ype of pul se oxi meter i s the t ransmi ssi on oximet er. Wi th this
t echnol ogy, a l i ght beam i s transmi t ted through a vascular bed and i s det ect ed on
t he opposi te si de of that bed.
Reflectance Pulse Oximetry
Ref l ectance oxi metry rel i es on l i ght that i s ref lected (backscat tered) to determine
oxygen saturat i on. The probe has both an LED and a photodi ode (Fi g. 24.16).
Transmi ssion pul se oxi met ry probes are not accurat e when used in the manner of
ref l ectance oxi met ry (19). Ref lecti on originates f rom nonhomogenei t y i n the opt i cal
path, t hat is, at t he interf aces between materi al s wi t h di ff erent refl ecti ve i ndi ces.
The t issue must be wel l perf used t o obt ai n a st rong si gnal . Heati ng the
measurement si te and applying pressure may be hel pf ul (20,21).
There are a number of l i mi tat i ons of ref lectance oximet ry. The probe desi gn must
el i mi nate l ight that i s passed di rectl y to t he probe or i s scatt ered in the out er
surf ace of the skin. The si gnals are weaker than those f ound i n transmi ssion
oximet ry, so t he photodi ode area needs to be as large as possi bl e. I f the probe is
l ocated over an artery or a vei n, the reading may be art if actual l y low (22, 23).
Vasoconst ri ct ion can cause overesti mati on of the oxygen saturati on (23).
Physiology
Ef f i ci ent oxygen transport rel i es on the abi l i t y of hemoglobin t o reversibl y l oad and
unl oad oxygen. The rel at ionshi p bet ween oxygen tension and oxygen bi ndi ng i s
seen i n the oxyhemogl obin di ssoci at ion curve (Fi g. 24.2), whi ch pl ots the
hemogl obi n oxygen saturati on against t he oxygen tensi on. The si gmoi d shape of
t he curve is essenti al f or physi ol ogi c transport. As oxygen is taken up i n the lungs,
t he bl ood is nearl y f ul l y saturat ed over a l arge range of tensions. Duri ng passage
t hrough the
P. 778

systemic capi ll aries, a l arge amount of oxygen i s rel eased wi t h a rel at ivel y smal l
drop in t ension. Thi s al lows oxygen to be rel eased at suf f ici entl y hi gh
concentrati ons to provi de an adequat e gradi ent f or di f fusi on int o the cel ls.

View Figure

Figure 24.2 The oxyhemoglobin dissociation curve.
Hemoglobin saturation is plotted as a function of oxygen
tension.

The shape of the oxyhemogl obi n dissociat i on curve l imi ts the degree of
desaturati on that can be tol erated. Between 90% and 100% saturat ion, the part i al
pressure of oxygen in art eri al blood (PaO
2
) wi l l be 60 torr or above. Bel ow 90%
saturat ion, the curve becomes steeper, and smal l drops i n saturati on correspond to
l arge drops in oxygen part i al pressure. If a probl em develops, there may not be
much warni ng before the oxygen l evel becomes dangerously l ow. Normal sat urati on
wi l l decrease as al ti tude above sea level i ncreases (24).
Equipment
Probes
The probe (sensor, transducer) i s the part that comes i n contact wi th t he pati ent. It
contai ns one or more LEDs (phot odi odes) that emi t l ight at speci f ic wavel engt hs
and a photodet ector (photocel l , t ransducer). The LEDs provi de monochromatic
l i ght. Thi s means that they emi t a constant wavel engt h throughout thei r l i f e, so they
never need recal ibrat ion. LEDs cause rel at ivel y l i t t le heati ng and are so
i nexpensive that t hey may be used i n a disposabl e probe. The l i ght , parti al l y
absorbed and modulated as i t passes through the t issue, i s converted i nt o an
el ect roni c si gnal by the photodetect or.
Fi gures 24. 3 to 24.11 show several types of probes. Probes may be reusable or
di sposabl e. They have the same accuracy (25,26,27,28). A di sposable probe i s
usual l y at t ached by usi ng adhesi ve. Reusabl e probes ei ther cl ip on or are at tached
by using adhesive or Vel cro. Di sposabl e probes may be easi er t o use, but reusable
probes are more economical as l ong as personnel are careful not to damage t he
reusable probe (26, 29, 30,31). Self -adhesive (band, wrap) probes are l ess
suscepti bl e to moti on art i f act and are less li kel y to come off i f the pat i ent moves
t han those that cl i p on. However, t hey are usual l y not as wel l shi el ded f rom ambi ent
l i ght as cl i p-on probes. Attachi ng reusabl e probes by usi ng an adhesive or Vel co
wrap may improve thei r stabi l i t y. Probes li ned wi t h sof t materi al may be associ ated
wi th f ewer mot i on art i f acts (32).
Some probes are avai l able i n di f f erent si zes. If a probe i s t oo large f or t he pati ent,
some of the l i ght output f rom the LED can reach the phot ocell wi t hout passing
t hrough ti ssue, and f al sel y hi gh SpO
2
readings wi l l be produced (33, 34). The
photocel l may not al ign wi t h t he probe, and readi ngs wi l l not be possi bl e.
Loss of reusabl e probes can be reduced by maki ng i t di ff i cul t to separate t he probe
f rom the cabl e (31). At tachi ng the probe to the oxi met er case when not in use wi l l
reduce damage and make i t easy to f i nd (35).
P. 779



View Figure

Figure 24.3 Disposable flexible probe. This can be placed
on a variety of sites, including the finger, ear, cheek,
tongue, toe, penis, hypothenar or thenar eminence, palm,
foot, and wrist. (Picture courtesy of Masimo Corporation,
Irvine, CA.)

To reduce contami nat ion, a gl ove, the f i nger of a gl ove, or other covering may be
used ei ther over the appl icati on si t e or over the probe (36,37, 38). Mi tt s are
avai l able t o shi eld ambient l ight (Fi g. 24.12).
Cable
The probe i s connected t o the oxi met er by an elect ri cal cabl e. Cabl es f rom dif ferent
manuf acturers are not i nterchangeabl e.
Console
Many dif ferent consol es are avai labl e (Fi gs. 24.13, 24.14,24. 15). Most oxi meters
t hat are used i n the operat i ng room are part of a physiologic moni tor. Most stand-
al one uni ts are l i ne operat ed but wi l l work on bat teri es, maki ng them usef ul duri ng
t ransport. Some oxi met ers are hand-held (Fi gs. 24.14, 24.15).
A microcomputer moni tors and control s signal l evels, performs the cal cul at ions,
i mplements si gnal val idi t y schemes, acti vates alarms and messages, and moni t ors
i ts own ci rcui try to warn of mal f unct i ons. A vari et y of messages may be provided to
i nform the operator of i ts
P. 780

f uncti onal status (13). The panel usual l y di spl ays percent saturat ion, pulse rate,
and alarm l i mi ts. Most uni ts have a bri ght di spl ay, al lowi ng them to be seen i n a
wel l -l i ghted room.

View Figure

Figure 24.4 Disposable flexible probe in place on a finger.
(Reprinted by permission of Nellcor Puritan Bennett Inc.,
Pleasanton, CA.)


View Figure

Figure 24.5 Reusable probe. This is most commonly used
on a finger or toe. In infants, this type of probe can be
placed on part of the hand or foot. These probes offer good
shielding from ambient light. (Picture courtesy of Masimo
Corporation, Irvine, CA.)

View Figure

Figure 24.6 Reusable finger probe in place. (Reprinted by
permission of Nellcor Puritan Bennett Inc., Pleasanton,
CA.)

The displayed val ues f or SpO
2
and pulse rat e are usual l y weighted averages. Some
oximet ers al l ow t he averagi ng peri od to be adj usted. A mode that averages over a
l onger peri od of ti me may work bet ter i f t here is much probe moti on (39). Changes
i n pul se rat e or saturat ion wi l l be ref l ected more rapi dl y i f t he averagi ng i s done
over a short er peri od of t i me.
Pul se ampl i tude may be represent ed by a si gnal i ndi cator. Other uni ts use a
graphic t hat i ndi cates pulse ampl i t ude and may provide a pl ethysmographi c
waveform.
Most i nstruments provi de an audible t one whose pi tch changes wi t h the saturati on.
I n t hi s way, t he operator can be made aware of changes in SpO
2
wi t hout looki ng at
t he oxi met er. By usi ng a variable t one pulse oxi meter, anesthesia provi ders
recogni zed an epi sode of oxygen desaturati on more qui ckl y than those usi ng one
wi th a f i xed t one (40). There i s usual l y a means to cont rol the vol ume of t he audi bl e
si gnal .
Al arms are commonl y provided for l ow and high pulse rates and l ow and hi gh
saturat ion. Many uni ts
P. 781

generate an al arm when the probe i s not properl y appli ed to t he pati ent or if f or
some other reason t he si gnal is i nadequat e. ASA standards for Basi c Anestheti c
Moni tori ng requi re that the vari abl e pi tch pul se tone and low t hreshold al arm be
audibl e (41).

View Figure

Figure 24.7 Disposable nasal probe in place. The clip from
a disposable oxygen mask may be used to improve contact
and to hold the probe in place. (Reprinted by permission of
Nellcor Puritan Bennett, Inc., Pleasanton, CA.)


View Figure

Figure 24.8 Reusable probe designed for use on the ear.
This may be used on other locations, including the cheek.
(Picture courtesy of Masimo Corporation, Irvine, CA.)


View Figure

Figure 24.9 Reusable probe on the ear. (Reprinted by
permission of Nellcor Puritan Bennett, Inc., Pleasanton,
CA.)

Most pul se oxi meters off er t rend dat a. Interf aces f or hard copy recording and data
management systems are usual l y avail abl e.

View Figure

Figure 24.10 Disposable wraparound probe on the foot.
(Reprinted by permission of Nellcor Puritan Bennett, Inc.,
Pleasanton, CA.)


View Figure

Figure 24.11 Disposable wraparound probe on the toe.
(Reprinted by permission of Nellcor Puritan Bennett, Inc.,
Pleasanton, CA.)
Oximeter Standards
The i nt ernat ional and U.S. standards are qui t e si mil ar (42, 43). Among t he
provi si ons are the f ol l owi ng:
There must be a means t o l i mi t t he durat i on of conti nuous operati on at
t emperat ures above 41C.
The accuracy must be st ated over the range of 70% to 100% SpO
2
. If the
manuf acturer claims accuracy below 65%, the accuracy must be stat ed over
t he addi t ional range.
I f the manuf acturer cl ai ms accuracy duri ng moti on, t hi s and the test methods
used to establi sh i t must be discl osed i n the i nstructi ons for use.
I f the manuf acturer cl ai ms accuracy duri ng condi ti ons of low perf usi on, this
and the test methods used t o est abl ish i t must be di scl osed in t he
i nst ructi ons f or use.
There must be an indi cat ion when the SpO
2
or pulse rat e data i s not current.
I f the pul se oxi meter i s provided wi t h any physi ol ogi c al arm, i t must be
provi ded wi t h an alarm system that moni t ors f or equi pment f aul ts, and t here
must be an al arm f or low SpO
2
that i s not l ess than 85% SpO
2
i n the
manuf acturer-conf igured alarm preset . An al arm f or hi gh SpO
2
i s opti onal .
An i ndi cati on of si gnal i nadequacy must be provi ded i f t he SpO
2
or pul se rat e
value displ ayed i s pot ent ial l y incorrect.
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View Figure

Figure 24.12 Special mitts are available to shield
pulse oximeter probes from ambient light.

I f a variabl e pi tch audi tory signal i s provi ded t o i ndicate t he pul se si gnal , the
pi tch change shal l f ol l ow t he SpO
2
reading (i . e. , as the SpO
2
readi ng l owers,
t he pi tch shal l al so be l owered).
Use
Sites
Finger
The probe i s most commonl y at tached over t he f i ngert i p (Figs. 24.4, 24. 6). The
f ai l ure rate is l ess, and accuracy i s bet ter when the probe i s placed on t he f i nger
t han on the earl obe (44,45,46).
The f inger i s relat i vel y sensi t i ve to sympathet i c system vasoconstri cti on (47,48). If
t here i s poor ci rculati on, a f inger block, di gi t al pul p space i nfi l trati on, or a
vasodi l ator may i mprove perf ormance (48, 49, 50,51,52,53,54). Vi gorousl y rubbi ng
t he f i ngert i p may temporari l y i mprove ci rcul at i on to t he area (50).
I f there i s dark fi ngernai l pol i sh or synthet i c f i ngernai l s, t he probe shoul d be
ori ented so that i t transmi ts li ght f rom one si de of the fi nger to t he other (55). Some
cl ear acryl ic nail s do not aff ect pul se oxi met er readi ngs (56).
A di sadvantage of placi ng a probe on an ext remi t y i s that detecti on of desaturat ion
and resaturat ion i s sl ower than when probes are pl aced more cent rall y
(48,57,58, 59, 60,61,62, 63,64). Response ti me may be qui cker when the probe is
pl aced on the t humb (62).
Mot i on art i f acts are less f requent when the probe i s pl aced on one of the larger
f ingers (32). The l i t t le f inger may be usef ul i f the pat ient is part i cul arl y l arge (65).
The probe may be pl aced over a fi nger that has a burn (66).
The probe shoul d not be on the i ndex f i nger duri ng recovery. As a pat i ent awakens,
t he pat ient of ten wi l l want to rub his or her eye, usual l y wi t h t he i ndex f i nger. I f the
oximet er probe i s on that f i nger, the cornea can be scratched.
I n general , the arm opposi te f rom that on whi ch t he bl ood pressure cuff is appl i ed
or i n whi ch an arteri al catheter has been insert ed shoul d be used. The pulse
oximet er i s somet i mes integrated wi th t he noni nvasi ve bl ood pressure moni tor so
t hat the pul se oximeter wi l l not alarm during t he i nf l at i on cycl e i f pl aced on t he
same arm as the blood pressure cuf f . Insert i on of a radial artery catheter i s
commonl y f ol l owed by a transient
P. 783

decrease i n blood f l ow and l oss of an adequate signal f or a pul se oximeter i f t he
probe i s on a f i nger of that hand (67). However, perf ormance i s unaf fected if pulse
oximet er readi ngs are made on t he arm i n whi ch an arteri al cannul a is present (68).
Occasi onal l y, poor f uncti on may occur wi th probe at tachment to t he same extremi ty
as t he intravenous i nf usi on, due to l ocal hypothermi a and vasoconst ri ct i on.

View Figure

Figure 24.13 The console may be a freestanding unit.
(Reprinted by permission of Nellcor Puritan Bennett, Inc.,
Pleasanton, CA.)


View Figure

Figure 24.14 Small handheld, battery-operated pulse
oximeters are often used, especially during patient transport.
This unit is in its recharger. (Picture courtesy of Masimo
Corporation, Irvine, CA.)

The posi ti on of t he arm may aff ect the readi ng. In most pati ents, the SpO
2
fall s
af ter the moni tored arm i s rai sed (69). I t may al so f al l when the arm is l owered
(70).
Toe
The t oe i s an al t ernate si te when the f i nger i s not avail abl e or t he si gnal f rom the
f inger i s unsati sf actory. Det ecti on of desat urati on or resaturat ion wi l l not be as
rapi d as wi t h more cent ral l y pl aced probes (63). The delay i n detecti on of
hypoxemia may be up t o 1 t o 2 mi nutes (64,71). The toe may provi de a more
rel i abl e si gnal i n pati ents who have had an epi dural bl ock (72). An i ncrease in
pulse ampl i tude f rom the toe may be a si gn of a successf ul bl ock (73).

View Figure

Figure 24.15 Combined pulse oximeter and carbon dioxide
monitor. (Reprinted by permission of Nellcor Puritan
Bennett, Inc., Pleasanton, CA.)

Nose
The nose i s usual l y a conveni ent l ocati on. Nasal probes respond more rapi dl y t o
changes i n sat urati on than probes placed on extremi ti es. The bri dge (Fi g. 24.7), t he
wi ngs of t he nostri ls, and t he nasal septum have been used (74,75,76). The nose
cl i p f rom a di sposable oxygen f ace mask can be at tached to the outer surf ace of a
f lexible probe to make i t f i t snugl y over t he bri dge (77).
Accuracy at t hi s si te i s cont roversi al . It has been recommended under condi ti ons
such as hypothermi a, hypotension, and i nf usi on of vasoconstrictor drugs. In
hypothermic pati ents, the nasal septum was a more reli abl e si te than the f i nger
(74,76). However, some studi es have f ound that nasal probes of t en gi ve grossl y
erroneous resul ts and have a hi gher f ai lure rate t han other si tes under condi ti ons of
poor perfusi on (78,79).
I f the pati ent is pl aced i n the Trendel enberg posi ti on, venous congesti on may occur
around the nose, causi ng t he pul se oxi meter t o displ ay art i f i ci al ly l ow sat urati ons
(80,81).
Ear
An ear probe (Fi gs. 24. 8, 24.9) may be hel d i n pl ace by a pl asti c semi ci rcular
device hung around the ear.
P. 784

St abi l i zi ng devi ces such as headbands or around-t he-ear l oops may be useful .
Usi ng a cl i p may i mprove the qual i ty of t he si gnal (82). The earl obe shoul d be
massaged f or 30 t o 45 seconds wi t h alcohol or vasodi lator or EMLA cream can be
appli ed f or 30 mi nut es prior to probe appli cati on to i ncrease perf usi on (83).
An ear probe can be part icul arl y usef ul when there i s fi nger moti on. Response t ime
i s faster wi t h an ear probe t han wi th a f i nger probe (48,58, 62,64,84, 85). Under
condi ti ons of poor perf usion, some ear probes perf orm bet t er than fi nger probes
(78). The ear i s relativel y i mmune to vasoconst ri ct i ve eff ects of t he sympathetic
system (47). The ampl i tude of ear pl ethysmography wi l l respond mai nl y to changes
i n pul se pressure. Ear probes may give more erroneous readi ngs than f i nger probes
i n pati ents wi th t ri cuspi d i ncompet ence (86). A st eep head down posi t i on may resul t
i n erroneous readi ngs (87). An ear oximeter may be combi ned wi t h a
t ranscut aneous carbon dioxi de sensor (4,88).
Tongue
A tongue probe can be made by pl aci ng a mal leabl e aluminum st rip behind the
probe to al l ow i t to bend around the t ongue (89,90). A di sposable probe wrapped
around the t ip of t he t ongue i n the sagi ttal plane may al so be used (91).
Ref l ectance pulse oxi metry has been used on the superi or surface of the tongue.
The mouth shoul d be cl osed.
Gl ossal pul se oximetry has been shown t o be accurat e (91). Thi s si te may be
especi al l y usef ul i n pat ients who have burns over a l arge percentage of thei r body
surf ace (90, 91). Desaturat ion and resat urati on i s detected by a probe at the tongue
quicker t han one on t he f inger or t oe (63).
A l i ngual probe i s more resi stant t o si gnal interf erence f rom el ect rosurgery than
probes placed on peri pheral si tes but may be di f f icul t to mai nt ai n i n pl ace duri ng
emergence (89,90). Tongue quivering may mi mi c tachycardi a. Ot her problems are
venous congesti on f rom a head down posi t ion and excess oral secreti ons. The
probe must be posi t ioned af ter tracheal i ntubati on or i nsert i on of a supragl ot ti c
ai rway. I t can be easi ly di sl odged.
Cheek
A probe wi t h a metal st ri p backi ng can be used to hol d a di sposabl e probe around
t he cheek or l ips (92,93). A cl ip-on probe wi th a cover over the part of t he probe on
t he buccal surf ace can also be used (94,95,96,97). This met hod of use i s not
recommended by t he manuf acturer (98,99). Probes speci al l y desi gned f or t hi s si te
are commerci al l y avai lable.
Buccal pul se oxi met ry i s more accurate t han f inger pulse oxi metry (93,100). Probes
at t hi s locati on detect i ncreases and decreases i n sat urat i on more qui ckl y than
f inger or t oe probes (63). Buccal oxi metry has been found to be ef f ective duri ng
hypothermia, decreased cardi ac output , i ncreased systemi c vascul ar resi stance,
and other l ow pulse pressure states. Thi s si t e i s useful i n pati ents who have burns
(101). Di sadvant ages i nclude di f f icul t pl acement, poor acceptance by awake
pati ents, and art i facts duri ng ai rway maneuvers.
Esophagus
Thi s probe uses ref l ectance oxi metry. The esophagus, a core organ, i s bet ter
perf used than the ext remi t ies duri ng st ates of poor peri pheral perf usi on and may
t herefore provi de a more consi stent , rel i able source for pul se oxi met ry wi th
hemodynamic i nstabi l i t y (102,103,104,105,106,107,108). It ref lects changes i n
arteri al saturat i on more quickl y t han peri pheral si t es such as t he f i nger. This si te
may be usef ul f or pat i ents who have extensi ve burns, on whom convent i onal probes
woul d be di f f i cul t to place (109,110).
Accurate pl acement of the esophageal probe requi res practi ce by t he user (107).
Achievement of a rel i abl e si gnal may be a probl em (104).
Forehead
A f l at ref lectance pul se oxi meter sensor can be used on t he forehead (82,111,112)
(Fi gs. 24.16, 24. 17). I t shoul d be pl aced just above the eyebrow so t hat i t i s
centered sl i ght ly l at eral of the i ri s (113). The sensor si te should be cl eaned wi th
al cohol before appl yi ng the sensor t o hel p secure t he adhesi ve. Pressure on t he
probe f rom a headband or pressure dressi ng may i mprove the signal (21, 82).
Thi s si te i s usuall y easi l y accessi bl e. The forehead i s l ess aff ected by
vasoconst ri cti on f rom col d or poor
P. 785

perf usi on than the ear or f i nger (114, 115). Changes in saturat ion can be detected
more rapi dl y at the forehead than at t he fi nger (48, 116). However, pool i ng of
venous bl ood due to compromi sed ret urn to the heart may cause l ow saturati on
readi ngs i n supine pati ents (81). It shoul d not be used i f the pati ent is i n the
Trendelenburg posi t ion. There are usual l y few mot i on art i facts when t he f orehead i s
used (117,118).

View Figure

Figure 24.16 Reflectance pulse oximeter probe. The light
source and sensor are situated next to each other. (Picture
courtesy of Masimo Corporation, Irvine, CA.)


View Figure

Figure 24.17 Reflectance pulse oximeter on the forehead.
Note the headband securing it in place. (Picture courtesy of
Masimo Corporation, Irvine, CA.)

Other
Pharyngeal pul se oxi met ry by usi ng a pul se oxi meter at tached t o a l aryngeal mask
may be usef ul i n pati ents wi th poor peri pheral perf usi on (119, 120).
Fl exi bl e probes (Fig. 24.3) may work through the pal m, foot, peni s, ankl e, l ower
calf , or even the arm in i nf ants (27,121,122) (Fi g. 24.10).
Pul se oxi met ry may be used t o moni tor fetal oxygenat ion duri ng l abor by at tachi ng
a ref l ect ance pul se oxi met ry probe t o the presenti ng part (20,23, 123,124). A
di sadvantage i s that t he probe has t o be placed bl i ndl y and may be posi ti oned over
a subcutaneous vei n or art ery, whi ch wi l l aff ect t he reli abil i t y of t he readi ngs (23).
Fixation
Proper probe placement is cruci al f or good perf ormance. A mal posi ti oned probe can
resul t i n fal se-posi ti ve and f al se-negati ve al arms. Probes can be tot al l y or parti al l y
di sl odged wi t hout this being noti ced.
Adhesi ve probes may stay on bett er t han cl i p-on probes. It may be benef i ci al t o
t ape probes i n pl ace when they wi l l be i naccessi bl e duri ng surgery, but i t i s
i mportant to avoi d compression of the f inger or other part . Wrapping t he l imb l ightl y
wi th gauze may hel p to f i x t he probe i n posi t i on. Anot her method is to sl i p the cut
f inger of a gl ove over the probe (125). The probe shoul d be protected f rom bri ght
l i ght (Fig. 24.12).
Stabilizing the Signal
The search that the pul se oxi met er goes through when a probe is i ni ti al l y appl ied
(or di sl odged) i ncl udes sequent i al tri als of vari ous intensi t i es of l ight i n an eff ort to
f ind a si gnal st rong enough to t ransmi t through the t issue but not so strong t hat the
detecti on system i s sat urated (12). Once a pulse i s f ound, there i s usual l y a del ay
of a f ew more seconds whi l e SpO
2
val ues f or several pul ses are averaged.
Appearance of a satisf actory wavef orm is an i ndi cat i on that the readings are
rel i abl e. Comparison of the pul se rate shown by the oxi meter and that by an
el ect rocardi ograph moni t or i s also an i ndicati on t hat saturati on readi ngs are
rel i abl e. A di screpancy between the rates i s f requentl y an i ndi cati on of probe
mal posi t i on or mal f uncti on. A discrepancy can al so occur duri ng cert ai n
dysrhythmias.
Reusing Disposable Probes
Because disposabl e probes are costl y, many i nst i tut ions reuse t hem
(126, 127,128,129, 130, 131,132, 133, 134). Al t hough concerns about thi s have been
raised (135, 136), several studi es show that the f ai l ure rate of reprocessed probes
i s equal to or l ess than that of new probes, and the accuracy i s not af f ected
(132, 133,134,137).
Testing
Devices that can be used t o test pul se oxi met ers are avai l abl e (138). Some al low
t he tester to set the plethysmographic wavef orm at di f ferent ampl i tudes and to t est
t he accuracy of t he heart rate as wel l as the SpO
2
.
Applications
Monitoring Oxygenation
Anesthetizing Areas
Oxygen desat urati on can occur at anyti me duri ng anesthesia, regardl ess of the ski l l
and experi ence of the anesthesia provi der. Desaturati on greater t han 10%
P. 786

occurs i n up t o 53% of anestheti zed pati ents (139, 140,141,142). Pedi at ri c pat i ents
are especi al l y at ri sk (121,143,144,145,146,147). Most severe desat urati ons occur
duri ng induct i on or emergence. Duri ng mai ntenance, desat urati ons are mi l der but
more f requent (148). St udi es have shown t hat a reducti on i n the number of
hypoxemic events occurred when pulse oxi metry was used (144,149). The i nci dence
of myocardi al i schemi a was also decreased (150).
Pul se oxi met ry may hel p to detect inadvert ent bronchi al i ntubati on (8,151,152,153).
Thi s met hod i s not al ways rel i abl e, part icularl y if an elevat ed i nspi red oxygen
concentrati on i s bei ng used (12,154). The absence of desaturat ion does not rul e
out bronchi al intubati on (155). Met hods t o det ect bronchi al i ntubat i on are discussed
i n Chapt er 19.
Oxi met ry i s usef ul i n managi ng one-lung anesthesi a to hel p assess the
ef fectiveness of measures t aken to i ncrease t he oxygen saturat ion (156) Chapter
20).
Oxi met ry i s usef ul f or pati ents undergoi ng regi onal and moni tored care anesthesi a
(157, 158). Of ten, the si gns of hypoxia are confused wi t h restl essness f rom an
i nadequate bl ock. Instead of suppl yi ng oxygen and assi st ing respi rat ion, addi t ional
sedati on i s provi ded, whi ch compounds the probl em. Wi th oxi met ry, the pat ient' s
oxygenati on st atus can be assessed and measures t aken t o improve SpO
2
.
Pul se oxi met ry may be usef ul t o conf i rm correct t racheal tube pl acement when a
f uncti onal carbon di oxi de moni tor i s not avai l able (159). I f oxygen sat urati on rises
af ter intubati on, correct t ube pl acement i s l i kel y. However, a pulse oxi meter should
not be rel i ed on for this purpose because preoxygenat ion may delay the onset of
desaturati on beyond the ti me when esophageal i nt ubati on woul d be consi dered
l ikel y.
Ot her probl ems that can cause a drop i n oxygen saturat ion i ncl ude f at embol ism,
amni ot i c f l ui d embol ism, pul monary edema, breat hi ng system di sconnecti ons and
l eaks, aspi rat ion, t racheal tube obst ructi on, hypoxi c gas mixture, oxygen del ivery
f ai l ure, hypovent i l at ion, anaphyl axis, bronchospasm, pneumot horax, mal i gnant
hyperthermi a, and pul monary embol i sm (8,160,161,162,163, 164,165,166, 167,168).
Causes of hypoxia rel ated to equipment are discussed i n Chapter 14.
Postanesthesi a Care Unit
The recovery room i s another l ocati on where desaturati on i s common
(141, 169,170,171, 172, 173,174, 175, 176,177). Rout ine oxygen admi ni strati on to
recoveri ng pati ents may not be necessary when pati ents are moni tored wi t h pul se
oximet ry (178). Before leavi ng the recovery room, a tri al of breat hi ng room ai r whi l e
moni tori ng oxygen saturat i on may provi de an indi cat i on of the need to cont inue
oxygen beyond t he postanest hesi a care uni t (PACU) or to retain t he pati ent i n t he
uni t f or a l onger ti me (179).
Transport
Unrecogni zed oxygen desat urati on may occur whi l e the pati ent is bei ng t ransport ed
bet ween t he operati ng room and the PACU and bet ween that uni t and other areas
(180, 181,182,183, 184, 185,186, 187, 188,189). Pul se oxi met ry i s i ncluded on most
t ransport moni tors, and portabl e pul se oxi met ers are avai l abl e.
Other Intrahospital Areas
Pat i ents f requentl y experi ence hypoxi c epi sodes i n the postoperative peri od af ter
l eavi ng t he PACU (190,191,192,193,194). Pul se oxi met ry can det ect these epi sodes
and aid i n deci di ng when oxygen t herapy shoul d be di sconti nued. Tel emetric pulse
oximet ry moni tori ng may be a cost -eff ect ive method of maxi mi zi ng qual i ty of care
when used t o moni t or pati ents on a general care f l oor (195).
Pul se oxi met ry i s usef ul for moni tori ng pat ients i n the i nt ensive care uni t (196). It
may be helpf ul duri ng weani ng f rom art if i ci al venti l at ion (197,198).
Pul se oxi met ry has been used duri ng cardi opul monary resusci tati on (199, 200, 201).
Because of art i f acts and lag t imes, i t is more useful in pri mary respi ratory arrest
t han i n cardiac arrest . I t i s usef ul i n assessi ng oxygenati on duri ng newborn
resusci tati on (203).
Another area where pul se oxi met ry has proved useful is the emergency depart ment
(204, 205,206).
Ref l ectance pulse oxi meters can be usef ul f or assessi ng f etal status duri ng l abor
and del i very by appl ying a f orehead probe (207).
Pul se oxi met ry i s usef ul i n i denti f ying whi ch pati ents wi th t oni c-cl oni c sei zures are
at ri sk of hypoxi c cerebral brai n damage (208).
Out-of-hospital Use
Pul se oxi met ry i s usef ul i n the prehospi tal set ti ng, incl udi ng when transporti ng
pati ents by hel i copter or ambul ance (209,210, 211, 212,213, 214, 215,216).
Controlling Oxygen Administration
Pul se oxi met ry al l ows t he l owest saf e oxygen fl ow and concentrati on compati bl e
wi th safe l evel s of art eri al oxygenat i on to be admini stered. Keepi ng the oxygen
concentrati on and f l ow l ow wi l l hel p to decrease the ri sk of a f i re (Chapter 32).
Monitori ng Peri pheral Circulation
Pul se oxi met ry can det ect arm posi t ions that compromi se ci rcul at ion (217). The
pulse oxi meter that is at tached to a toe can hel p to warn of decreased perf usi on at
t he foot i n pati ents i n the l i thotomy posi t i on (218). However, i t cannot rel i abl y
detect inadequate perf usion (219,220).
Moni tori ng oxygen saturat i on duri ng shoul der art hroscopy has been recommended
as a test f or
P. 787

brachial art ery compression (221). However, an adequate pulse signal may be
present wi th brachi al pl exus compressi on (222).
Pat i ents wi t h l i mb f ractures may have compromised ci rculati on di stal to the
f racture. Pulse oxi metry may serve as a useful gui de t o blood fl ow to t hat area
(223, 224,225). However, i t may not be hel pf ul i n warni ng t hat a compartment
syndrome is devel opi ng, because di minuti on of the art eri al pul se di stal to t he
compart ment is a l ate sign (226).
Pat i ents who undergo mediasti noscopy are at ri sk for brachi ocephal i c art ery and
aort ic arch compressi on bet ween the medi ast i noscope and the st ernum. Arteri al
compressi on may be det ected by measuring pul se wave ampl i tude on a pul se
oximet er (227,228).
Pul se oxi met ry may be used t o eval uate the eff ect of a sympatheti c bl ock as
i ndi cated by an i ncrease i n peri pheral bl ood f l ow (229,230). It may be usef ul duri ng
and af t er angiography to detect i nadequate bl ood f low (231).
Pul se oxi met ry may be used t o determi ne t he best si te of amputati on or art eri al
bypass surgery (232). I t has been used t o moni tor rei mpl anted or revascul ari zed
di gi ts (233, 234,235).
Pul se oxi met ry can be used to measure palmar col lateral ci rcul at i on
(236, 237,238,239, 240, 241,242, 243, 244). However, i ts usef ul ness f or t hi s has been
di sputed (245,246). There is a report of radi al art ery occl usi on that was detect ed by
pulse oxi metry (247). It has proved useful in eval uat ing a painful hand af t er
creat i on of an arteri ovenous f istul a (248). A simi l ar t est of the coll ateral ci rcul at ion
may be perf ormed on the f oot by usi ng pul se oxi met ry (237).
Determining Systolic Blood Pressure
A pul se oxi met er can be used t o det ermi ne t he systol i c bl ood pressure
(249, 250,251,252, 253, 254,255, 256). The blood pressure cuf f i s appl ied to the same
arm as the pul se oximeter. The cuff is i nf lated sl owl y, and the pressure at the poi nt
at whi ch t he wavef orm is l ost is noted. It also can be det ermined by inf l at ing the
cuff wel l past t he systoli c pressure and l ooki ng f or t he onset of a si gnal as t he cuff
i s def lat ed. One study f ound that t he best agreement wi th Korotkof f sounds and
noninvasive bl ood pressure equi pment occurred when t he average of bl ood
pressures est imat ed at t he di sappearance and reappearance of the wavef orm was
t aken as t he systol i c pressure (257). I n pedi at ri c pat ients, bl ood pressure
determined by this met hod was f ound to be more accurate than that determi ned by
an automati c noni nvasive bl ood pressure moni t or (258).
Pul se oxi met ry has been used f or pati ents wi t h pul sel ess diseases of the
extremi t i es to moni t or saturati on and systoli c bl ood pressure (259).
Locating Arteries
When t he axi l lary artery cannot be palpated, i t may be l ocat ed by pl aci ng a pulse
oximet er on a f i nger on t hat side and pressi ng i n the axi l l a unti l t he pul se wave
di sappears (260,261,262). Pulse oxi metry has al so been used t o locate the f emoral
and dorsal i s pedis art eri es by using a pulse oxi meter appl i ed to a t oe
(231, 263,264).
Avoiding Hyperoxemia
I n premature neonates, admini st rati on of oxygen may be associ at ed wi t h
devel opment of reti nopat hy and other pathol ogi c condi t i ons. Pulse oxi met ry can ai d
i n t i trat ing i nspi red oxygen by detecti ng hyperoxemi a (265,266,267,268,269). I t i s
recommended t hat t he hi gh SpO
2
al arm be set at 95% or lower f or this purpose
(269, 270,271).
Monitoring Vascular Volume and Sympathetic Tone
I f the pul se oxi meter begins ski ppi ng beats or perf orming i ntermi t tentl y, t he cause
could be hypovol emia (272). A correlat i on bet ween pulse wavef orm ampl i tude
vari ati on duri ng posi ti ve-pressure venti lati on and hypovol emia has been reported
(272, 273,274,275, 276). I f brief int errupti on of vent il ati on causes the wavef orm to
return to normal or more constant funct ion, a tri al of f l uid t herapy may be
war ranted.
One of t he most useful and commonl y overlooked pl et hysmographi c f eatures i s
waveform ampl i tude (277). Ampl i tude changes can be conceal ed by the aut o-gai n
f uncti on found on most pul se oxi meters. When the auto-gai n i s turned OFF, cert ai n
observat ions can be made. The pl ethysmograph si gnal ampl i tude i s di rectl y
proport ional to the vascular distensi bi l i ty over a wi de range of cardiac output.
During anesthesi a, the ungained pul se oxi met er si gnal may be used to determine
t he extent of at tenuat ion of the sympat heti c response to st imul i .
Another i mport ant feature of t he wavef orm i s the dicroti c notch (277). The notch
t ends to descend t oward t he basel ine duri ng i ncreasing vasodil ati on and gets
hi gher wi t h vasoconst ri ct ion.
Other Uses
Ot her si tuat i ons where oxi met ry may be useful i ncl ude hi gh-f requency j et
venti l ati on and det ermi ni ng the eff ect i veness of t herapeuti c bronchoscopy. I t can be
combi ned wi t h measurement of mi xed venous oxyhemogl obi n sat urat ion to esti mate
oxygen consumpti on (278,279).
Pul se oxi met ry has been used to gauge pulmonary blood fl ow i n i nf ants and
chil dren wi t h cyanot ic congeni tal heart l esi ons (280,281).
P. 788


Pul se oxi met ry can gi ve warni ng of f l ui d extravasati on (282).
Advantages
Accuracy
Pul se oxi met ry i s accurate, and accuracy does not change wi t h ti me. Numerous
studi es have shown t hat the dif f erence bet ween saturat ion det ermi ned by pulse
oximet ry and art eri al bl ood gas anal ysi s i s cli ni cal l y i nsigni f i cant above an SpO
2
of
70%
(13,14,26, 28, 46,57,60, 121,156, 267,283,284, 285,286,287,288,289,290,291,292,293,
294,295,296,297,298,299,300). Most manufacturers cl ai m that errors are less than
3% at saturat i ons above 70% (243). Thi s accuracy should be suff i ci ent f or most
cl i nical purposes, except possi bl y neonatal hyperoxi a. Changes i n accuracy are
negli gi bl e over t emperatures encount ered in cl i ni cal use (301).
Pul se oxi met ry i s accurate i n pat ients wi t h dysrhythmi as, provided that the SpO
2
i s
stabl e and t he pl ethysmogram i s noi se-f ree and has reasonabl e ampl i tude (302).
The SpO
2
may be correct even if t he pul se rat e i s not .
Independence from Gases and Vapors
Pul se oxi met ry readi ngs are not af f ected by anestheti c gases or vapors.
Fast Response Time
Pul se oxi met ry has a f ast response ti me, especial l y compared wi t h t ranscutaneous
measurements (156).
Noninvasive
Pul se oxi met ry i s noninvasive, whi ch al lows i t t o be used as a routi ne moni tor. I t i s
readi l y accepted by awake pati ents, so i t can be appl i ed bef ore i nduct ion of
anesthesi a. The bl eedi ng, art eri al insuf fi ci ency, embol i zati on, and infecti on
someti mes seen af t er art eri al puncture are avoi ded. Temporary el evat ion of the
PaO
2
i nduced by pain and apprehensi on is avoi ded.
Continuous Measurements
Sat urati on, pul se rate, and bl ood f low are conti nuousl y moni tored. Developing
t rends can be detected and remedi al act i on taken bef ore severe hypoxi a ensues.
Separate Respiratory and Circulatory Variables
Conti nuousl y moni tori ng the qual i t y of the peri pheral pulse may be hel pf ul i n
determining whether a hypotensi ve pati ent has good cardi ac output. If bl ood
pressure i s l ow and pul se si gnal st rength i s hi gh, the pat i ent i s probabl y
vasodi l ated but perf usi ng adequat el y. If , however, bot h blood pressure and pulse
st rengt h are l ow, perf usi on may be i nadequat e.
Perfusi on is i ndi cated by t he pul se si gnal st rengt h, and oxygenat i on is i ndi cat ed by
saturat ion. Unl i ke trans-cutaneous moni tori ng, the val ues di splayed do not requi re
i nterpretat ion. Most oxi meters wi l l si gnal i f the fl ow i s not adequate to provide a
saturat ion val ue. This i s hel pf ul i n determi ni ng a trul y l ow saturati on val ue as
opposed to one caused by l ow f l ow.
Convenience
The probe i s si mpl e and fast t o appl y. Si t e preparati on is mi ni mal . Arteri al izati on
of t he skin i s not usual l y not necessary, except when the earl obe i s the moni tori ng
si te. No cal i brati on or changi ng of elect rol yte or membrane i s requi red. A vari et y of
di ff erent probes are avai l abl e f or dif ferent si te appli cati ons.
Fast Start Time
There i s mi ni mal delay i n obtai ni ng t he oxygen saturati on. Readout t ypi cal l y begi ns
wi thi n a few beats af t er appl i cati on of the probe. Thi s is a di sti nct advantage over
t ranscut aneous moni t ori ng, whi ch requi res a prol onged warm-up ti me.
Tone Modulation
Changes i n pul se tone wi th varyi ng sat urat ion all ow the user t o be conti nuousl y
updat ed on SpO
2
wi thout t aki ng hi s or her eyes of f the pat i ent . Tone modul ati on
al l ows a much qui cker recogni ti on of hypoxi c epi sodes than does a f ixed tone (40).
Most anesthesi a providers can detect t he di recti on (but not t he magni tude) of a
change i n saturati on by l istening to the change in pi tch of a pul se oximet er t one
(303).
User-friendliness
Most i nstruments are user-f ri endl y. Minimal trai ni ng is requi red to l earn to operate
t he i nstrument.
Light Weight and Compactness
The console can be made l i ght wei ght and compact . Thi s faci li tates use duri ng
t ransport. Hand-hel d pul se oxi meters are avai lable. Oxygen sat urati on moni t oring i s
avai l able i n nearl y al l physi ol ogi c moni tors.
P. 789


Probe Variety
The wi de vari et y of probe confi gurat ions conf ers broad cl inical appl i cabi l i ty to al l
t ypes of pati ents, i ncl udi ng preterm infants. The abi l i t y to use vari ous vascul ar
beds off ers advantages f rom t he standpoint of access duri ng surgery and avoi ds
di sturbing t he surgi cal fi el d.
No Heating Required
Heati ng the ski n is not requi red. The probe can usual l y be lef t i n pl ace f or ext ended
peri ods wi thout ri sk of thermal inj ury.
Battery Operated
Most stand-al one uni ts and those i ncorporated i nto t ransport moni t ors can be
operated on batteri es.
Economy
The use of pul se oximetry can save money by l i mi ti ng oxygen admi ni strat ion to
si tuat ions where i t i s reall y needed and by decreasing the number of bl ood gas
analyses (178,194,304,305,306). I t may be cost -ef fect ive t o moni tor certain pat i ents
at hi gh ri sk f or transf er t o the i nt ensive care uni t (307). The use of moni tors wi t h
superior art i f act f i l teri ng abi li t y may resul t in cost savi ngs (308,309,310).
Limitations and Disadvantages
Failure to Determine the Oxygen Saturation
There i s a smal l but defi ni te i nci dence of f ai l ure wi th pulse oxi metry
(140, 311,312,313, 314, 315). Factors that are reported to contri bute t o hi gher f ai l ure
rates i nclude ASA physical stat us 3, 4, or 5 pati ents; young and el derl y pat ients;
orthopedic, vascul ar, and cardi ac surgery; el ectrosurgery use; hypothermia;
hypotensi on; hypert ension; durat ion of intraoperati ve procedure; chroni c renal
f ai l ure; l ow hematocri t; and moti on (140, 312,313, 314, 316,317,318, 319). The act ual
f ai l ure rate vari es wi t h the moni tor (320).
A pul se oxi met er may zero out, meani ng that i t di spl ays 00 f or t he SpO
2
and pul se
rates val ues when i t f ai ls to produce a measurement or i t mi ght displ ay ______ for
t he val ues (321). Some pulse oxi meters bl ank t he di spl ay or give a message such
as Low Qual i t y Si gnal or I nadequat e Signal . Ot hers f reeze the di splay.
Poor Function with Poor Perfusion
Pul se oxi meters requi re adequat e pul sat i ons to disti nguish l i ght absorbed f rom
arteri al bl ood f rom venous blood and ti ssue l i ght (322). Readi ngs may be unrel i abl e
or unavail abl e if there i s loss or di minuti on of t he peri pheral pul se (proxi mal blood
pressure cuff i nf l ati on, ext ernal pressure, i mproper posi ti oni ng, hypotensi on,
hypothermia, Raynaud' s phenomenon, cardi opulmonary bypass, l ow cardi ac output ,
hypovolemi a, peri pheral vascul ar di sease, a Valsal va maneuver such as seen in
l abori ng pat ients or in t hose wi th i nf usi on of vasoactive drugs
(78,140,251,287,319,322,323,324,325,326,327,328,329,330,331,332,333).
Met hods to improve t he si gnal i ncl ude appl yi ng vasodil ati ng cream, perf ormi ng
sympathet ic and digi tal nerve bl ocks, admi ni steri ng i ntra-art eri al vasodi lators, and
warmi ng cool ext remi ti es (49,51, 52,83,334,335,336,337). The use of a probe on a
bet ter perf used si t e such as t he cheek, tongue, nasal septum, or esophagus may be
hel pf ul . Improved si gnal technology by newer pul se oxi meters can improve
perf ormance duri ng l ow-perf usi on condi t i ons (320, 330,338, 339, 340,341).
Difficulty in Detecting High Oxygen Partial Pressures
At PaO
2
val ues above 90 mm Hg, smal l changes i n saturat i on are associated wi th
rel ativel y l arge changes i n PaO
2
. Thus, i t has l i mi ted abi l i t y to di st i ngui sh hi gh but
saf e l evel s of art eri al oxygen f rom excessi vel y el evated l evels (342).
Delayed Hypoxic Event Detection
Whi le t he pul se oxi meter response t ime i s general l y fast, t here may be a si gni fi cant
del ay between a change in al veolar oxygen tensi on and a change i n the oxi meter
readi ng. It i s possi ble f or arteri al oxygen t o reach dangerous l evel s before the
pulse oxi meter alarm is acti vated (343). Sett i ng t he low SpO
2
al arm threshol d
hi gher wi l l decrease the del ay.
Del ayed response can be related to probe locat ion (62,85). Desaturati on is
detected earl i er when t he probe i s placed more cent ral l y. Lag ti me wi l l be i ncreased
wi th poor perf usi on (251, 344, 345). Venous obst ructi on, peri pheral vasoconst ri cti on,
cold, and mot ion art if acts wi l l cause i ncreases i n t he t ime to detect hypoxemia
(32,325,327).
The al gori thms that are used to prevent f al se al arms may i ncrease t he del ay i n
detecti ng hypoxi c events (346). A pul se oximeter may respond t o a noisy or weak
si gnal by si mpl y hol di ng on to an ol d val ue (321). I ncreasi ng the ti me over whi ch
t he pul se si gnals are averaged also i ncreases t he del ay t i me.
Erratic Performance with Dysrhythmias
I rregul ar heart rhythms can cause the pulse oxi meter to perf orm errat i cal l y (347).
During aorti c bal l oon pul sat i on, t he augment ati on of di astoli c pressure exceeds
P. 790

t hat of systol i c pressure. This l eads to a doubl e- or t ri pl e-peaked art eri al pressure
waveform that confuses t he pul se oxi meter, so i t may not provide a readi ng
(348, 349). Pulse oxi metry works i n pati ents who have had an aortomyopl asty (105).
Inaccuracy
Different Hemoglobi ns
Most pul se oxi meters are designed to detect onl y t wo speci es of hemogobi n:
reduced and oxygenated. Whol e bl ood of ten contai ns other moi et ies such as
carboxyhemogl obi n, sulf hemogl obi n, and methemogl obi n. This di sturbs the
absorbance rat io of the wavel engths used to determi ne oxygen saturati on (350).
Methemoglobin
Normal l y l ess than 1% of the total hemogl obin, methemogl obi n (metHb) is an
oxidati on product of hemogl obi n that f orms a reversi bl e compl ex wi th oxygen and
i mpai rs the unl oadi ng of oxygen to t issues (351,352). Methemogl obi nemi a can be
congeni tal (353) or acqui red. Drugs causi ng methemogl obi nemi a incl ude
ni trobenzene (354), benzocai ne (355, 356), pri locai ne (357, 358, 359), and dapsone
(352, 360,361). Methemogl obi n absorbs l i ght equal l y at the red and i nf rared
wavel engt hs that are used by most pulse oxi meters. When compared wi th f uncti onal
saturat ion, most pul se oxi meters give f al sel y l ow readings f or sat urati ons above
85% and f al sel y hi gh val ues f or saturati ons bel ow 85% (351, 362,363,364,365,366).
The discrepancy between SpO
2
and f uncti onal saturati on i ncreases as t he level of
metHb i ncreases and functi onal hemogl obi n sat urati on decreases (351). Wi t h
t reatment of the methemogl obi nemia, the SpO
2
readings become more accurat e
(357, 358,361,365).
I f there are conf l icti ng resul ts between the pulse oxi meter and arteri al bl ood gas
analysi s, methemoglobi nemi a shoul d be suspected, and t he di agnosi s shoul d be
confi rmed by mul t i wavel ength co-oxi metry. The standard bl ood gas anal ysi s is not
capabl e of detecti ng and measuring metHb (367).
A new pul se oximet er capable of measuri ng metHb as wel l as carboxyhemoglobin i s
now avai labl e (Fig. 24.18).
Carboxyhemoglobin
Carboxyhemoglobi n (HbCO, COHb), f ormed when hemogl obi n is exposed t o carbon
monoxi de (CO), has an absorpt ion spect rum simi l ar to that of oxyhemogl obin, so
most pul se oxi meters wi l l over-read SpO
2
by t he percentage of carboxyhemogl obi n
present (18,368,369,370,371,372,373,374,375). I n one study, the pulse oxi meter
readi ng di d not go below 96% wi t h carboxyhemogl obin l evel s as hi gh as 44% (376).
I n vi t ro CO-oxi met ry can measure the percent ages of other moi et ies by usi ng more
t han two wavel engths.

View Figure

Figure 24.18 Pulse oximetercarbon monoxide monitor.

An i ncrease i n HbCO may occur duri ng laser surgery i n t he ai rway, but the l evel s
are not hi gh enough t o keep pulse oxi metry f rom rel i abl y est imati ng saturat ion
(377). Carbon monoxi de producti on in associati on wi th dry carbon di oxi de
absorbent i s di scussed i n Chapter 9.
Pul se oxi meters that di ff erent iate bet ween oxyhemogl obi n and carboxyhemogl obi n
and that can measure carboxyhemogl obi n are now avai l abl e (Fi g. 24.18).
Fetal Hemoglobin
Most studi es show t hat f etal hemogl obi n (Hb F) does not appear to aff ect the
accuracy of pul se oxi met ry t o a cl i ni cal l y i mportant degree (378,379, 380, 381,383),
al though very hi gh l evels may cause i t to read sl i ght l y l ow (382).
Hemoglobin S
The use of pul se oximetry i n the pat ient wi th si ckl e cel l disease i s controversi al .
Several i nvesti gat ors have concl uded t hat pul se oxi met ry i s inaccurate i n t hese
pati ents, which makes i t unrel iabl e f or detecti ng seri ous hypoxemi a (383,384,385).
Ot her st udi es have found i t to be suff i ci ent ly accurate t o be useful
(386, 387,388,389, 390).
Sulfhemoglobin
Sul f hemogl obinemi a may be caused by drugs such as metoclopramide, phenaceti n,
dapsone,
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and sul fonamides (391). Sul fhemogl obi n causes the pul se oxi meter t o displ ay
arti f actual l y l ow oxygen saturati on.
Other Hemoglobinopathies
Hemogl obin Koln i s associ at ed wi t h art i f actual l y l ow oxygen saturati on as measured
by t he pul se oxi meter (392,393).
Hemogl obin Hammersmi t h and Hemogl obin M (Mi l waukee) af f ect pul se oximeter
readi ng so much that oxi metry i s not useful (394, 395, 396).
Hemogl obin-H di sease wi l l cause the pul se oximet er t o indicate a hi gher saturat ion
t han i s actual l y present (397).
A pat ient wi th hemogl obi n Constant Spri ngs and al pha-t hal assaemi a 2 i n whi ch
pulse oxi metry readings were consistentl y low has been reported (398).
Hei nz Body hemol yt ic anemi a causes the pul se oxi meter to read l ow (399).
Bil irubi nemia
Severe hyperbi l i rubi nemi a can cause an arti factual el evati on of metHb and
carboxyhemogl obi n when using i n vi tro oxi metry but does not af fect pul se oximet ry
readi ngs (283,378,400,401,402,403).
Low Saturations
Pul se oxi met ry becomes l ess accurat e at l ow oxygen saturat ions
(10,26,57, 58, 61,84,284,285, 288, 291,293,294, 297, 298,306, 404, 405,406,407,408,40
9, 410,411,412, 413, 414). Thi s i naccuracy i s great er i n pati ents wi th dark skin (415).
I t should be used wi th cauti on i n pat ients wi th cyanoti c heart di sease
(410, 411,416). Measuri ng PaO
2
or SaO
2
at l ow saturati ons i s recommended for
i mportant cl i nical decisions.
Malpositioned Probe
Oxi met ers wi t h probes that are not appl i ed wel l vary greatl y in thei r behavi or,
dependi ng on both the actual SpO
2
and the manuf acturer and model of the oxi meter
(70,417,418,419,420,421,422). If the probe i s not properl y posi t ioned, i t may al l ow
t he l i ght f rom t he emi tter t o the detector to onl y graze t he t issue inst ead of passi ng
t hrough i t. This penumbra eff ect reduces the si gnal -to-noise rat io and may resul t i n
spuri ous SpO
2
val ues i n the l ow 90s i n normal pati ents. I f the pat ient i s hypoxic,
t he oxi met er may overesti mat e the t rue val ue (418,423). In one case, the probe was
compl etel y unattached but cont inued to provide apparent l y accurat e readings.
Cl oser exami nat i on of t he waveform reveal ed an unusual pattern (424).
To avoid t he probl ems of probe posi ti on, the posi ti on shoul d be checked f requent l y
and i naccessi bl e l ocati ons avoi ded. The use of too l arge or t oo smal l a probe may
resul t i n inaccurate readi ngs (33,34,300). Long f i ngernai l s can cause i naccurate
posi t i oni ng (425).
Venous Pulsations
Pul se oxi meter desi gn assumes t hat t he pul sati le components of l i ght absorbance
are due to art eri al blood. Promi nent pul sations of venous blood may lead to
underest imat i on of t he SpO
2
(70,426,427,428, 429, 429A). Pulse rat e det ermi nati on
may be correct . The error may be worse when probes are used on the head (86, 87)
but l ess when the probe is placed on the f i nger. I n pat ients wi th l ow systemi c
vascul ar resi stance, the pul se oximeter may under-read the saturat ion, possi bl y
because t he oximet er i s sensi ng pul sat i le venous f low (430).
Hi gh ai rway pressures during art if i ci al venti l at ion may cause phasi c venous
congesti on, whi ch may be interpreted by the oxi meter as a pul se wave (431). I n
some cases, i t may be necessary t o turn the vent il ator OFF to obtain a correct
readi ng.
Mixing Probes
SpO
2
measurements may not be accurate i f one manuf acturer' s probe is used wi t h
a di f f erent manufacturer' s i nstrument (432,433).
Severe Anemia
The pulse oxi meter may overesti mat e SpO
2
, especi al l y at l ow sat urati ons, i n
pati ents wi t h severe anemia (434,435,436, 437). However, i t is accurat e f or non-
hypoxi c SaO
2
values in t hese pati ents (438).
Skin Pi gmentation
Al though some earl i er studi es have shown t hat pul se oxi meter readi ngs were
sl i ght ly hi gh i n pat ients wi th dark ski n (286,439,440), newer st udi es have shown
t hat pi gmentati on does not make a si gnif i cant di f ference in pulse oxi meter accuracy
(26,441,442). Spuri ous readi ngs were report ed i n a pat i ent wi t h ocul ocutaneous
al bi ni sm who was taki ng a herbal remedy (443).
Dyes
Certai n dyes incl udi ng met hyl ene bl ue, indocyani ne green, l ymphazuri n (i sosulf an
bl ue), i ndi go carmine, ni t robenzene, and pat ent bl ue when inj ected i nt ravenousl y,
i ntra-art eriall y, i nt o the l ymphati cs, i ntradermal l y, or i nto the uterine cavi ty can
resul t i n decreases in SpO
2
wi t hout actual decreased saturati on
(354, 360,444,445, 446, 447,448, 449, 450,451, 452,453,454). In vi t ro oxi met ry may
al so be af f ected by dyes (360,445, 455, 456,457). Usual l y, the i nterf erence l asts onl y
a few mi nutes but may persi st much l onger, even hours, when l ymphatics are
i nj ected (451,452).
The reacti on of t he pul se oxi meter t o exogenous dyes has been used as a means of
confi rmi ng i nt ravascular cat heter pl acement. The dye is i nj ected i nto the cathet er,
and the pul se oximeter i s observed (458). The pulse oxi meter may be usef ul t o
esti mate cardiac output by the dye di l ut ion method (459).
P. 792


Fi ngerpri nti ng i nk wi l l cause a l ow sat urati on readi ng (460). Henna, a st ai n used by
some Mi ddl e Eastern women on the fi ngers and toes, can cause a l ow saturati on
readi ng (461). Chi ldren who have been f i nger pai nt i ng wi th blue paints may exhi bi t
l ow SpO
2
readi ngs (462).
Optical I nterference
St ray l i ght or l i ght f l ickering at f requenci es si mi l ar to the f requenci es of the LEDs,
i ncl udi ng sunl i ght, f l uorescent l ights, operat i ng room l i ghts, inf rared heat i ng lamps,
i nf rared radiant warmers, l ight sources f or vari ous scopes, xenon l amps, bi l i rubi n
l i ghts, photot herapy, or surgi cal i magi ng i nstruments, can ent er t he photodetector
and resul t i n inaccurate or errati c readi ngs
(14,332,463,464,465,466,467,468,469,470,471,472,473,474). Havi ng probes on t wo
adj acent f i ngers can cause an abnormal trace (475).
One cl ue that opti cal interf erence i s occurring i s inconsistency bet ween the pul se
rate on the pul se oximeter and that on other moni tors (350). Al though excessi ve
ambi ent l i ght usual l y prevents the oxi met er f rom tracking t he pulse, i t can resul t i n
apparent l y normal but i naccurate measurements i n some i nstances (470).
Oxi met ers vary signif i cantl y i n thei r suscepti bil i ty to opt ical i nterf erence (326,466).
Some manufacturers try to mi ni mize the ef fect of stray l ight by taki ng intermi tt ent
readi ngs when both of the LEDs in t he probe are turned OFF and then subt racti ng
t hese background readi ngs f rom measurements taken by the phot odet ector when
ei ther LED i s turned ON. Sensi tivi t y t o l ight may be i ncreased wi t h reduced pulse
ampl i tude.
There are a number of ways to mini mi ze the eff ects of opti cal i nterference. These
i ncl ude sel ecti on of the correct probe f or t he pati ent and use, appl yi ng the probe so
t hat the det ector i s across f rom t he LEDs, maki ng cert ain the probe remains
properl y posi t ioned, and shi el di ng the probe f rom l ight and other nearby probes
(Fi g. 24.12). Ext raneous l i ght can be el i mi nat ed by covering the probe wi t h an
opaque material such as a surgical towel , gauze, f i nger cot, blanket, al cohol wi pe
packet , or other f oi l shi el d (59, 127,476). Thi s may al so hel p to st abi l i ze t he probe.
Al l l ight may not be adequatel y shi el ded by a si mpl e coveri ng (463,470).
Nail Polish and Coveri ngs
Some shades of brown, bl ack, bl ue, and green (but not red or purple) nai l pol i sh
may cause si gni f icant l y l ower sat urati on readi ngs (477,478,479). Synthet i c nai ls
may i nterf ere wi t h pul se oxi met ry readi ngs. The presence of onychomycosi s, a
yell owi sh gray col or caused by fungus, can cause falsel y l ow SpO
2
readings (480).
Di rt under t he nail can al so cause di ff icul ty i n obtaining rel iable readi ngs (481).
Al though t here is one report of dri ed bl ood on a f inger t hat caused erroneous l ow
saturat ion readings (482), other authors have f ound that dried blood does not af fect
pulse oxi meter accuracy (483,484). Pat ients receiving docet axel may have
di scolored f ingernai ls that cause l ower sat urati on readi ngs (485).
I n most cases, thi s probl em can be overcome (wi thout removi ng the pol i sh or t he
synthetic nail ) by t urning the probe 90 degrees so that i t transmi ts l i ght f rom one
si de of the f i nger t o t he ot her side (55,481).
Electrical I nterference
El ect ri cal interf erence f rom an el ect rosurgi cal uni t can cause the oxi meter to gi ve
an i ncorrect pulse count (usual l y by counti ng ext ra beats) or t o fal sel y regi ster a
decrease i n oxygen saturati on (486). Thi s probl em may be increased i n pat ients
wi th weak pul se si gnal s (13). Manuf acturers have made signif i cant progress in
reducing t hei r i nst ruments' sensi ti vi t y to el ect ri cal interf erence (13,207,243,326).
Some moni tors displ ay a noti ce when si gni f i cant i nterf erence i s present . Some
f reeze the SpO
2
di spl ay duri ng such i nterference, whi ch may gi ve a f alse sense of
securi t y. Addi ti onal st eps to mi ni mi ze electri cal i nterference include l ocati ng t he
el ect rosurgery groundi ng pl at e as cl ose to, and the oximet er probe as f ar f rom, the
surgi cal fi el d as possi ble; routi ng the cabl e f rom the probe to the oxi meter away
f rom the electrosurgery apparatus; keepi ng t he pul se oxi meter probe and console
as f ar as possi bl e f rom t he surgi cal si te and t he el ect rosurgery groundi ng pl at e and
t abl e; and operati ng the uni t i n a rapi d response mode. The el ect rosurgical
apparatus and pul se oximet er shoul d not be plugged i nto the same power ci rcui t
(486).
Motion Artifacts
Mot i on of the probe can cause an arti fact that t he pul se oximeter i s unabl e to
di ff erenti ate f rom normal art eri al pul sat ions. Moti on arti fact creat es bot h false-
posi t i ve (f al se al arm) and false-negati ve (mi ssed hypoxemi a) errors (32,487).
Changi ng al arm threshol ds to reduce one of t hese errors wi l l of ten increase the
i nci dence of the ot her t ype of error (488).
Mot i on i s usual l y not a probl em duri ng general anesthesi a, but i f the pati ent is
shiveri ng, has a condi t i on such as Parkinson' s di sease, or is moving about or bei ng
t ransported, mot ion art i f acts can be signi f i cant (489, 490). Evoked pot enti al
moni tors and nerve sti mul ators can produce moti on arti facts i f the pul se oximeter
probe i s on the same ext remi t y (491,492, 493, 494,495). Moti on arti f acts have been
caused by pati ents t appi ng t hei r fi ngers whi l e under regi onal anesthesia (496).
The oxi meter' s abi l i ty to deal wi t h moti on art i f act depends on the correl at ion wi t h
t he onset of t he moti on and the start of moni t ori ng. If the moti on precedes the
onset of moni tori ng, t here is a great er decrement i n performance (497,498).
I n t he 1990s, pul se oxi met er manufacturers began to make desi gn i mprovements,
and the newer generati on
P. 793

i nst ruments have i mproved abi l i t y to f i l ter mot ion art if acts
(320, 321,338,341, 488, 497,498, 499, 500,501, 502,503,504,505). In addi ti on to
reducing al arms, the use of these i nst ruments has resul ted i n less need f or arteri al
bl ood gas measurements and f aster weani ng f rom hi gh concent rati ons of oxygen
(309). They are al so associ ated wi th a short er l oss of signal when pl aced dist al to a
bl ood pressure cuf f or t ourni quet (506).
Lengt heni ng t he averagi ng t ime wi l l increase the l i kel i hood t hat enough t rue pul ses
wi l l be detect ed to rej ect mot i on arti facts (15, 507) but may delay det ecti on of
hypoxemia. Most pulse oxi meters al l ow t he user to sel ect one of several t ime-
averaging modes.
Mot i on art i f acts can usual l y be recogni zed by f al se or errat ic pulse rate displ ays or
di storted pl ethysmographi c waveforms. Increased pul se ampl i tude indi cates
movement but not necessari l y arti f actual SpO
2
readi ngs (487, 508).
Mot i on art i f acts may be decreased by appl yi ng the probe to a less acti ve si te.
Fl exi bl e probes t hat are taped i n place are l ess suscept ibl e to mot i on art i facts than
are cl i p-on probes (13,15). Larger f i ngers may be l ess suscepti bl e to mot ion art i f act
(32).
Pressure on the Probe
Pressure on t he probe may resul t i n i naccurat e SpO
2
readi ngs wi thout aff ect ing
pulse rat e determi nat ion (429).
Hyperemi a
I f a l i mb becomes hyperemi c af ter blood f l ow i s i nt errupted, the oxygen saturati on
shown by the pul se oxi met ry may be arti f icial l y l ow (509). A pul se oximeter pl aced
near the si te of bl ood t ransf usi on may show transi ent decreases i n oxygen
saturat ion wi t h rapi d bl ood i nf usi on (510).
Probe Damage
A damaged pul se oxi met er probe can cause the oxygen saturat i on to be hi gher than
t he actual val ue (511, 512). The use of a cl eani ng agent t hat i s not recommended by
t he manuf act urer on a reusabl e probe can resul t in damage to the probe, prevent i ng
i ts reuse (513).
False Alarms
A hi gh percent age of pul se oxi met ry al arms are spurious or t ri vi al
(489, 503,505,514, 515, 516,517). Art i f act-induced alarms occur i n two ways. When
an arti f act i s mistaken f or a pul se, i t can corrupt the measurement and resul t i n an
al arm. When an arti fact obscures the pul se, i t can resul t in a l oss-of -pul se al arm.
Fal se al arms are most commonl y caused by moti on arti f act but are also associ ated
wi th poor si gnal qual i ty, probe di spl acement, ext ernal pressure, and i nterference.
Fal se al arms are a more signi f i cant probl em outsi de the operati ng room because
pati ents are commonl y movi ng, t hey are of ten poorl y perf used, and there are many
sources of el ectroni c and opt i cal i nterference.
Fal se al arms do not represent a di rect danger t o the pati ent but may encourage t he
care provi der t o take inappropri ate acti ons such as di sabli ng the al arm, set ti ng the
l i mi ts t o inappropriate values, or loweri ng the al arm vol ume. Mi si nterpretat i on of
al arms can resul t i n f ai l ure t o t reat hypoxemia or unnecessary t reatment.
Some f al se al arms can be avoi ded by simple measures such as putt i ng the probe
on a di ff erent extremi ty than the aut omated bl ood pressure cuff and in a l ocat i on
where i t is unli kel y t o be aff ected by external pressure.
Newer pul se oxi met ers t hat are desi gned t o reduce mot ion-rel ated art i facts can
si gni f icant l y reduce the i nci dence of f al se al arms
(320, 497,498,499, 503, 518,519, 520, 521,522, 523,524,525,526). However, some of
t hese have shown l ess rel i abi l i ty i n i dent if yi ng hypoxi c epi sodes and bradycardi a
t han ol der model s (346).
Del ayi ng the ti me bet ween detecti ng l ow SpO
2
and alarm activati on, usi ng a longer
averaging t i me, and sett i ng the l ow SpO
2
al arm l i mi t l ower can reduce t he number
of f al se al arms (311,517, 527, 528,529) but may i ncrease the lag t i me before
detecti ng hypoxemi a. Wi th some pul se oxi met ers, turni ng OFF t he low pulse rate
al arm prevents alarmi ng when the bl ood pressure cuff i s inf l ated (13).
Synchroni zi ng the pul se oxi meter wi th t he el ect rocardi ogram (ECG) moni tor can
l essen art i facts (32, 39). However, the oximeter may synchroni ze wi t h ECG art i facts
generated by moti on or shivering, resul ti ng i n erroneous readi ngs (13).
Furt hermore, wi t h thi s system, the pul se rate di spl ayed by the oximeter wi l l
necessari l y be equal to t he pul se rate shown by the ECG moni tor, so equal i t y of t he
pulse rat es cannot be used as an i ndi cat i on that the displ ayed saturati on data are
vali d.
Failure to Detect Impaired Circulation
The presence of a pul se oxi meter si gnal and a normal readi ng does not necessari l y
i mpl y that ti ssue perf usion i s adequate. Some pulse oxi meters show pul ses despi te
i nadequate ti ssue perfusi on (251,327) or even when no pul se is present
(200, 530,531,532). Ambi ent l i ght may produce a false si gnal (471).
Pul se oxi met ry i s not rel i abl e i n di agnosi ng i mpai red perf usi on wi th i ncreased
i ntracompartmental pressures (533,534).
Discrepancies between Readings from Different
Monitors
A di screpancy i n readi ngs bet ween di ff erent brands of oximeters on the same
pati ent at the same ti me is not uncommon (17,270,535,536,537, 538). There i s also
vari ati on i n
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t he ti me that i t takes vari ous moni tors to det ect resaturati on (539).
Failure to Detect Hypoventilation
Hypoventi l ati on and hypercarbi a may occur wi thout a decrease in hemogl obi n
oxygen saturat i on, especial l y if t he pat i ent i s receivi ng supplement al oxygen
(540, 541,542). Pul se oxi met ry cannot be rel i ed on to det ect l eaks, disconnect i ons
(543), or esophageal intubati on (544). Met hods to detect esophageal i ntubat ion are
di scussed i n Chapter 19.
Problems with Sound Recognition
There i s considerable vari at ion i n the vol ume and audio spect rum of avai l abl e pul se
oximet ers bet ween models and even wi thi n models (545). Some cli ni ci ans have
t rouble detecti ng changes in the pi tch of the sound emi t ted by pulse oxi meters as
t he saturati on changes (303,546).
There i s wi de vari at ion i n the pi tch f requency of di ff erent pul se oxi met ers (547).
Thus, i n locat i ons where dif f erent pul se oximeters are encountered, the potenti al
f or confusi on exi sts.
Lack of User Knowledge
Pul se oxi met ry i s of ten used by personnel whose knowl edge of i t is l imi ted.
Physi ci ans, nurses, and ot hers who use t he i nstrument of ten do not know t he basic
pri nci pl es and make seri ous errors i n int erpreti ng readi ngs (548,549,550, 551).
Interference with Other Monitors
El ect romagneti c interference f rom the pulse oxi meter power suppl y may cause
arti f acts and false readings on certain t horaci c i mpedance moni tors (552).
I f a pul se oxi meter probe i s pl aced i n f ront of certai n pl asma di spl ay t ouch screens,
a normal -appeari ng wavef orm and 100% saturati on i s di spl ayed (553).
Patient Complications
Corneal Abrasions
Pat i ents recoveri ng f rom general anesthesia f requentl y rub t hei r eyes. If there i s a
pulse oxi meter on the i ndex f i nger, a corneal abrasi on may resul t (65, 554,555). A
f inger other t han the i ndex f inger may be a more appropri ate l ocati on for the probe
duri ng recovery (556).
Pressure and Ischemic Injuries
I njuri es rangi ng f rom persi st ent numbness to i schemic i nj ury at the si te on whi ch a
probe was pl aced have been reported
(557, 558,559,560, 561, 562,563, 564, 565,566, 567,568). Loss of t he si gnal may occur
(569). These ri sks are i ncreased by prolonged probe appl i cati on, compromi sed
perf usi on of t he ext remi t y, and ti ght appl icat i on of the probe. Frequent examinati on
of t he si te and movi ng the probe to di ff erent si tes wi l l reduce the l i kel i hood of
i nj ury. Pat ients wi t h l arge f i ngers shoul d not have a ci rcumferent i al probe pl aced on
t he f i nger. I f t he pul se oxi met er readi ng appears to be weak, t he si te shoul d be
checked for i ncreased pressure.
Burns
I njuri es rangi ng f rom reddened areas to t hi rd-degree burns under pulse oxi meter
probes have been report ed
(562, 570,571,572, 573, 574,575, 576, 577,578, 579,580,581). Consi deri ng the mi l l i ons
of l ong-t erm appli cati ons, the i ncidence of these burns is qui te l ow (43).
Burns can resul t f rom i ncompat ibil i t y bet ween the probe f rom one manufact urer wi t h
t he pul se oxi meter of anot her (575,578). A number of pul se oxi meter probes have
connectors that f i t dif ferent pul se oximet ers, but the probes are not compat i bl e. The
use of a damaged probe can resul t i n a burn (570,577). A pulse oxi meter probe may
provi de an al ternate pathway for elect rosurgical currents (582).
Burns t hat are associ at ed wi t h hypothermi a have been reported (579). Burns have
been report ed when a pulse oxi meter was used duri ng photodynamic therapy
(583, 584).
To avoid t hese i nj uri es, f requent i nspect i on of t he probe si te and si te rotat i on are
recommended (585). When a probe i s pl aced on a fi nger or t oe, t he l ight source
shoul d be pl aced on the nai l rather t han on t he pul p (576). A gl ove can be pl aced
on the fi nger to prot ect i t f rom t hermal i nj ury wi thout af f ect ing t he accuracy of t he
i nst rument (36). If the pulse oxi meter displ ay f reezes, t he cause shoul d be
i nvesti gat ed. Onl y the probes recommended by t he oximeter manuf act urer shoul d
be used (578).
Burns t hat are associ at ed wi t h pul se oximetry duri ng magnet ic resonance i magi ng
(MRI) as a resul t of induced ski n current beneath l ooped cabl es acti ng as antennae
have been report ed (586,587,588). The MRI envi ronment i s di scussed i n Chapter
30. Duri ng MRI , the danger of burns can be reduced by t he f ol lowi ng measures:
Al l pot enti al conductors shoul d be checked before use t o ensure that t here i s
no f rayed insul at ion, exposed wi res, or other hazards.
Al l unnecessary conduct i ve materi al s such as unused surf ace coi ls shoul d be
removed f rom t he MRI system bore bef ore pat ient moni tori ng i s i ni t iat ed.
P. 795


The probe shoul d be pl aced as far f rom the i magi ng si te as possi bl e.
Cables, l eads, or wi res f rom moni tori ng devi ces shoul d be posi t ioned so t hat
no l oops are f ormed. A brai d shoul d be made of the sl ack port ion of wi res.
I f possi ble, no potenti al conductors shoul d touch the pati ent at more than
one l ocati on.
A thick l ayer of t hermal i nsulat i on should be placed bet ween any wi res or
cables and the pati ent' s ski n.
Moni tori ng devi ces that do not appear t o be operat ing properl y shoul d be
removed f rom t he pat ient .
Electric Shock
An el ect ri cal shock rel ated t o diathermy has been reported (589). I n thi s case,
t here were bare wi res i n the pulse oxi meter probe.
Carbon Monoxide Monitoring
Carbon monoxi de can accumul at e i n the breat hi ng system f rom various sources,
i ncl udi ng t he react ion between anestheti c agents and desi ccated absorbent. Thi s i s
di scussed i n detai l i n Chapt er 9. It i s di ff icul t to determi ne if CO i s present i n the
i nspi red gases when the pat i ent i s anest heti zed.
I n 2005, a combi nat ion pul se CO-oximeter capable of measuri ng
carboxyhemogl obi n (SpCO) became avai l abl e (Fi g. 24.18). The same sensor i s
used for measuri ng bot h SpCO and SpO
2
. It alarms wi th CO concent rati ons
bet ween 5% and 50%. The i nst rument uti l i zes an eight- wavelength sensor to
di st ingui sh bet ween oxygenated bl ood, deoxygenated blood, and bl ood contai ni ng
CO. I t can also measure metHb.
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P. 803


Questions
For the f ol lowing quest ion, sel ect the correct answer
1. I n which wavelength does reduced hemogl obin absorb more li ght?
A. The purple band
B. The red band
C. The i nf rared band
D. The near i nf rared band
E. The blue band
Vi ew AnswerFor the fol l owing quest i ons, answer
i f A, B, and C are correct
i f A and C are correct
i f B and D are correct
i s D i s correct
i f A, B, C, and D are correct .
2. Cause(s) of burns associated with pulse oxi meters probes include(s):
A. Hypot hermia
B. I ncompat ibl e probe and pulse oxi meter
C. Photodynamic therapy
D. Vol tage surges
Vi ew Answer3. Fracti onal oxygen saturation i s
A. The rati o of oxyhemogl obin to al l t he f unct i onal hemo-gl obi ns
B. Cl ose to funct ional oxygen saturati on in pati ents wi th l ow l evel s of
dyshemoglobi ns
C. Determined by i n vit ro oxi met ry
D. The rat io of oxyhemogl obin t o the sum of al l the hemo-gl obin present
Vi ew Answer4. Effects on pulse oximeter readi ngs of a methemoglobi n
l evel higher than 1% i ncl ude
A. The discrepancy bet ween SpO
2
and functi onal sat urati on increases as the l evel
of metHb i ncreases and f uncti onal hemogl obi n sat urati on decreases
B. Normal l y, there i s l ess than 1% methemogl obi n i n the bl ood
C. Saturat ion readings may be falsely l ow f or readi ngs above 85%
D. Si nce methemogl obi n has the same absorpti on coeff icient i n the red and i nf rared
bands, t here wi l l be no dif f erence i n the pul se oximeter readings
Vi ew Answer5. Which of the foll owing do not affect pulse oximeter
readi ngs si gni fi cantly?
A. Hyperbi l i rubinemia
B. Hemogl obi n S
C. Hemogl obi n F
D. Severe anemi a
Vi ew Answer6. When using a finger probe,
A. Response ti me is quicker i f the probe is placed on the t humb
B. I nsert ion of a radial art ery cat heter i mproves pulsati on
C. The probe can be pl aced si deways t o avoid dark fi ngernail pol ish
D. Smal l er f ingers cause f ewer moti on arti f acts
Vi ew Answer7. Pulse oximetry can be used to
A. Detect brachi al art ery compression duri ng shoul der art hroscopy
B. Moni tor ci rcul at ion t o rei mpl anted or revasculari zed di gi ts
C. Determine t he best si t e f or art eri al bypass surgery
D. Eval uat e a sympathet i c block
Vi ew Answer8. Factors reported to contribute to higher fail ure rates wi th
pul se oxi metry include
A. Physi cal status 3, 4, or 5; young and el derl y pat ients
B. Orthopedic, vascul ar, and cardi ac surgery
C. Hypertensi on
D. Low hemat ocri t
Vi ew Answer9. Measure(s) to i mprove the peripheral pulsation i ncl ude
A. Appl icati on of vasodil ati ng cream
B. Di gi tal nerve bl ocks
C. Admi ni st rati on of i nt ra-arteri al vasodi l ators
D. Sympathet ic bl ock
Vi ew Answer10. Reflectance pulse oxi metry differs from transmission
pul se oxi metry in which ways?
A. The ref l ection ori gi nates f rom homogenei ty i n the opti cal path
B. The ref l ectance oxi metry rel i es on backscatt ered li ght to determine the oxygen
saturat ion
C. The t i ssue does not need to be wel l perfused to obtain a st rong si gnal
D. I f the probe is over an artery or vei n, the reading may be art i f i ci al l y l ow
Vi ew Answer11. Concerni ng the nose as a monitoring si te for pul se
oxi metry,
A. Nasal probes are sl ower to respond than f i nger probes
B. Nasal probes have a hi gher f ai l ure rate than other si tes during peri ods of
hypothermia
C. The Trendel enberg posi t i on i mproves the accuracy of pul se oximet ers readi ngs
D. The nasal probe is recommended when vasoconstri ctor drugs are i nf used
Vi ew Answer12. Which of the foll owi ng statements about ear probes are
true?
A. Response ti me is f aster t han wi th a f inger probe
B. Tri cuspid i ncompetence may cause erroneous readings
C. The ear i s rel at ivel y i mmune to vasoconstri cti ve ef f ects of t he sympatheti c
system
D. The ampl i t ude of ear pl et hysmography does not respond t o changes in pulse
pressure
Vi ew Answer13. Problems wi th the tongue as a l ocati on for pulse
oxi metry include
A. Tongue quiveri ng can mi mi c tachycardi a
B. Excessi ve secret ions
C. Venous congesti on wi th t he Trendenberg posi ti on
D. Decreased resi st ance to el ect rosurgical signal i nt erf erence
Vi ew Answer14. Situations where buccal pulse oxi metry may be
preferable are
A. Low pul se pressure stat es
B. I ncreased systemi c vascul ar resi stance
C. Hypothermia
D. Decreased cardi ac output
Vi ew AnswerP. 804


15. Advantages of using pulse oxi metry include
A. Usual ly accurate in pat i ents wi t h dysrhythmi as
B. An i ndi cati on of the adequacy of perfusi on
C. Readi ngs are not af f ected by anesthet ic gases and vapors
D. Accurate readi ngs to an SpO
2
of 50%
Vi ew Answer16. What factors cause delayed detecti on of hypoxemi a by a
pul se oxi meter?
A. Peri pheral l ocati on of the pulse oxi metry sensor
B. Peri pheral vasoconstricti on
C. Poor perf usi on
D. Decreased t ime over whi ch t he pul se si gnals are averaged
Vi ew Answer17. Concerni ng carbon monoxide and pulse oximetry,
A. The absorpt i on spectrum of carboxyhemogl obi n is si mi l ar to that of
oxyhemoglobi n
B. The pul se oxi meters does not read bel ow 94% when carboxyhemogl obi n i s
present
C. Pulse oxi meters that can dif f erenti at e oxyhemogl obi n and carboxyhemogl obi n
are avai l abl e
D. Standard pulse oxi meters can warn t hat CO is present but cannot quant i tat e i t .
Vi ew Answer18. Which hemogl obin(s) does(do) not affect the pul se
oxi meters?
A. Hemogl obi n H
B. Sul f hemoglobi n
C. Hemogl obi n S
D. Fetal hemoglobi n
Vi ew Answer19. Causes of probe posi ti on problems incl ude
A. Too smal l a probe
B. Long fi ngernai l s
C. Too l arge a probe
D. The penumbra ef f ect
Vi ew Answer20. Concerni ng pul se oxi meter inaccuracy resul ti ng from
venous pul sations,
A. The pul se oxi meter underesti mates t he SpO
2

B. Venous pulsati ons are more promi nent i n t he f inger t han i n t he head
C. The pul se oxi meter reads venous pulsations as i f they were arteri al pulsati ons
D. Hi gh systemic vascul ar resistance promotes venous pul sati ons
Vi ew Answer21. Condi ti ons i n which the pul se oxi meters reads hi gh SpO
2

values i ncl ude
A. Venous pulsati ons
B. Cert ai n i nt ravenous dyes
C. Ski n pi gmentat i on
D. Severe anemi a
Vi ew Answer22. Which dye(s) affect the pulse oximeters?
A. I ndocyani ne green
B. Isosul f an bl ue
C. Patent bl ue
D. I ndi go carmi ne
Vi ew Answer23. Opti cal interference to pulse oxi metry can come from
which source(s)?
A. Bi l i rubi n l i ghts
B. Xenon l ights
C. I nf rared heati ng l amps
D. Sunl i ght
Vi ew Answer24. What col ors of nai l pol ish i nterfere wi th pulse
oxi meters?
A. Brown
B. Green
C. Bl ack
D. Red
Vi ew Answer25. What other substances besides nai l pol ish i nterfere wi th
pul se oxi meters?
A. Onychromycosi s
B. Di rt under the f i ngernai l
C. Synthetic nail s
D. Dri ed blood
Vi ew Answer26. What are some of the moti on artifacts that may affect
pul se oxi meters?
A. El ectrosurgery
B. Nerve st i mul ators
C. Surgi cal movements
D. Evoked potenti al moni tors
Vi ew Answer27. Causes of false alarm(s) i ncl ude
A. Poor si gnal qual i ty
B. Probe di splacement
C. External pressure
D. Mot i on art i fact
Vi ew Answer28. What are the common causes of pressure and i schemic
i njuri es related to pul se oxi metry probes?
A. Prol onged probe appl i cati on
B. Ti ght appl i cat ion of the probe
C. Compromi sed perf usi on under t he probe
D. Probes hel d on by a cli p
Vi ew Answer