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Pulse oximiter and why does it mater?

Background/Semantics:
Fractional Oximetry:
SaO2 = HbO2 / total HB = HbO2 /(HbO2 + HHb + metHb +COHb)
Pulse Oximetry:
SpO2 (HbO2/HbO2 HHb)
Mechanism of pulse oximetry:
-HHb (deoxy) absorbs more light in the red band (600 to 750 nm) than does
HbO2 (oxy), whereas HbO2 absorbs more light in the infrared band (850 to 1000
nm) than does HHb. The conventional pulse oximeter probe contains two light-
emitting diodes (LEDs) that emit light at specific wavelengths: one in the red band
and one in the infrared band. Typical wavelengths are 660 nm and 940 nm. Light is
absorbed at pressure peaks and troughs = must need pulsatile flow!

Accuracy:
-Pulse oximeters have generally been found to be accurate to within 5% of in
vitro oximeters, in the range of 70% to 100%.
-Average data on 5-7seconds delay

Common pathologies and pulse ox:

-COHb: From house fire, cigarette smoking, engine exhaust). Causes a left shift if
OxHb curve (binds to Hb with affinity 200-300x > o2 = met acidosis (LA) due to
tissue inability to extract O2. It is interpreted by the pulse oximeter as a mixture of
approximately 90% HbO2 and 10% HHb. Thus, at high levels of COHb, the pulse
oximeter will overestimate true SaO2, pulse ox typically 92-100%, cherry red
appearance and PaO2 is typically normal. Dx with co-oximetry.
Signs: cherry red blood, acidosis, PaO2 and Spo2 normal despite acidosis.
Dx: co-oximetry
Tx: O2

-metHb: When iron in the Fe3+ state instead of Fe2+. MetHb unable to release O2 =
left shift. Formed from drugs: nitrites, chlorates, nitrobenzenes, antimalarial agents,
amyl nitrate, nitroglycerin, sodium nitroprusside, and local anesthetics (benzocaine,
prilocaine). MetHb is very dark and tends to absorb equal amounts of red and
infrared light, resulting in a red:infrared ratio of 1 = corresponds with a saturation
of 85%. Treatment = methylene blue 1-2mg/kg (however it can cause hemolysis in
G6PD individuals, use VitC).
Signs: cyanosis and dark blood despite normal PaO2, SpO2 85%, acidosis.
Dx: co-oximetry
Tx (symptomatic or >20%): Methylene blue 1-2mg/kg, VitC, hyperbaricO2,

-Fingernail polish: dark colors are the worst, turn 90 degrees so parallel to
fingernail. Problematic = blue, black, green. Red is ok.
http://journal.publications.chestnet.org/article.aspx?articleid=1081672
-Methylene blue, indocyanine green, and indigo carmine all cause transient
decreases in SpO2 lasting 30s to 20m

Rules to remember:
SpO2 90% = PaO2 60mmHg
SpO2 60% = PaO2 30mmHg
SpO2 50% = PaO2 27