Dr. S.

Dingezweni

Pulse oximeter -History -principles employed -Haemoglobin extinction curve -Limitation of pulse oxymeter ` Capnography -History -principles used -Sampling methods -Normal & some abnormal capnogram
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History -Was developed 1972

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Using ratio of red to infrared light absorption of pulsating component at measuring site
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Commercialised by Biox 1981 Prior to it

-painful ABG
-single point measure took 20-30min lab prossecing determined ptn oxygenation Then studies in anaesthesia journals estimated U.S pt mortality <> 200-10000 due to undetected hypoxemia

Pulse oximeter -non invasive -continuous measure of ptn O2 was possible -Revolutionised practise of anaesthesia -Improved pt safety ` It has since became standard of care for G.A administration ` From O.T spread throughout hospital
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Oxygen supply to tissues depend on -cardiac output -O2 content of blood ` Content depend on -Hb concentration -O2 tension in blood ` Pulse oximetry measures only one aspect -the degree(%) of saturation of Hb with O2
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Spectrophotometry Passing radiation through a sample and determining the quantity absorbed Plethysmography Measure changes in volume of organ/body as volume of air or blood in it changes

Oxymetry

-subset of spectrophotometry -determines the concentration of various Hb species -By measuring the absorbance of light at multiple wavelength

Multiwavelength co-oximeter use four or more wavelengths to measure concentration of different Hb species in vitro i.e -oxyhaemoglobin -deoxyhaemoglobin -methaemoglobin -carboxyhaemoglobin ` The conventional pulse oximeter is a two wavelength oximeter - uses the different absorption spectra of oxy- and deoxyHb to determine saturation
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-Two laws describing the absorption of radiation as it passes through a sample are ` Beers law
-intensity of transmitted light decreases exponentially as the concentration of the substance increases, the path length being constant

Iincident = Itransmitted .eD =the distance through which light has to travel C =concentration of solute -a =extinction coefficient of the solute
(D.C.a)

Bouguers or Lambertt law - Intensity of transmitted light decreases exponentially with increased distance through the substance
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Wavelengths used -Two light emitting diodes (L.E.D) -Two wavelengths -HbO2 absorb more infrared light (960nm) -Deoxyhaemoglobin absorb more red light (660nm) appears blue on naked eye -Photodetector
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Cycle ON & OFF -at rate of 480/s at 60 Hz current -and 400/s at 50Hz ` Purpose-of using different cycling frequencies is to keep these out of phase with that of artificial ambient light & so eliminate the effects of this from interfering with oxymeter detection
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Cycling sequence of these 2 LED is Red ON Infrared OFF Red OFF Infrared ON Red OFF Infrared OFF Ambient light is measured during the dark period when both LED are OFF Photodetector on the opposite side of the tissue bed records the transmitted light and generates output signal

Pulsatile and non pulsatile tissue absorb red and infrared AC signal represent pulsatile tissue i.e arterial blood DC represent non pulsatile tissue i.e venous blood ,bone & soft tissue Pulse oxymeter determines the AC component of absorbance at each wave length and divide it by DC component

Functional saturation is calculated as the Oxygenated to(Oxygenated +reduced) Hb quotient i.e So2=HbO2/(HbO2+HHb) ` Fractional Saturation is calculated as the oxygenated total Hb quotient i.e HbO2 fraction=HbO2/total Hb
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Safe Technical
Mechanical artefacts Electromagnetic interference MRI

Dangerous
Accuracy Calibration Delay Flooding Penumbra

Physiological

Pulse dependence Pulse volume Pulse rhythm

Abnormal Hb Other absorbents Dyes &pigmentation Pulsatile veins

Carboxyhaemoglobin

-similar absorption to HbO2 spectrum at660nm

-Falsely high
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Methaemoglobin

-Similar absorption as HbO2 at 660nm highest 940nm -Reads 85 % regardless of level of SaO2 -For SaO2 >85% under read <85% over read
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Haemoglobin F

-SaO2 readings little effect

Any substance in pulsatile blood absorbing light at 66onm or 940nm will affect absorbance ratio Methyline blue(large decrease) or indocyanine green used for diagnostic purposes have a drastic effect on accuracy of pulse oximeter

1. Motion Artifact -Result in large AC/DC signal ratio -overcome by averaging over long time 2. Ambient light -Photodetector cant distinguish red, infrared or Ambient light -alternate red and infrared light during OFF cycle ambient light processed -Ambient light also processed out by high frequency cycling

3. Low perfusion states -Result in poor AC/DC signal ratio -Signal gets amplified, but so does background noise resulting in an increased signal:noise ratio 4. Venous pulsation -Light absorbance of venous blood can also have a pulsatile component -May get false low readings/fail with venous congestion

5. Penumbra effect
-Improper positioning on ear lobe or finger may result that light travelling to detector only graze tissues -reduces signal: noise ratio resulting in a falsely low reading

6. Temperature -Hypothermia significant with reduced perfusion

-Room/body temperature slight shift in absorption spectrum

7. Nail polish/blood on finger nails

-absorb light according to extinction coefficient at wavelength concerned -Decrease amount of red &infrared reaching the detector Blue 5,92% Green 5,19% Black 3,08% Purple 1,68% Red 0,29%

8. Skin pigmentation
Normal reading when SaO2 correct, but increasing error with lower readings 9. Anaemia No effect on SaO2 per se

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Used by anaesthesiologists since the 1970s Standard of care in the OR since 1991 Non-invasive, continuous measurement of exhaled carbon dioxide (EtCO2) concentration over time Digital display provides EtCO2 value Provides a distinct waveform (tracing) for each respiratory cycle

End tidal CO2 (ETCO2)is useful in assessing 1. The adequacy of ventilation 2. Detect oesophageal intubation 3. Indicate disconnection of breathing system or ventilator 4. To diagnose circulatory problems and 5. Malignant hyperthermia ` Provided the pt has a stable cardiac status, stable body temp absence of lung disease and normal capnography trace ETCO2 approximates PaCO2 ` Normal PaCO2=5,3kPa/40mmHg
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Infrared absorption spectroscopy Photo-acoustic Spectroscopy Raman spectroscopy Mass spectroscopy

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Barometric presure
number of infrared absorbing molecules and increasing intermolecular forces

-Increase in Atm pressure increases EtCO2values by increasing the

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Nitrous oxide

-Collisions broadening N2Oabsorb IR at 4,5micrometer very close to CO2 absorption spectrum so can give falsely high CO2
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Water vapour

-Condenses on IR cell- interferes with measurements. -Condenses and clog the sample line

Separates and counts ionized molecules to determine the concentration of gas A gas sample is aspirated into a vacuum chamber when an electron beam ionizes and fragments the components of the sample The ions are accelerated into a final chamber which has a magnetic field that allows for determination of the components of the gas and the concentration of each component Very expensive and bulky, but have the advantage of being able to monitor multiple patients at a time (eg-OR)

Raman scattering occurs when light hits a molecule and it scatters the lightmost of the scattered light is the same wavelength as the laser source, but a small amount of light scattered is at a different wavelength The different wavelength produced gives information about the molecule An argon laser is shone through a gas sample and the CO2 in the sample will scatter itthe amount of scattering is related to the CO2 level

Side stream

Mainstream

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Gas is sampled through a small tube Analysis is performed in a separate chamber Very reliable Time delay of 1-60 seconds Less accurate at higher respiratory rates Prone to plugging by water and secretions Ambient air leaks

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Sensor is located in the airway Response time as little as 40msec Very accurate Difficult to calibrate without disconnecting (makes it hard to detect rebreathing) More prone to the reading being affected by moisture Larger, can kink the tube. Adds dead space to the airway Bigger chance of being damaged by mishandling

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Shark fin waveform With or without prolonged expiratory phase Can be seen before actual attack Indicative of Bronchospasm( asthma, COPD, allergic reaction) Management: Bronchodilators (albuterol, atrovent, or Epinephrine)

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Curare Cleft is when a neuromuscular blockade wears off The patient takes small breaths that causes the cleft Management: Consider neuromuscular blockade readministration/reversal/sv

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Shortened waveform ETCO2 < 35 mm Hg Management: If conscious gives biofeedback. If ventilating slow ventilations If ventilations are high and ETCO2 is high consider other causes (DKA, sepsis, TCA overdose, acute renal failure, methanol ingestion, salicylate poisioning)

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Prolonged waveform ETCO2 >45 mm Hg Management: Assist ventilations or intubate as needed

Rebreathing of CO2

ESOPHAGEAL INTUBATION/ DISCONNECTION FROM VENTILATOR

Pul e O i etr

`O en Saturati n `Reflects O enati `S O changes lag `

n hen 2 atient is hypoventilating or apneic Should e used ith Capnography

Apnea detected ediately i Should e used ith Pulse Oxi etry

`Car on Dioxide `Reflects Ventilation `Hypoventilation/ `

Capnography

SaO2

ETCO2

Early Warning: When do you want the patients parachute to open?

Capnography 4-10 minutes

Pulse Oximetry 30-60 seconds

No monitor = free fall!