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Pulse oximetry failure rates
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Pulse oximetry failure rates
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PULSE OXIMETRY FAILURE RATES by Laura Vu A Thesis Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF SCIENCE (Biomedical Engineering) December 1994 Copyright 1994 Laura Vu This thesis, written by L ........................................................... under the guidance of Faculty Com m ittee and approved by all its members, has been presented to and accepted by the School of Engineering in partial fulfillment of the re quirements for the degree of l l i U r j . ............................... Faculty Com mittee Acknowledgments Special thanks to Dr Stephen Barker, Dr. N.S Trivedi and John Hyatt at the University of California, Irvine Medical Center for allowing me to participate in the oximetry study and to Dr. David D'Argemo at the University of Southern California for his guidance and support throughout the course of the study and beyond Contents Acknowledgements ii List of Tables v List of Figures vi 1.0 Introduction 1 11 Background......................................... 1 12 T heory...................................................................................................................2 12 1 Measuring Sa02 2 1.2 2 Calculating S a 0 2 .................................................................................... 3 12 3 Hemoglobin ............................................................................................4 1.3 Signal Processing................................................................................................8 13 1 The P ro b e................................................................................................ 8 13 2 Analog Processing 10 13 3 Digital Processing ................................................................................11 2.0 Statement of Objective 13 2.1 Functional vs Fractional Saturation............................................................... 13 2 2 Motion and Low Perfusion ........................................................................... 15 2 3 External Optical Interference..........................................................................16 2 4 Objectives and A im s................................... 16 3.0 Methods 18 3 .1 Obtaining Data ................................................................................................ 18 3 1 1 Ambient L ig h t.........................................................................................19 3 12 Oscillating Motion , 20 3.1.3 Low Perfusion........................................................................................ 20 3.1 4 Desaturation............................................................................................20 3 2 Data Collection System ..................................................................................21 3.2.1 S cope..................................................... 21 3.2 2 C om puter.................................................................................................21 3.2 3 Software M e n u .......................................................................................22 3 2 4 Pulse O xim eter.......................................................................................26 3.2.4 1 Ohmeda Biox 3740 ................................................................26 3.2.4,2 Novametrix O xypleth............................................................ 27 3.2.4 3 Nellcor N-200 ....................................................................... 27 3.2.4 4 Criticare 504-U S.....................................................................29 3.2.4.5 N arkom ed................................................................................ 29 3.3 Data M anagem ent.............................................................................................30 4.0 Results 32 4 1 Ambient L ig h t..................................................................................................32 4 2 Oscillating Motion ......................................................................................... 33 4 3 Low Perfusion.................................................................................................. 35 4.4 Desaturation .....................................................................................................36 5.0 Discussion 38 5.1 Optica] Interference .......................................................................................38 5 2 ECG Synchronization..................................................................................... 39 5.2.1 Optical-Mode Pulse Oximetry and A rtifact..................................... 39 5 2 2 Pulse Oximetry with ECG Synchronization......................................41 5 2.3 Optimizing the ECG S ignal..............................................................43 5 3 Pa02 vs S a 0 2 .................................................................................................43 6.0 Conclusion 46 Bibliography 47 Appendix 1 - Summary of Results 49 Appendix 2 - Raw Data 50 IV List of Tables 3.1 Ohmeda Pin Configuration.................................................................................... 26 3 2 Ohmeda Cable Arrangement...................................................................................26 3.3 Novametrix Cable Arrangem ent........................................................................... 27 3.4 Nellcor Dip Switches ....................................................................................... 27 3 5 Nellcor Dip Switches for Output F orm at....................................................... 28 3.6 Nellcor Dip Switches for Baud R a te ............................................................... 28 3 7 Nellcor Cable Arrangement................. 29 3.8 Cnticare Cable Arrangement....................................................... 29 3 9 Narkomed Cable Arrangement..............................................................................30 4 1 Resaturation . . 37 v List of Figures 1 1 Hemoglobin Light Absorbance S pectra.................................................................5 1 2 Oxyhemoglobin Dissociation C u rv e ....................................................................... 8 1.3 Analog S ignal............................................................................................................10 2.1 Oximeter Sp02 vs. Co-Oxim eter......................................................................... 14 3 1 Configuration M en u.............. 23 3 2 Digital Port Setup M enu.........................................................................................24 3.3 Collect Data M enu ..................................................................................................24 3.4 View Data Screen - Pulse O xim eter....................................................................25 3 5 View Data Screen - N arkom ed............................................................................ 25 3 6 Header for Comment F ile .................................................................................. 25 4 1 Ambient L ight......................................................................................................... 32 4 2 Motion - 2 H z .......................................................................................................... 34 4.3 Motion - 4 H z .......................................................................................................... 34 4 4 Low Perfusion 36 5 1 C-LOCK Signal Processing.................................................................................. 42 5 2 Hemoglobin-oxygen Dissociation C u rv e............................................................. 44 vi Chapter 1 Introduction 1.1 Background Pulse oximetry is a standard non-invasive method of measuring arterial hemoglobin saturation and pulse rate in the operating room and the intensive care units It is established as one of the gold standards for monitoring oxygenation during anesthesia. Pulse oximeters provide reliable continuous measurement, display and alarm for oxygen saturation (Sa02) and heart rate It can warn of a number of disasters in progress, including airway disconnect, loss of oxygen supply, severe increases in venous admixture or loss of a pulse. Pulse oximeters fail to measure an Sp02 value whenever their signal to noise ratio falls below preset limits. Such failures are common during low cardiac index, anemia, hypotension, hypothermia, or extremes of systemic vascular resistance. The pulse oximeter determines hemoglobin saturation by measuring the light absorbance at two wavelengths and comparing the ratio of the absorbances to a built-in calibration function. Because it senses only two wavelengths of light, the oximeter is in theory unable to differentiate oxyhemoglobin from other non-reduced species, specifically carboxyhemoglobin. The goal of the present study is to determine the accuracy of the pulse oximeter prediction of actual oxyhemoglobin (Sa02) in the presence of various conditions which may produce artifact and erroneous results. 1 1.2 Theoiy of Pulse Oximeter Pulse oximeters measure oxygen saturation optically by sensing color changes in hemoglobin. Oximeters consists of two light emitting diodes as a light source and a photodiode as the light receiver One light emitting diode emits red light (approximately 660 nm) and the other emits infrared light (approximately 920 nm) Arterial hemoglobin saturation is measured by calculating the absorption of the two wavelengths of light passed through an arteriolar bed The light from the LEDs is transmitted through the blood and various components, such as skin, tissue, pigmentation, bone and fingernails. A portion of light is absorbed by the blood and tissue constituents while some light passes through. The photodiode in the sensor measures the light not being absorbed and uses this measurement in calculating the amount of light that was absorbed Pulse oximetry is based on the assumption that hemoglobin exists in two principle forms in the blood - oxygenated/Hb02 (with 02 loosely bound) or reduced/Hb (with no molecules bound) Arterial oxygen saturation (Sa02) is defined as the ratio of oxygenated hemoglobin (Hb02) to total hemoglobin (Hb02 + Hb + other forms of hemoglobin present in arterial blood Sa02 = HbQ2_______________ (11) Hb02 + Hb + other forms of hemoglobin 1.2.1 Measuring Sa02 At each heartbeat, a pulse of oxygenated arterial blood flows to the sensor site (carrying oxygenated hemoglobin) This oxygenated hemoglobin differs from 2 deoxygenated hemoglobin in the relative amount of red and infrared light that it absorbs. The pulse oximeter measures absorption of both red and infrared light and uses those measurements to calculate the percentage of functional hemoglobin that is saturated with oxygen The Sp02 displayed represents the ratio of oxygenated hemoglobin to total hemoglobin. Initially, light absorption is determined when the pulsatile blood is not present This measurement indicates the amount of light absorbed by tissue and non-pulsatile blood. This is the reference measurement since its absorption does not change significantly during the pulse The blood in the tissue can be divided into two parts, the non-pulsatile blood that remains relatively constant in the tissue during a pulse, and the pulsatile blood that flows completely to and away from the tissue with each beat. The pulsatile blood is the component of interest since it represents oxygenated arterial blood Absorption is measured following the next heartbeat, when the pulsatile blood enters the tissue. In the measurement, the light absorption at both wavelengths is changed by the presence of the pulse of arterial blood The algorithm for the corrections of the measurements during pulsatile flow varies with different manufacturers 1.2.2 Calculating Sa02 The pulsation of arterial blood flow present at a particular test site modulates the tight the oximeter probe detects. Since other fluids and tissues present at the test site generally do not pulsate, they do not modulate the light passing through the test site area. Therefore, the attenuation of light energy due to arterial blood flow can be detected and isolated, thus providing the basis for the necessary calculations, by using the pulsatile portion of the incoming signal Oxygenated hemoglobin absorbs more infrared light while reduced hemoglobin absorbs more red light. When pulsatile blood is not present, tissue, bone and venous blood absorb relatively constant amount of light. Each time the heart beats, a pulse of arterial blood flows to the tissue which causes an increase in the absorption of both wavelengths Since this blood is particularly high in oxygenated hemoglobin, proportionally more infrared light is absorbed For each wavelength, the pulse oximeter determines the light absorbed when pulsatile blood is present as well as the light absorbed when it is absent. From these two values, the calculation is done using the logarithmic ratio in Beer's Law; If = I,e — (12) where the medium is the tissue bed, Ir is the intensity of light exiting the medium, I, is the intensity of light entering the medium, m is the attenuation coefficient (dependent on medium) and x is the distance through the medium. From this, saturation of arterial hemoglobin is determined 1.2.3 Hemoglobin Hemoglobin is the oxygen transporting pigment of erythrocytes A hemoglobin molecule is comprised of four heme moieties, each of which contains one iron atom. Around each iron atom, there are four coiled polypeptide globin chains. 4 Hemoglobin has the ability to reversibly bind with molecular oxygen. In the pulmonary capillaries, high oxygen tension favors the reversible binding of oxygen to hemoglobin The oxygen is then released in the tissue capillaries where the oxygen pressure is low Because each of the four heme groups can bind one oxygen molecule, each saturated hemoglobin molecule carries four oxygen molecules. Functional hemoglobins are capable of transporting oxygen to tissues, as described. Functional hemoglobin is called oxyhemoglobin when it is carrying four oxygen molecules, and deoxyhemoglobin when it carries no oxygen Because the pulse oximeter uses only two wavelengths of light, it can theoretically determine the concentration of only two hemoglobin species: reduced hemoglobin (Hb) and oxyhemoglobin (Hb02) It is not clear how the pulse oximeter will behave in the presence of dyshemoglobins such as methemoglobin (MetHb) or carboxyhemoglobin (COHb). Previous studies have shown that in the presence of COHb, Sp02 overestimates fractional saturation (Sa02) by an amount roughly proportional to COHb The pulse oximeter thus "sees" COHb as though it were composed mostly of Hb02 me themaglobin oxyhemoglobin carboxyhemoglobin 920 1000 .01 600 Log ♦ 760 840 W a v e l e n g th (n m ) 660 Figure 1.1: Hem oglobin Light Absorbance Spectra 5 Dysfunctional hemoglobins (dyshemoglobins) are unable to transport oxygen to the tissues. They include methemoglobin, carboxyhemoglobin, sulfhemoglobin and carboxysulfhemoglobin. Dyshemoglobins are unable to bind with oxygen and in some cases also interfere with the ability of oxyhemoglobin to release its oxygen to the tissue Methemoglobin is formed when the iron ion in the heme moiety is oxidized from the predominant ferrous form (Fe++) to the less common ferric form (Fe+++). Fe++ —> Fe-HH- + e- (1.3) Carboxyhemoglobin is formed when carbon monoxide binds with hemoglobin CO + Hb ---> COHb (14) Sulfhemoglobin occurs when hydrogen sulfide reacts with oxyhemoglobin, irreversibly changing the globin component for the life of the blood cell Sulfhemoglobin may further combine with carbon monoxide to form carboxysulfhemoglobin Fetal hemoglobin also affects the pulse oximeter's Sp02 values. Fetal hemoglobin (HbF) has a greater affinity for oxygen than adult hemoglobin (HbA) Fetal hemoglobin comprises about 75% of the hemoglobin in newborns and an even greater percentage in premature infants. Because of differences in spectral absorption between HbF and HbA, the Co-Oximeter may report false carboxyhemoglobin (COHb) levels and consequently low oxyhemoglobin percentages when analyzing blood containing a significant level of fetal hemoglobin. The Cornelissen formula corrects the erroneous fractional oxygen saturation (Sa02) values that may be reported by the Co-Oximeter 6 when fetal blood is being analyzed Thus, when comparing the Co-Oximeter of a HbF rich sample of arterial blood, the following correction is made, requiring a laboratory measurement of the percentage of HbF to be obtained: %COHB(err) = (0 065 x %HbF/100 + 0 005) x %Sa02(frac)1 L + 0.24 (15) %COHb(corr) = %COHbI L - %COHb(err) (16) %Sa02(frac,corr) = %Sa02(frac)I L + %COHb (17) where %HbF is the percent fetal hemoglobin determined by laboratory analysis, % Sa02(frac)! L is the fractional value for oxygen saturation reported by the Co-Oximeter, %COHb(err) is the erroneous elevation of the percent carboxyhemoglobin as reported by the Co-Oximeter, %COHb,L is the erroneous percent carboxyhemoglobin reported by the Co-Oximeter, %COHb(corr) is the corrected percent carboxyhemoglobin and %Sa02(frac,corr) is the corrected fractional oxygen saturation An additional correction must be made before comparing the Co-Oximeter measurements to the pulse oximeter The fractional Sa02 measured by the Co-Oximeter must be converted to functional Sa02. The functional conversion formula: Sa02 = _____%SaQ2( frac.corr)______ x 100 (1.8) (func,corr)100 - (%COHb(corr) + %MethHbIL ) where %MetHb,L is the percent methemoglobin reported by the Co-Oximeter and the parameters are defined as those in the Comelissen formula Full term infants have about 75% HbF and 25% adult hemoglobin (HbA), while premature infants may have an even higher percentage of HbF The HbF percentage decreases with age, as the HbA percentage increases As this happens, the infant's oxyhemoglobin dissociation curve moves progressively closer to that of an adult. S O 60 40 20 60 40 SO 20 Pa02(mmHg) Figure 1.2: Oxyhemoglobin Dissociation Curve HbF has a higher affinity for oxygen than HbA because HbF is less sensitive to the effects of 2,3-diphosphoglycerate (2,3-DPG) Therefore, at any partial pressure of oxygen, the arterial oxygen saturation (Sa02) of HbF will be higher than that of HbA. This helps to protect a fetus or neonate in an oxygen-poor environment. The increase Sa02 of HbF is reflected in a shift of the oxyhemoglobin dissociation curve to the left 1.3 Signal Processing 1.3.1 The Probe The probe consists of the light source and the photodetector Two light emitting diodes serve as the light source - one Red and one Infrared The photodetector is a 8 photodiode which produces and electrical current proportional to the incident light intensity A timing sequence controls the LEDs in the following sequence; red on - infrared on - both off The cycling of the sequence allows the photodetector to quantify the light energy at the appropriate wavelength by producing a current at the particular point in the cycle. The cycling also determines the effect of ambient light hitting the photodetector. The off point in the light sequence is measured and utilized to cancel the effects of the ambient light There are two types of sensors transmission and reflectance With conventional transmission oximetry sensors, the light sources (LEDs) and photodetector are positioned on opposite sides of an arteriolar bed. Light scatters within the tissue, and the photodetector measures the amount of light that passes through to the other side Reflectance oximetry sensors obtain measurements using the same technology as transmission sensors but the optical components are positioned differently. The LEDs and photodetector are positioned on a flat surface that has a good arterial supply. Light from the LEDs passes into the vascular region that underlies the surface and scatters within it The photodetector measures the amount of light that re-emerges at the surface. The reflectance sensor is designed for application to the forehead or temple of patients weighing more than 40kg. It is particularly valuable when peripheral vasoconstriction affects the performance of digit sensors (e.g., during stress or exercise testing) or when digit application sites are unavailable or inaccessible In each case, the probe's photodetector converts the light into an electronic signal Since Hb02 and Hb allow different amounts of light to reach the photodetector at the 9 selected wavelengths, the electronic signal varies depending on which light source is "on" and the oxygenation of the arterial hemoglobin The oximeter amplifies the electronic signals it receives. Analog and digital signal processing converts the light intensity information into Sa02 and pulse rate values and displays them on the oximeter front panel 1.3.2 Analog Processing The cycling routine makes many measurements for the red and infrared voltages This pulsatile signal is then amplified and filtered simultaneously for both light sources. Filtering the signal reduces "noise" present due to motion of the probe, ambient lighting, electrical interference, etc , and neglects constant signal levels (non pulsating) The A/D converter takes the pulsatile signals from the filters and converts them to digital signals A microprocessor performs the calculations in determining the saturation of the measured arterial blood. The actual signal generated, as it relates to light absorption, is represented in figure 13 A VARIABLE ABSORPTION OF ARTERIAL BLOOD ABSORPTION DOE TO VENOUS BLOOD ABSORPTION DUE TO OTHER TISSUES TIME Figure 13: Analog Signal 10 1.3.3 Digital Processing The microprocessor performs mathematical processes comparing the data from the red and infrared channels to each other. A ratio of the change in voltage in the red channel to the change in voltage of the infrared channel over some small interval of time is used to calculate Sa02 From theory, oxygen saturation is calculated as follows; Sa02 = K1*(R*R) + K2*R + K3 (19) where R = Red/Infrared and K.1, K2, and K3 are constants. So that oxygen saturation at any point in time is a function of the change in the red channel divided by the change in the infrared channel The basis of the calibration coefficients: K l, K2, and K .3 are dependent upon the physical optical characteristics of hemoglobin The oximeter processes the instantaneous oxygen saturation values to produce the average saturation value which appears on the digital display. A weighted average of instantaneous values provides a much more accurate result than the running average method. Perfusion at the test site and the current average saturation are the basis for the weight assigned to each instantaneous calculation. For example, movement at the probe site can create signal distortion, creating erroneous instantaneous oxygen saturation values. The weighting function provides a stable reading, with low sensitivity to motion while retaining the capability of responding quickly to saturation changes. The calibration mechanism, or sensor, is checked by a calibration resistor. The effective mean wavelength of the LED is determined and coded into a calibration 11 resistor. The calibration resistor is read by software to determine the calibration coefficients that should be used for the measurements obtained by that sensor Calibration is performed each time it is turned on and periodically thereafter The intensity of LCD in the sensor is adjusted automatically to compensate for differences in tissue thickness. In software, calculations o f initial measurements and during pulsatile flow vary due to noise, ambient light, motion, occlusion, etc 12 Chapter 2 Statement of Objective 2.1 Functional vs. Fractional Saturation When arterial oxygen saturation is measured by pulse oximetry, Sa02 is often referred to as Sp02 because of limitations in the kinds of hemoglobin the oximeter measures. Pulse oximeter measures the Sa02 of functional hemoglobin, referred to as Sp02. Functional hemoglobin called oxyhemoglobin when it is carrying oxygen and deoxyhemoglobin when it is not. Dyshemoglobin (dysfunctional hemoglobin) cannot transport oxygen It arises when hemoglobin is bound to a molecule other than oxygen or in any other way rendered incapable of combining with oxygen Functional saturation, Sp02, is the ratio of oxyhemoglobin to all functional hemoglobins Fractional saturation, Sa02, is the ratio of oxyhemoglobin to all hemoglobin measured, including measured dyshemoglobins. Pulse oximeters only measure functional hemoglobin and exclude dyshemoglobins Thus, a measurement of functional saturation lets the physician know what percentage of the hemoglobin that is capable of transporting oxygen is actually doing so Pulse oximeters are generally calibrated to Co-Oximeters, which measure fractional saturation Because of the difference in the way the two instruments measure Sa02, when enough dysfunctional hemoglobins are present they may produce 13 different readings For example a patient has 15 g hemoglobin per 100 ml whole blood. The 15 g consists of 11 g of oxyhemoglobin, 2 g of deoxyhemoglobin and 2 g of dyshemoglobtn. The pulse oximeter would report functional Sa02, that is 1 1 g/13g = 85%, excluding the 2 g of dyshemoglobin. The Co-Oximeter would report fractional Sa02, that is 1 Ig/15g = 73%. The following formula can be used to convert fractional Sa02 from the Co-Oximeter to functional Sa02: % Sa02 func = SaQ2 frac_____________ x 100 (2.1) 100 - (%COHb + %MetHb) where % Sa02 func is the functional oxygen saturation (pulse oximeter value), % Sa02 frac is the fractional oxygen saturation (Co-Oximeter value), % COHb is the percent carboxyhemoglobin (Co-Oximeter value) and % MetHb is the percent methemoglobin (Co-Oximeter value). The following shows the relation between arterial saturation from a Co-Oximeter and pulse oximeter saturation; 100 Z o 3 p so • < to u U i U 5 70 X O u vj £ 60 100 90 SO 70 60 ARTERIAL HEMOGLOBIN OXYGEN SATURATION ( J ) Figure 2 1: Oximeter Sp02 vs. Co-Oximeter 14 The value calculated for saturation using two wavelengths account for only two hemoglobin species, oxygenated and reduced. Two other species, methemoglobin (MetHb) and carboxyhemoglobin (COHb) are not accounted for Therefore, the resulting saturation is labeled functional saturation and represents oxygenated hemoglobin expressed as a percentage of hemoglobin available for oxygen transport Functional Sa02 = HbQ2 x 100% (2.2) Hb + H b02 Fractional saturation is defined as oxygenated hemoglobin expressed as a percentage of total hemoglobin whether or not it is available to bind with oxygen Fractional Sa02 = HbQ2________________ x 100% (2 3) Hb + H b02 + MetHb + COHb A Co-Oximeter is used to measure fractional saturation using a sample of whole blood. The difference is significant only when there is a substantial quantity of carboxyhemoglobin. 2.2 Motion and Low Perfusion Clinical settings and physiological conditions have also created discrepancies in pulse oximeter saturation values. Patient movement and poor peripheral pulses present problems for a conventional pulse oximeter Performance may deteriorate because the oximeter is unable to distinguish between the true optical pulse signal and background noise. ECG synchronization improves signal quality in these difficult signal-detection. 15 2.3 External Optical Interference Bright external light sources are known to affect pulse oximeters because these instruments use optical means to make their measurements For saturation and heart rate measurements to be accurate, ALL the light received by the detector must first have passed through the arteriolar bed. Optical interference occurs either when light reaches the detector without passing through a pulsatile arteriolar bed or when excessive light from and external source reaches the detector Such interference can result in inaccurate or erratic measurements or can prevent the oximeter from tracking the pulse The three types of optical interference are: excessive ambient light, optical shunt and cross-talk 2.4 Objectives and Aims Since pulse oximetry is a non-invasive method of measuring arterial saturation, many factors present in the operating room settings can affect the accuracy of the pulse oximeter and cause its failure This study will evaluate seven different pulse oximetry set-ups, involving four different manufacturers. The study will be conducted on healthy volunteers under various physiological conditions. Each volunteer will be monitored by seven pulse oximeters and data collected by the computer. The volunteers will also be connected to a bedside monitor, evaluating ECG and blood pressure Blood gas samples are drawn from a radial cannula for each of the volunteer at interval time. The blood is then analyzed by a Co-Oximeter to determine the fractional saturation and is documented for comparison with the values recorded by 16 each of the seven pulse oximeters. Failure rates are then determined for each of the seven pulse oximeters based on zero displayed failures and out of range failures 17 Chapter 3 Methods 3.1 Obtaining Data Since the algorithms on which pulse oximetry is based are produced from human volunteer data, our study is on healthy, conscious, adult volunteers breathing hypoxic gas mixtures and under extreme physiological conditions. The Sp02 will be determined by each oximeter in the study and compared to the IL-282 Co-Oximeter to evaluate accuracy and failure rate The following pulse oximeters were used in the volunteer study 1. Novametrix Oxypleth (Digit probe) 2. Criticare 504-US (Digit probe) 3. Ohmeda BIOX 3740 (Digit probe) 4. Ohmeda BIOX 3740 (Ear probe) 5. Nellcor N-200 (Digit probe) 6. Nellcor N-200 with C-LOCK (Digit probe) 7. Nellcor N-200 (Forehead probe) The categories of data were (number correlates to heading "cat" in appendix 2 - Raw Data): 10 Ambient light on hands (control is N-200 with C-LOCK covered) 2 0 Cross-talk on six hand probes (control is Ohmeda ear probe) 18 3 0 Ambient light on forehead and ear (control is N-200 with C-LOCK covered) 4.0 2Hz oscillation on Nellcors and Masimo 4.1 2Hz oscillation on Ohmeda, Criticare and Novametrix 5.0 4Hz oscillation on Nellcors 5.1 4Hz oscillation on Ohmeda, Criticare and Novametrix 6 0 Radial occlusion on Nellcors 6.1 Radial occlusion on Ohmeda, Criticare and Novametrix 7 0 Minimum desaturation (-70% for 1 min) The Nellcor N-200 digit, Nellcor digit with C-LOCK and Nellcor ear probe were always used on the same side of the body The Ohmeda digit, Criticare digit, Criticare ear and Novametrix digit probes were always used on the same side of the body (either right or left - opposite of the Nellcor probes) The location of the probes were alternated in digit and side (of the body) in each study to simulate random placement. Each condition was administered one side at a time with the other as a control The healthy volunteers were monitored with radial artery cannulas (to obtain samples for Co-Oximeter), ECG, mass spectrometer (to monitor percent oxgygen administered to volunteer for desaturation study), and pulse oximeters with sensors on the earlobe, index finger and forehead 3.1.1 Ambient Light For ambient light, a light source of 150 Watts was used. The housing was a Sybron Model L339 with a GE #62539G 150 Watt Sytvania bulb. The light barrier 19 used was 0,05 inch black felt with a 0.001 inch aluminum sandwiched between the felt. 3.1.2 Oscillating Motion The oscillator used was built in the laboratory so that the arm rests on a wooden platform which oscillates a variable rates of two and four hertz. Each arm was placed one at a time on the oscillator and data collected to see the effect of motion on pulse oximeter failures. 3.1.3 Low Perfusion Radial occlusion was performed by applying a piston to the inner forearm proximal to the body, creating a pressure of approximately 9-11 PSI 3.1.4 Desaturation Desaturation was obtained utilizing the Narkomed anesthesia unit to control percent of 02 inhaled with the Datascope Multinex as the monitoring device. Volunteers breathed a controlled mixture of oxygen and nitrogen through a sealed mask. Inspired oxygen fraction (Fi02) was gradually lowered to 10%, yielding steady-state Sa02 values of approximately 70% The Sa02 values were determined by arterial blood sampling and 1L-282 Co-Oximeter. Fi02 was then abruptly changed to 100% and pulse oximeter saturation (Sp02) was recorded digitally until steady-state was again reached. The Sp02 from each pulse oximeter was recorded every second. 20 Dr. Trivedi administered the various conditions to be studied on the healthy volunteer Data was collected for the duration of the study by the Data Collection System Manual documentation was obtained at the start and stop of each condition to be verified with collected results before data manipulation. Each condition/category was maintained continuously for three minutes with the exception of the desaturation which was up to the discretion of Dr. Trivedi. Blood gas samples were taken approximately one minute after the condition was administered, which allowed time for the body to stabilize. 3,2 Data Collection System 3.2.1 Scope This system collects real-time data simultaneously from up to nine electronic instruments. There are eight RS232 interfaces and one RS422 interface. The system also collects data from a keyboard to serve as a comments file during the data collection process. Collected data along with comments will be stored separately in individual files Data can also be viewed in real time from a pre-selected channel while simultaneously being collected. 3.2.2 Computer The Data Collection System is loaded on a 486 computer with 4MByte of RAM and a 175 MByte hard drive. The computer is also equipped with a RISCOM-8 RS232 multiplexer card that will multiplex the output from up to eight RS232 ports 21 into a single port and one RS422 communication port. The system is written in QuickBasic version 4.5 with the compiled program executing under DOS. 3.2.3 Software Menu The Data Collection System implements the following function: 1. Acquire configuration parameters from user via menu screens 2 Configure communication ports and comments file according to the parameters collected above 3 On receipt of a command from the user to initiate data collection: a Open communications channels b. Open files for storage c. Write headers for new files d. At the beginning of every received string, write the current date and time followed by the string to the bottom of the relevant file for that channel. A line feed character will signify the end of the string The next string is then time stamped in a similar fashion. 4. On receipt of a command to Halt Data Collect the software will close all open files and return to the Data Collect Menu 5 On receipt of a command to display data the software will display the received data in real-time for the chosen channel 6. On receipt of a command to store user comments, collect typed characters from the keyboard into a buffer. Display the comments of the buffer on the 22 screen. When ENTER is depressed the time and dated is written to the beginning of the paragraph and the buffer is appended to the file 7. On receipt of a command to return to the configuration menu - test to ensure that the Data Collection Process is halted and the files closed before display of that menu 8. On receipt of a command to display the contents of a file, read the file and display it to the screen in the same manner as the DOS command TYPE/p. The top level menu is the Configuration Menu The menu appears at the boot up of the program and presents six choices. 1 DOS Path Setup 2 Digital Port Setup 3 Analog Port Setup 4. Comment File 5 Collect Data 6 View a Collected Data File Enter a number to choose the desired selection Figure 3 1: Configuration Menu The Digital Port Setup menu presents a sequence of configuration options for the user to select for the communication ports All options have default options available based on the last selection entered for that port The parameters are displayed in figure 3.2. 23 Port Number (1*8, Connector number) File Name (will end in dcd) Equipment Name (1-18 characters) Baud Rate (300, 1200, 2400, 4800, 9600, 19200 - normally 1200) Number of data bits (7 or 8) Number of stop bits (1 or 2) Protocol 1 - Receive only 2 - Receive and command (not used) 3 - Vitalink for communication with Narcomed ventilator Figure 3 2: Digital Port Setup Menu The Comment File menu will accept each comment and precede it with a time stamp written from the computer at the time the ENTER key is pressed. The Collect Data selection will present five options 1 Start Data Collection 2. Halt Data Collection 3 View Data in Real Time 4. Enter User Comments to (file name) 5. Return to Configuration Menu Figure 3.3: Collect Data Menu A flashing "DATA" flag on the top right comer of the screen indicates that data collection is active and any data being transmitted will be stored. Selection of option 3 to view data in real time will show a screen (for the Novametrix pulse oximeter), as shown in figure 3 4 24 Received Data Screen Current Time is 17:50:25 Port Number 2 NOVAMETRIX :Sp02 = 000 Rate = 000 Status: PROBE OFF PATIENT Figure 3.4 View Data Screen - Pulse Oximeter Received Data Screen Current Time is 17:57:07 Port Number 2 NARCOMED MEAN BREATHING PRESS 8 PEEP BREATHING PRESS 2 PEAK BREATHING PRESS 25 TIDAL VOLUME 0 55 RESPIRATORY MINUTE VOLUME 4 3 RESPIRATORY RATE - VOLUME 8 INSP OXYGEN (SLOW) 88 INSP C02 Figure 3 5: View Data Screen - Narkomed In each data file the program will write a header immediately below the last collected data This can be used to separate old data from new appended data in the file An example of a header is as follows: 09-02-1993 09:30:36 OHMEDA 3700 On Port Number 1 Baud Rate is 1200 Parity is E Data Bits are 7 Stop Bits are 1 Figure 3.6. Header for Comment File 25 3.2.4 Pulse Oximeter There are configuration information for the RS232 communication parameters for the oximeters to be used in the Failure Study The four pulse oximeter manufacturers/models to be studied are the Ohmeda Biox 3740, the Novametrix Oxypleth, the Nellcor N-200 and the Criticare 504-US Note: The RISCOM cable is a 25 pin male connector 3.2.4.1 Ohmeda Biox 3740 The RS232 Parameters for the Ohmeda pulse oximeter requires a DB25 (female) connector with pin configuration described in table 3 1 The fixed parameters are set at 1200 baud, 7 bit data, odd parity and 1 stop bit. Pin no Function 1 Chassis ground 2 Receive data by the oximeter 3 Transmit data from the oximeter 4 Signal ground Table 3.1: Ohmeda Pin Configuration The oximeter will output data every two seconds with the following message: :Sa02= PR= OHMEDA Biox 3700 RISCOM end Pin Color Pin Color 2 Green 2 Green 3 Red 3 Red 7 Black 7 Black Table 3.2 Ohmeda Cable Arrangement 26 3.2.4.2 Novametrix Oxypleth The RS232 Parameters for the Novametrix pulse oximeter requires a DB25 (female) connector with pins 6 and 20 wired together. The parameters are programmable for baud rate, bit parity and stop bit via the front panel. NOVAMETRIX Oxvdeth RISCO Pin Color Pin Color 2 Green 2 Green 3 Red 3 Red 6 White 6 Yellow 7 Black 7 Black 20 Yellow 20 White Table 3 3: Novametrix Cable Arrangement 3.2.4.3 Nellcor N-200 The RS232 Parameters for the Nellcor pulse oximeter requires a DB9 (female) connector. There are a row of dip switches in the back of the unit that configure the port Setting of the switches are as follows in table 3.4. The RS232 format output is determined by switches 3. 4 and 5 and the baud rate format uses switches 7 and 8 Dip Switches Function 1 Adult or Neonatal alarm set 2 and 6 Unused J 3,4 and 5 RS232 format 7 and 8 Baud rate select Table 3.4: Nellcor Dip Switches 27 Dip Switch Positions Format Description 3 4 5 | Full Full readable strings for CRT or printer D D U I Computer Single identifier character plus values D U U I Conversation Request for parameter (always available) D U U 1 N-9000 Recorder Communication with Nellcor N-9000 recorder interface D D D Beat to Beat Outputs rate and saturation once per beat U D U No Real Time Output Suppress real time data output, trend and event data will be output if connected U D D Graphics Only Suppress sign on message and real time data output, trend and event data will be output if connected u " 1 D = Down U = Up Table 3 5: Nellcor Dip Switches for Output Format Baud Rate Switch Position Switch 7 Switch 8 1200 Down Down 2400 Down Up 9600 Up Down 19200 Up Up Table 3 6: Nellcor Dip Switches for Baud Rate 28 Our study will utilize the beat to beat mode which will be transmitted once per beat and display the saturation and pulse rate data in the following format: R S CRLF, so that the switches will be set in the following manner: Switch Number: 1 2 3 4 5 6 7 8 Position U D U D U U D D (U - Up, D - Down) NELLCOR 200 RISCOM end Pin Color Pin Color 2 Green 2 Red 3 Red 3 Green 7 Black 7 Black Table 3.7: Nellcor Cable Arrangement 3.2.4A Criticare 504-US The RS232 Parameters for the Criticare pulse oximeter requires a DB25 (female) connector Communication parameters are programmed from the front panel using the "ALARM MENU" button and the buttons marked as Up and Down arrows CRITICARE 504-US RISCOM end Pm Color Pin Color 2 Green 2 Red 3 Red 3 Red 7 Black 7 Black Table 3.8: Criticare Cable Arrangement 3.2.4.S Narcomed Anesthesia (Jnit The RS232 Parameters for the Narcomed anesthesia unit requires a DB9 (male) connector. The system will accept data from the Narkomed anesthesia machines with a cable to Port A in the back of the anesthesia cart. This device only 29 outputs data in response to a request from the Data Collection System. This occurs every five to six seconds provided the correct protocol has been selected in setting up the program. The Data Collection System wilt then receive a data stream form the Narkomed and translate it into English prior to storage and display on the screen NARKOMED RISCOM end Pin Color Pm Color 2 Green 2 Red 3 Red 3 Green 7 Black 7 Black Table 3 9: Narkomed Cable Arrangement 3.3 Data Management Data file manipulation was done utilizing the Microsoft Excel software Over view table and graphs with statistical analysis were done on the Macintosh computer In each category the non-displays or "0"s will be counted as failures. For oxygen saturation, a deviation of greater than 3% from the Co-Oximeter will also qualify as a failure. Values were logged every second for 180 points (three minutes) However, the first and final thirty seconds will not be used to achieve a stability effect yielding 120 points per subject per category. Failure percentages are calculated as the number of pulse oximeter readings which failed in the categories above over the total number of readings evaluated Desaturation varied greatly in duration and depth, therefore, plotting was necessary before analysis. 30 The "gold standard" against which Sp02 is compared is a multi wavelength Co-Oximeter, the IL-282, using arterial blood specimens. Linear regression slopes and correlation coefficients are provided to asses the accuracy of the pulse oximeter data 31 Chapter 4 Results 4.1 Ambient Light In the ambient light study, Figure 4.1, the Sp02 failure rate was highest in the Ohmeda pulse oximeter with 57% followed by the Nellcor N-200 digit probe with 28% failure. The Nellcor reflectance probe was negibly affected showing a failure rate of approximately 0.11%. 6 0 .0 1 ---------------------------------------------------------------------------------------------------------------------------------------------- 5 0 . O X 40. OX 3 0 .0 1 ' 2 0 .0 Z - 10. ox- O.OZ t i i t i i NELLCOR NELLCOR OHM EDA NOVAMETRIX CRITICARE NELLCOR N200 DIGIT C-LOCK REFLECTANCE Figure 4.1: Ambient Light AMBIENTLIGHT E3 Sa02 DIF >3% ID % o Sp02 DISPLAYS In transmission sensors as on the digit probes, the LEDs and photodetectors are positioned on opposite sides of a vascular bed. This allows for some external light to 32 be detected by the photodetector which was not generated by the LED nor passed through the vascular bed Since the probe is usually placed on the finger, the distance from the LED to the photodetector is approximate one inch allowing for a significant amount of open space for interference from bright tights The reflectance probe, however, is designed with the LED and photodetectors adjacent to one another. Since the two are close in vicinity to one another, the amount of external light interference is kept to a minimum Reflectance probes are also not limited to sensor locations, as transmission probes where the light source and detector need to be on opposite sides of tissue, such as finger or ear The study also shows that the failures are mostly due to "0" displays This means that the pulse oximeter failures are due to its inability to detect and/or process the signal and not to an inaccurate processing of the signal. That is to say, if a failure due to ambient light occurs, the oximeter would alarm with H 0"s on the digital display, not reflecting the true Sp02 values This problem may be eliminated by properly placing or protecting the sensors from any probable cause of external light interference Most pulse oximeter software contain filters which would filter out excessive light, however, when there is intense light directly over the probes, it tends to produce failure in the Sp02 readings, as our study indicates 4.2 Oscillating Motion In the oscillating motion study, Figure 4 2 and 4.3, we see more failure at the higher oscillating rate, 4Hz than at 2Hz as expected. The pulse oximeter most affected 33 by motion artifact is the Criticare with digit probe (especially at 4Hz with a failure rate of approximately 42%), the Ohmeda with digit probe and the Novametrix with digit probe. 2 HTZ SaQ2 DIF >3% O Sp02 D ISPL A Y S 5.01 0.01 NOVAMETRIX CRITICARE NELLCOR C-LOCK Figure 4 2: Motion - 2Hz 40.01 HTZ 0 SiOl OIF Q HOSpQZ DISPLAYS 30. O Z 10.OZ - NELLCOR NOVAMETRIX CRITICARE NELLCOR N200 DIGIT C-LOCK Figure 4,3: Motion - 4Hz 34 With movement, the blood volume at the sensor site is altered resulting in a change in the amount of light transmitted through the blood Motion will also interfere with the processing of the signal from the photodetector The failures predominantly occur as deviation error and not as H 0" display errors This is critical since the erroneous data would be interpreted as real data in cases in the operating room or intensive care unit Since motion artifact cannot be filtered, it can be controlled utilizing an external synchronizing device, such as the C-LOCK in the Nellcor N-200. With this type of tracking, the pulse oximeter is able to handle the data more accurately, eliminating erroneous motion artifact data which would corrupt real Sp02 readings. Our study does show that the Nellcor N-200 with C-LOCK is able to maintain a low and consistent percentage failure at both rates o f oscillation. 4.3 Low Perfusion For the low perfusion study, Figure 4.4, the Criticare pulse oximeter failed 100% in the H 0H display failure category. The Ohmeda and Novametrix also showed failure at 48% and 33% respectively. The Nellcor with and without C-LOCK showed no failure at low perfusion. We did not expect to see failure with C-LOCK since the external ECG signal is used to synchronize the heartbeat. With low perfusion, there is inadequate amount of blood flowing to the tissue bed, thus, the pulse oximeter photodetector does not detect the correct amount of light coming from the tissue bed This problem is common in the operating room 35 1 0 0 .OZ 7 5 .OZ - 5 0 .OZ - 2 5 .OZ - O.OZ NELLCOR NELLCOR OHMEDA NOVAMETRIX CRITICARE N200 DIGIT C-LOCK Figure 4.4: Low Perfusion The "0" display errors indicate that the pulse oximeter is unable to process the signal at all This is handled clinically by increasing perfusion via heat etc. Another approach would be to amplify the pulse signal so that it would exceed the "background noise" thus enabling the pulse oximeter to continue to process the signal. 4.4 Desaturation The study shows that ear probes respond to rapid desaturation or resaturation earlier than finger probes. We present a comparison of forehead reflectance pulse oximetry with finger and ear sensors during rapid recover from an Sa02 value of 65% The time to resaturation of 98% was determined for each pulse oximeter for each LOW PERFUSION 36 subject. The mean differences between these resaturation times were computed to compare time lags between finger, ear, and forehead sensors. The forehead reflectance pulse oximeter provides data on rapid changes in saturation with the same time lag as the ear sensor, which is significantly faster than the finger sensor. The average time difference between ear or forehead and finger sensors in these healthy subjects may be much longer in critically ill patients LOWEST Sp02 98% RESAT (sec) Criticare 68 5 +/- 3,8 24 8 +/- 8 0 Ohmeda (digit) 67.7 +/- 2.0 18.0 +/- 7.0 Ohmeda (ear) 70.3 +/- 6,8 7 5 +/- 9 4 Novametrix 66.3 +/- 3 5 18.2 +/- 5.0 A Nellcor (digit) 66 0 +/- 6 2 21.8 +/- 7.0 Nellcor (forehead) 65.5 +/- 6 0 12 3 +/- 4.1 Nellcor (C-LOCK) 67.8 +/- 5.6 21 5 +/- 6.7 Comment: All values are equa mean +/- standard deviation, p-■values < 0 05 Table 4.1: Resaturation 37 Chapter 5 Discussion 5.1 Optical Interference Because a pulse oximeter's optical components are in the sensor, proper sensor application and use are key factors in eliminating optical interference Excessive Ambient Light Extremely bright light sources can cause inaccurate measurements if that light reaches the sensor's detector in sufficient quantity since the oximeter cannot differentiate between the different lights. Light sources that can interfere with performance include surgical lamps, bilirubin lamps, fluorescent lights, infrared heating lamps and direct sunlight. Excessive ambient light usually prevents the oximeter from tracking the pulse, but in some instances can result in apparently normal but inaccurate measurements Optical Shunt: An optical shunt occurs when some of the light from the sensor's LEDs reaches the detector without passing through an arteriolar bed This results in either erratic or stable but tow inaccurate measurements Optical shunts typically occur when an inappropriate sensor is selected and used incorrectly That is, when a patient's weight, the available sensor sites, the amount of patient activity, the intended duration of monitoring and the adequacy of the patient's perfusion is not taken into consideration This condition also exists when the LEDs are not opposite 38 on another, on either side of an arteriolar bed and light is allowed to leak from the LEDs to the detector around the site rather than through the tissue bed. 5.2 ECG Synchronization Some pulse oximeters are equipped with ECG synchronization which enhances the original signal-processing capabilities of the monitor As we have seen in the Nellcor N-200, this technology improves the quality of the optical signal in certain clinical settings in which the performance of a conventional pulse oximeter may deteriorate, e.g., when a patient is moving or has poor peripheral pulses With ECG synchronization, the pulse oximeter uses the electrocardiographic (ECG) QRS complex as a timing indicator that the optical pulse will soon appear at the sensor site By using the QRS complex (i.e., the peripheral pulse) to time the oximeter's analysis of the optical pulse signal, the processing passes unchanged those elements of the signal that are time-coupled with the QRS and attenuates those that are random with respect to cardiac activity Therefore, it improves the instrument's ability to distinguish between a true pulse, which is the result of cardiac activity, and motion artifact and background noise, which normally are random with respect to the ECG. 5.2.1 Optical-Mode Pulse Oximetry and Artifact Pulse oximeters use the differential transmission of red and infrared light by oxyhemoglobin and deoxyhemoglobin as the basis of oxygen saturation measurement. The instrument passes red and infrared light through pulsatile tissue at the sensor site and measures the amount of light that is transmitted through the tissue many times per 39 second. These measurements produce the optical pulse signal, which reflects the changing light transmission during and between pulses. This optical pulse signal is used to determine the oxygen saturation of pulsatile arterial blood. In a pulse oximeter, as each optical pulse signal is acquired, the waveform is analyzed to determine whether its characteristics are those of an acceptable pulse waveform (e g , in shape, amplitude and timing) If anomalies are present in the signal, the pulse is rejected and not used in saturation determinations However, patient movement and low amplitude pulses may interfere with the ability of a conventional pulse oximeter to recognize the true optical pulse signal In a poorly perfused patient, the amplitude of the pulse signal may be quite small and resemble that of background noise. Inadequate perfusion may be caused by blood pressure cuffs, restraints or radial artery catheters which restrict arterial flow to the hand With such a weak pulse, the instrument may not consistently differentiate between the pulse signal and background noise. As a result, either the oximeter may mistake noise for a pulse signal, distorting the oxygen saturation and pulse rate measurements or the oximeter may be unable to track the pulse signal accurately When a patient moves, inertia may cause a slight change in the venous blood volume at the sensor site. This, in turn, alters the amount of light transmitted through the blood and the resulting optical pulse signal Movement by the patient can also scramble the signals from the photodetector, making it difficult for the microprocessor to lock onto the steady arterial pulsations Some of these "motion artifacts" are rejected by a conventional pulse oximeter because the characteristics of the artifacts 40 differ from those of an acceptable pulse waveform (e.g., the signal amplitude may be too high or the period too short or erratic peak and trough values) However, some motion artifacts fulfill the oximeter's requirements for a typical pulse waveform When this happens, the conventional pulse oximeter accepts the artifact as a pulse and uses it to measure saturation, distorting the measurements 5.2.2 Pulse Oximetry with ECG Synchronization With ECG synchronization, the oximeter still measures red and infrared light transmission many times each second. However, the processing of the resulting data differs significantly to produce enhanced oximeter signal quality under conditions of patient motion or a low amplitude peripheral pulse The processing involves four stages: filtering, positioning, combining and measuring. In the first stage, the optical pulse signal is filtered when it is acquired Filtering the signal minimizes the effects of electronic high frequency noise (low pass filtering). In the second stage, the pulse signal is positioned in the oximeter's memory window, using the QRS complex as a reference point for aligning sequential signals. When the QRS complex occurs, the oximeter begins processing the optical pulse data In the third stage, the pulse signal is combined with the composite of the signals that have been previously positioned and stored in the memory, yielding a new composite signal. Signals are combined using an adjustable weighted algorithm. The existing memory contents are weighted more heavily than the new optical pulse signal. Signal averaging logarithms have also been used in calculating new composite signals. 41 In the fourth stage, oxygen saturation is measured from the composite signal. This determination is made in the same manner as in optical-mode pulse oximeter It is based on the ratios of the maximum and minimum transmission of red and infrared light As each sequential QRS complex and optical pulse signal are acquired, the process of filtering, positioning, combining and measuring saturation is repeated. Figure VI.A optical pulse signal is acquired and filtered Figure VI.B ECG QRS complex is used as a marker for the optical pulse signal Figure VIC the optical pulse signal is positioned in the memory with reference to the QRS complex Figure VI D the new optical pulse signal is combined with those already in the memory (old composite) to yield new composite Saturation is measured from new composite signal Figure 5.1: C-LOCK Signal Processing ® vv s i g n a l CD H v QRS c o m p le x © • V V b u f f e r © .'V'' \ - Old / New : c o m p o s i t e s i g n a i co m p o site s i g n a l 42 5.2.3 Optimizing the ECG Signal Because the timing of ECG synchronization data collection is dictated by the QRS complex, an appropriate ECG signal must be provided to the pulse oximeter For ECG synchronization to function optimally, the peak amplitude of the ECG signal, the width of the R-wave and the timing of the ECG output signal must meet the following requirements: the R-wave amplitude must be between 0.5 and 2.0 millivolts, at least 10 milliseconds wide at 50% of the peak amplitude and the delay between the actual QRS complex and ECG monitor's output signal should be no more than 40 milliseconds. 5.3 Pa02 vs. Sa02 Pulse oximeters sensors provide continuous real-time data and thus give early warning of impending hypoxia However, the pulse oximeter will not warn of impending danger until the arterial oxygen tension (Pa02) is low enough to cause significant desaturation Oxygen tension (Pa02) can be calculated from saturation by using the oxygen dissociation curve, which describes the relationship between saturation and tension The curve is shifted by changes in temperature, pH, PC02, and 2,3-DPG, or by concentrations of fetal blood, so that a saturation value calculated from a measured blood gas Pa02 may differ significantly from a saturation measured directly. When Pa02 is above lOOmmHg, the hemoglobin is almost completely saturated so that 43 increasing Pa02 has little effect on the saturation value or the oxygen content of the blood 100 — i 4, Temp *PC02 ♦2,3-DFG __ c 5 0 —1 n j c o + pco§eraCure ♦ 2', 3-DPG 50 P a 0 2 (nnnHg) Figure 5 2: Hemoglobin-oxygen Dissociation Curve The two prominent features of this relationship in figure 5 2 is: (1) it is nonlinear with a decreasing slope in the range of interest and (2) for Pa02 greater than 100 torr the curve is virtually flat. This nonlinearity and "flatness" at high Pa02 (greater than 100 torr) values suggest uncertainty in the relationship of Sp02 and Pa02 by linear regression Also, this dissociation curve is not fixed and varies with each individual patient due to changes in ion concentration, temperature, and 2,3-DPG, as discussed From the graph, also notice that normal saturation is maintained even with large variations within the Pa02's normal range of 80 to lOOmmHg. However, as the Pa02 falls below 80mmHg, hemoglobin's attraction to oxygen decreases and saturation levels begin to drop. A saturation of 90% (5% below normal) correlates with a Pa02 44 of 60mmHg From this point on, small changes in Pa02 coincide with rapid declines in hemoglobin affinity, saturation and oxygen content. Patients with alkaiosis, low levels of carbon dioxide, hypothermia and decreased 2,3-DPG (a substance that regulates hemoglobin-oxygen affinity) may have inadequate tissue oxygenation even with high saturation levels That is because hemoglobin binds more easily with oxygen under these conditions but does not relinquish the oxygen as readily to the tissues The reverse is true for patients with the opposite balances - acidosis, high Pa02 levels, fever and increased 2,3-DPG 45 Chapter 6 Conclusion The pulse oximeter estimates arterial hemoglobin saturation by measuring the light absorbance of pulsating vascular tissue at two wavelengths. The relationship between measured light absorbances and saturations is built into the oximeter software The study of human volunteers showed good performance of the device in healthy adult volunteers for saturations of 65 - 100%. The limitations of the pulse oximeter is due to the dissociation curve of Hb02, where at Pa02 greater than 100 torr, saturation measurements will not be sensitive to Pa02 changes Also, the pulse oximeter is limited to two wavelengths and therefore cannot distinguish more than two hemoglobin species From our studies, we have seen that pulse oximeters can detect desaturations when it does occur. Other limitations due to external artifacts vary as the software for each pulse oximeter study vanes Overall, we have seen that the Nellcor pulse oximeter addresses these external factors to the fullest providing the most efficient and correct data under all the conditions studied. 46 Bibliography 1 Blood Gas Technical Bulletin, Instrumentation Laboratories, Spring 1984 2 Brodsky JB, Shulman MS, Swan M, Mark JBD: Pulse oximetry during one-lung ventilation. Anesthesiology 1985, 63:212. 3 Broods TD, Paulus DA, Winkle WE: Infrared heat lamps interfere with pulse oximeters. Anesthesiology 1984, 61:630 4. Comelissen PJH, van Woensel CLM ,et al.: Correction factors for hemoglobin derivatives in fetal blood , as measured with the IL282 Co-Oximeter. Clin Chem 1983, 29 1555 5. Goldie EAG: Device for continuous indication of oxygen saturation of circulating blood in man. Joum of Instrum 1942, 19:23. 6. Introna RPS, Silverstein PI: A new use for the pulse oximeter. Anesthesiology 1986; 65:342. 7 Kim JM, Arakawa K, Benson KT, Fox DK: Pulse oximetry and circulatory kinetics associated with pulse volume amplitude measured by photoelectric plethysmography Anesth Analg 1986; 1333:1339 8 Knill RL, Clement IF, Kieraszewicz HT, Dodgson BG: Assessment of two noninvasive monitors of arterial oxygenation in anesthetized man Anesth Analg 1982, 67.580. 9. Mertzlufft F, Zander R: Noninvasive oximetry using the Biox III oximeter: Clinical evaluation and physiological aspects In Payne FP, Severinghaus JW, eds. Pulse oximetry Berlin: Springer-Verlag 1986. 10 Mihm FG, Halperin BD: Noninvasive detection of profound arterial desaturations using a pulse oximetry device. Anesthesiology 1985; 62:87 11 Nakajima S, Hirai Y, Takase H, et al.: Performances of new pulse wave earpiece oximeter. Respir Circ 1975; 23:45. 12 Payne, JP, Severinghause JW: Pulse oximetry. In: Payne JP, Severinghause JW, eds Definitions and symbols. Berlin: Springer-Verlag, 1986. 13. Pulse Oximetry Technical Bulletin, Nellcor, Summer 1987 47 14 Pulse Oximeter Technical Bulletin, Ohmeda, Spring 1987, 15 Stephen CR, Slater HM, Johnson AL, Sekelj P: The oximeter: a technical aid for the anesthesiologist Anesthesiology 1951, 15:541 16 Viitanen A, Salmenpera M Heinonen J: Comparison ofanscutaneous oxygen tension measurement and pulse oximetry during one-lung ventilation. Anesthesiology 1986;65:482 17 Yelderman M, New W Jr: Evaluation of pulse oximetry Anesthesiology 1983, 59 349 48 2Hlz: Appendix 1 - Summary of Results MANUFACTURER S a02 DIF >3% % 0 Sp02 DISPLAYS 1111 DIF > 5% CONTROL % 0lin DISPLAYS NELLCOR N20Q DIGIT 0.00% 0.00% 44.507. 0.007. NCILCOO CLOCK 0.52% 0.00% 10.00% 0.007, a WE DA 12.15% 0.00% 2.00% 0.00% NOVAMCtnx 11.50% 0.00% 22.00% 0,007. CNIC/WE 13.20% 0.34% 3.1147. 0,237. 4HU: MANUFACTURER S a0 2 DIF >3% % 0 S p02 DISPLAYS I in DIF >57* CONTROL % 0 l i n DISPLAYS NELLCOfl N200 DIGIT 3.40% 0.007. 51.707, 0.007. N E L L C O R CLO C K 3.50% 3.30% 24.00% 0.007. aWCDA 27.00% 4.007. 73.207. 4 .U Q V , NCWMEinK 27,40% 0.007. 50,407. 0.00% o iic /we 30.40% 3.007. 51.007. 3.007. LOW PERFUSION: MANUFACTURER So02 DIF >3% % 0 Sp02 DISPLAYS Mil DIF >5% CON I MOL % 01 III DISPLAYS N E L L C O H N200 DIGIT 0.007. 0-007. G.30% 0.007. N C L L C O Il CLO C K 0.00% 0.007. 0.007. 0.00% O i W E O A B.077. 30.047. 13.597. on 01% N O V A M E T L B X 0.547. 32.307. 10.91% 32.397, ClllCAnE 0.00% 100.00% 0.007. 100.007. AMBIENT LIGHT: MANUFACTURER Sa02 DIF >3% % 0 S|)02 DISPLAYS H IT DIF >5% CONTFIOL % 0 HR DISPLAYS N E L L C O R N 2 0 Q D IG IT 10.91% 17.057. 14.14% 17.711% M C L L C O n CLO CK S.31X, 0.00% 0.007. 0.00% O W C D A 2.49%' 54.57% 7.90% 54,577. NO V A M O rtX 0,21Y. 0.3G7. 13.577, 9.367. cm c/inc 0.62% 5.007. 13.317. 4,997. 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S ;8 8 8 8 8 8 S 8 8 8 8 8 8 8 8 8 S S 8 8 8 8 3 > Z S28S883SSSSSSX33X8X888X888XX8XXS88XSS88SS888533388SSS8SSS883S3828S3S33£§ o 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 3 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 5 z SS8SSSS8XSS8SS883S!535:5S3SSXS8!388SX£SS8:388SX8X8SS8SSS!33!:833!3SSS!3;5!5SS88S5§ 3 SSS8SXSSX33 3333333333333SSSS88S8SX8SSSSS88S88SS888S88S8SX88SS8SSSS8S88?; 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 ^ S 8 S S 8 S 8 S S 8 S S 8 38 3 88 8 83 8 88 8 S 8S 8 8 83 8 88 8 88 8 8S S 88 8 88 8 S 8 8 88 8 88 S S 8 8 S 38 8 88 S 8 8S £8 w X TME CAT MAS HR SAT c r it HR SAT OHM HR SAT OHM (C) HR 1013:40 5.0 54 88 56 97 57 96 57 10:33:41 5.0 5 6 96 56 97 57 96 57 10:33:43 5.0 56 96 57 97 59 96 67 10:33:43 5.0 57 98 57 97 59 96 57 10:33:44 5 .0 57 96 57 97 80 96 57 10:33:46 5 0 58 96 57 97 80 95 57 10:33:46 5 .0 58 96 58 97 60 96 56 10:33:47 5.0 58 96 57 96 60 86 58 10:33:48 5 0 58 96 56 96 80 96 56 10:33:40 5.0 58 98 56 96 60 96 59 10.33:50 5.0 59 98 59 96 60 94 58 10:33:61 5.0 60 96 59 96 60 94 58 10:33:53 5.0 80 88 59 96 62 64 58 10:33:53 5 0 56 98 59 96 82 94 56 10:3354 5 .0 58 98 56 88 61 64 58 10:33:55 5 0 58 88 59 96 61 94 59 10:33:56 5.0 58 96 59 96 61 96 59 1033:57 5 0 58 96 60 96 61 95 59 10:33:58 5.0 59 96 80 96 61 96 59 10:33:50 5 0 59 96 60 96 64 96 80 1 0:3400 5.0 80 98 60 96 64 98 60 10:34:01 5.0 80 98 60 96 64 97 61 10:3402 5 0 6 0 98 61 96 84 97 61 10:3403 5 0 60 98 62 96 63 96 62 10:3404 5-0 60 98 61 96 63 88 62 1 0:3405 5 0 60 96 61 97 63 99 62 10:3406 5.0 81 96 62 97 63 99 62 10:34:07 5 .0 61 96 81 97 63 100 65 1 0:3406 5 0 62 99 62 97 63 100 86 10:34:00 5.0 62 99 62 97 82 100 66 1 0:3410 SO 64 98 62 97 62 100 66 10:34:11 5.0 64 99 62 97 81 100 64 10:34:12 5.0 64 99 61 97 61 100 64 10:34:13 5 .0 64 88 61 97 60 100 63 10:34:14 SO 63 99 61 97 80 100 63 10:34:15 5.0 63 99 61 97 60 100 61 10 34:16 5 0 61 99 61 97 60 100 61 10:34:17 5.0 81 99 6 0 97 60 100 61 10:34:16 5.0 61 96 60 97 60 100 59 10:34:16 5.0 61 98 61 97 61 100 58 10:34:20 5 0 61 96 61 •7 61 100 58 10:34 21 5.0 61 96 62 97 61 100 58 10:34:22 5.0 61 88 81 97 61 100 58 10:34:23 5.0 61 86 81 97 61 100 58 10:34:24 5.0 61 96 61 97 62 100 59 10:34:25 5 0 63 99 62 97 62 100 59 10:34:28 SO 63 99 62 97 62 100 60 10:34:27 5.0 63 99 92 97 62 100 90 10:34:28 5 0 63 89 62 97 63 100 60 10:34:28 $.0 62 89 62 97 63 100 80 10:47:30 S.1 57 96 103 90 167 57 76 10:47:31 5.1 57 88 103 80 187 87 76 10:47:32 5.1 57 86 103 90 167 87 79 10.47:33 5.1 57 96 103 90 187 67 79 10:47:34 5 1 57 96 103 90 190 67 83 10:47:35 5.1 57 88 103 90 190 87 83 10.47.38 5.1 57 96 103 90 193 88 67 10:47:37 5.1 58 98 103 80 193 88 67 10:47:38 5.1 58 98 103 90 194 66 93 10:47:39 5.1 56 96 103 90 194 88 86 10:47:40 5.1 58 96 109 90 196 68 96 10:47:41 5.1 58 98 103 80 200 89 101 10:47:42 5.1 58 96 103 90 200 68 101 10:47:43 5.1 58 97 103 90 201 89 104 10:47:44 5.1 56 97 103 89 201 89 104 10:47:45 5.1 58 97 104 90 201 89 101 10:47:46 5.1 58 97 104 90 201 89 101 10:47:47 5.1 58 97 104 90 206 86 106 10:47:48 6.1 58 97 104 80 205 88 106 10:47:46 5 1 58 97 104 90 209 88 139 NOV N200 (C) N200 (R) N200 CO o x SAT HR SAT HR SAT HR SAT HR SAT S « 0 2 95 58 96 62 100 59 98 244 100 99.2 95 59 87 63 100 56 98 242 1Q0 99.2 95 S O 96 63 0 58 98 243 100 9 9 2 96 59 88 63 0 58 96 242 100 99.2 96 58 97 63 0 59 98 248 100 9 9 2 96 58 97 63 0 59 96 243 100 99.2 96 58 97 86 0 59 96 244 to o 9 9 2 96 58 97 66 0 59 98 244 100 99.2 96 59 97 66 0 59 98 243 100 9 9 2 96 59 97 66 0 58 96 243 100 9 9 2 96 56 98 86 0 58 96 239 100 99.2 96 58 88 66 0 58 96 238 100 9 9 2 96 58 88 86 0 59 96 239 100 9 9 2 96 59 98 66 0 59 96 240 100 9 9 2 96 58 96 66 0 59 96 233 100 9 9 2 96 58 86 88 0 80 98 238 100 99.2 95 58 98 69 a 61 98 243 100 9 9 2 96 59 98 71 0 62 98 238 100 9 9 2 96 60 96 70 0 63 98 241 100 9 9 2 98 61 86 70 0 63 98 245 100 9 9 2 96 62 88 70 0 83 98 245 100 99.2 97 82 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MAS HR SAT CRfT HR SAT OHM HR SAT OHM (B) HR 1103 00 6.1 56 97 0 0 0 0 60 11:03:01 6.1 56 97 0 0 0 0 61 11:03:03 6.1 59 97 0 0 0 0 61 11:03:03 6.1 61 96 0 0 0 0 62 1 1 0304 6 1 61 96 0 0 0 0 62 11:03:06 6.1 61 96 0 0 0 0 63 11:03.06 6.1 6 t 96 0 0 0 0 63 11:03:07 6.1 61 96 0 0 0 0 63 11:03:06 6 1 61 96 0 0 0 0 63 11 0 3 0 9 6.1 62 96 0 0 0 0 63 1103:10 6.1 62 96 0 0 0 0 63 11.03:11 6.1 63 96 0 0 0 0 63 1103:12 6.1 63 96 0 0 0 0 63 11:03:13 6.1 64 96 0 0 0 0 63 11.03:14 6.1 64 96 0 0 0 0 63 11:03:15 6 1 63 96 0 0 0 0 62 11 03:16 6 1 63 96 0 0 0 0 62 11:03:17 6.1 62 98 0 0 0 0 62 11:03:18 6.1 62 98 0 0 0 0 62 11 03:16 6 1 62 98 0 0 0 0 61 11:03 20 6.1 62 98 0 0 0 0 61 11 03:21 6 1 61 98 0 0 0 0 61 1103:22 6.1 61 96 0 0 0 0 60 11:03.23 6 1 61 96 0 0 0 0 60 11:03:24 6.1 61 96 0 0 0 0 60 11:03:25 6.1 61 98 0 0 0 0 60 11:03:26 6.1 60 96 0 0 0 0 60 1103:27 6.1 60 96 0 0 0 0 60 11:03:28 6.1 90 96 0 0 0 0 60 11:03:20 6.1 60 98 0 0 0 0 60 11:03:30 6.1 56 98 0 0 0 0 59 1103:31 6.1 56 96 0 0 0 0 59 1103:32 6 1 59 96 0 0 0 0 59 11:03:33 6.1 56 96 0 0 0 0 59 11:03:34 6.1 59 96 0 0 0 0 59 11:03:36 6.1 59 96 0 0 0 0 59 11:03:36 6.1 59 96 0 0 0 0 56 1103:37 6.1 59 96 0 0 0 0 56 11:03.36 6.1 56 96 0 0 0 0 56 1103 30 6.1 $6 96 0 0 0 0 56 11:03:40 6.1 57 96 0 0 0 0 56 11:03:41 6.1 57 96 0 0 0 0 56 1103:42 6.1 57 96 0 0 0 0 57 11.03:43 6.1 57 96 0 0 0 0 57 11:03:44 6.1 57 96 0 0 0 0 57 1103:45 6.1 57 96 0 0 0 0 58 11:03:46 6.1 57 96 0 0 0 0 56 11:03:47 6.1 57 96 0 0 0 0 56 1103.46 6.1 57 96 0 0 0 0 56 1103:49 6.1 56 96 0 0 0 0 56 1103:60 6.1 56 96 0 0 0 0 56 11:03:51 6.1 59 96 0 0 0 0 56 11:03:52 6.1 59 96 0 0 0 0 56 1103:53 6.1 56 96 0 0 0 0 58 11:03:54 6.1 56 96 0 0 0 0 56 11:03:55 6.1 56 96 0 0 0 0 56 11:03:66 6.1 58 96 0 0 0 0 56 11:03:57 6.1 59 98 0 0 0 0 56 1103:56 6.1 59 96 0 0 0 0 56 11:03:59 6.1 59 96 0 0 0 0 59 1142:30 7 0 61 96 50 99 Sft 100 56 11:42:31 7.0 61 96 59 99 56 100 56 11:42:32 7.0 63 96 59 99 57 100 58 11:42:33 7.0 63 96 56 99 57 100 56 11:42:34 7 0 66 96 56 99 56 100 56 11:42:35 7.0 66 96 56 99 56 100 56 11:42:36 7.0 64 96 56 99 56 100 56 11:42:37 7 0 64 99 56 99 56 100 56 11:42:36 7.0 62 96 57 99 56 100 56 11:42:39 7.0 62 96 56 96 56 100 56 SAT NOV HR SAT N200 (C) HR SAT N200 4R) HR SAT N200 HR SAT COO SaO 97 0 0 60 100 61 96 56 too 96 97 0 0 60 100 91 96 56 100 99 97 0 0 60 100 62 96 56 100 96 97 0 0 60 100 62 98 56 100 96 97 0 0 61 100 62 96 56 100 96 97 0 0 61 100 64 96 56 100 96 97 0 0 61 100 66 96 56 100 96 97 0 0 62 99 66 98 56 100 96. 97 0 0 62 99 66 96 60 100 99 97 0 0 62 100 65 96 60 100 96 97 0 0 62 100 63 96 60 100 96. 97 0 0 62 100 63 96 61 100 99 97 0 0 62 100 62 96 60 100 99 97 0 0 62 100 63 96 60 100 96 97 0 0 62 100 62 96 60 100 96 97 0 0 62 100 61 96 60 100 96 97 0 0 62 100 61 96 60 98 96 97 0 0 62 100 61 96 60 96 96 97 0 0 61 100 61 96 60 96 96 97 0 0 61 100 61 99 60 96 96 97 0 0 61 100 61 99 60 96 96 97 0 0 61 100 60 99 60 96 96 97 0 0 61 100 60 99 60 96 96. 97 0 0 60 100 59 99 60 96 96 97 0 0 60 99 59 99 60 96 96 97 0 0 60 100 59 99 60 96 96 97 0 0 60 100 60 99 60 98 96 97 0 0 60 100 60 99 60 96 96 97 0 0 60 100 60 99 60 98 96 97 0 0 60 100 60 99 60 96 96. 97 0 0 60 100 60 99 60 96 96. 97 0 0 60 100 59 99 60 96 96. 97 0 0 60 100 59 96 60 96 96. 97 0 0 60 100 56 96 59 96 96 97 0 0 59 100 56 96 59 98 96 97 0 0 59 100 57 98 59 98 96 97 0 0 56 100 57 96 59 96 98 97 0 0 56 100 57 96 59 96 98. 97 0 0 56 100 57 96 59 96 96. 97 0 0 58 100 57 96 59 96 96. 97 0 0 56 100 57 96 59 96 96. 97 0 0 56 100 57 96 59 96 96. 97 0 0 56 100 57 96 59 98 96. 97 0 0 56 100 56 96 59 96 96 97 0 0 58 100 56 96 59 96 96. 97 0 0 56 100 56 96 59 99 96. 97 0 0 56 100 56 96 60 99 96 97 0 0 56 100 56 98 60 99 96. 97 0 0 56 100 58 96 60 99 96. 97 0 0 56 100 59 98 60 99 96. 97 0 0 56 100 59 98 59 99 96 97 0 0 56 100 56 66 59 99 96. 97 0 0 56 100 58 96 59 99 96. 97 0 0 56 100 57 96 59 99 96 97 0 0 56 100 58 96 59 99 96. 97 0 0 56 100 59 96 59 99 98 97 0 0 56 100 56 96 59 99 96. 96 0 0 56 100 50 96 59 99 96. 96 0 0 56 100 59 96 59 99 96. 96 0 0 56 100 59 96 56 99 96 96 56 96 56 91 62 97 57 95 96 57 96 56 91 62 97 57 95 96 57 96 56 96 61 97 57 96 96 57 96 56 100 61 96 57 95 96 57 99 56 100 62 96 57 96 96 57 99 56 100 61 96 57 96 96 57 99 56 100 60 96 57 96 96 56 96 56 100 59 96 57 95 96 56 99 56 100 60 96 57 96 96 56 99 56 100 61 96 57 96 66 TME CAT. MAS HR SAT CRfT HR SAT OHM HR SAT OHM |E ) HR SAT NOV HR SAT N20Q (C) HR SAT N 200(R> HR SAT N200 HR SAT 11:42:40 7 0 61 66 56 66 56 100 58 66 56 66 58 100 61 96 60 66 11:42:41 7.0 61 66 56 66 56 100 56 96 66 96 58 100 61 96 60 96 11:42:42 7.0 61 66 56 66 56 100 56 66 58 66 58 100 60 97 60 97 11:42:43 7.0 60 66 56 66 56 100 58 96 56 66 56 100 56 97 80 97 11:42:44 7.0 60 66 57 68 56 100 66 66 56 66 56 100 59 67 60 97 11:42:45 7.0 56 66 56 66 56 100 56 66 56 66 56 100 6 0 97 60 97 11:42:46 7.0 56 96 56 68 56 100 58 66 57 96 56 100 60 97 60 97 11.42:47 7.0 56 67 56 96 56 100 56 66 57 66 56 100 59 67 60 97 11:42:46 7 0 56 97 56 66 56 100 56 96 57 96 56 100 59 97 60 97 11 42:49 7 0 56 67 58 66 56 100 66 66 57 96 56 100 66 67 90 97 11:42:90 7.0 5 6 67 56 66 58 100 66 66 57 96 58 100 56 97 60 97 11:42.51 7.0 56 67 56 66 56 100 56 66 56 66 56 100 56 97 60 97 1142:32 7.0 56 67 56 68 56 100 56 96 50 66 56 100 60 67 0 67 11.42.93 7 0 56 67 56 66 56 100 56 66 56 66 59 100 61 97 0 0 11:42:54 7.0 56 97 59 68 59 100 56 66 56 96 56 100 61 97 0 0 11:42:55 7 0 56 66 56 98 56 100 56 66 59 66 60 100 60 97 0 0 11:42:56 7 0 58 66 56 96 56 100 56 66 60 96 60 99 60 97 0 0 11.42:57 7 0 56 66 60 68 60 100 59 65 60 96 60 96 61 97 0 0 11:42:56 7 0 56 96 50 96 60 100 59 96 60 96 60 69 60 97 0 0 11:42:56 7 0 56 66 60 66 60 100 60 65 60 96 60 98 60 97 0 0 11:43:00 7 0 56 96 60 68 60 100 60 96 60 96 60 66 60 96 0 0 11:43:01 7.0 5 6 67 60 66 60 100 60 65 60 96 60 66 56 98 0 0 11:43:02 7.0 56 97 60 96 60 100 60 96 60 96 60 66 60 66 0 0 11:43:03 7.0 60 66 60 66 60 100 60 66 59 66 60 66 60 98 0 0 11.43.04 7.0 60 66 50 66 60 100 60 64 56 98 60 96 60 66 0 0 11:43:05 7.0 56 66 60 66 6 0 100 6 0 94 56 66 60 100 60 66 0 0 11:43 06 7.0 59 66 61 96 60 100 60 64 60 66 60 100 61 96 0 0 11:43:07 7.0 56 66 50 96 60 100 60 94 56 66 60 100 61 96 0 0 11:43:06 7.0 56 67 60 66 60 100 6 0 94 56 96 60 100 61 96 0 0 11:43:00 7.0 56 67 60 66 60 100 60 64 60 66 60 100 61 66 0 0 11:43:10 7,0 57 67 51 68 60 100 60 64 61 68 60 100 61 96 0 0 11:43:11 7.0 57 67 60 60 60 100 60 64 61 96 61 100 61 66 0 0 11:43:12 7.0 57 66 60 68 61 to o 61 94 61 66 61 100 61 65 0 0 11:43:13 7.0 57 68 61 66 61 100 61 94 61 98 61 100 62 95 0 0 11:43:14 7 0 57 66 61 66 61 100 61 64 61 96 61 to o 63 95 0 0 11:43:15 7.0 57 66 62 66 61 100 61 64 51 66 61 69 63 95 0 0 11:43:16 7.0 58 68 62 66 61 100 61 93 61 98 61 99 63 95 0 0 11:43:17 7.0 56 66 62 68 61 100 61 93 62 66 62 96 62 95 0 0 11:43:16 7.0 56 66 63 66 62 100 62 63 62 96 62 100 62 95 0 0 11:43.16 7.0 56 98 63 66 62 100 62 63 63 06 63 100 63 94 0 0 11:43:20 7.0 59 66 63 66 63 100 63 93 63 96 63 100 03 94 0 0 11:43:21 7.0 56 66 64 66 63 100 63 63 63 66 64 100 66 94 0 0 11:43:22 7 0 60 66 64 66 63 100 63 63 64 98 64 100 65 94 0 0 11:43:23 7.0 60 66 64 68 63 100 63 63 65 96 64 100 66 64 62 0 11:43:24 7.0 62 66 64 66 64 100 64 63 65 68 64 100 66 64 64 100 11:43:25 7.0 62 66 64 66 64 100 64 63 66 96 64 100 66 64 66 100 11:43:26 7.0 63 65 65 66 66 100 64 63 65 66 64 100 6 6 64 66 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7.0 76 67 76 64 76 87 76 64 7* 65 75 90 75 82 75 69 11:46:12 7.0 76 67 76 64 76 87 76 84 75 65 75 91 75 82 75 89 11:46:13 7.0 77 67 75 64 76 67 76 84 74 65 75 91 75 83 75 89 11:46:14 7 0 77 67 75 64 76 87 76 64 73 85 75 91 75 83 75 89 11:46:15 7 0 76 64 75 64 76 87 76 84 74 85 75 91 75 63 75 89 11:46:16 7 0 76 64 74 84 75 87 75 64 74 85 75 91 75 63 74 89 11:46:17 7.0 76 64 74 64 75 87 75 64 73 65 75 91 75 63 74 69 11:46:16 7 0 76 64 74 64 75 87 74 64 73 85 74 91 74 83 74 89 11:46:16 7.0 77 63 74 *4 75 87 74 64 73 85 74 90 T4 63 74 89 11:46:20 7.0 77 63 74 64 74 67 74 84 73 65 74 90 74 S3 74 69 11:46:21 7.0 76 63 74 64 74 67 74 84 73 65 74 90 74 83 74 88 11:46:22 7.0 76 S3 74 64 75 67 74 65 73 65 74 90 75 63 75 89 11:46:23 7.0 75 63 74 64 75 87 74 8 5 73 65 75 90 75 *3 74 68 11:46:24 7.0 75 63 74 64 75 67 75 85 74 85 75 90 75 63 74 88 11:46:25 7 0 75 63 74 63 75 87 75 85 74 85 75 90 75 83 75 88 11 46:26 7 0 75 64 74 S3 74 86 74 65 74 84 74 90 75 83 75 88 11:46:27 7 0 75 64 74 63 74 86 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8 8 8 8 * * * * s 8 8 * Ss s S 3 8 S S 8 8 3 * 8 a * S 8 S 8 S S 8 S 8 liSRRiejiiSECCRCKCCPPiiPRCPSssppiPgssssajojsJSss S 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 o 8 i'^ P " P P C C S S t :t S S ^ c n 8 3 £ S S * ; £ S S 3 i* 8 J 8 8 S 3 S S C S S 2 iS S * 8 * 8 8 8 8 8 8 8 tssg * 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 g S R R p g s g e e p t r s i s R i e i e s p s s s s s s s s s s s a s s s s s s s s s s s - ^SSSISSI8SISi2S& ;& S;& &5SSSSSSS!SSUSSSSSSS8 u ICCeCCECpeCRPEPPPPSSJSSJSSSSJillSSSSSBSSBS < 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 | | p p p p p p p p p p p p c c p p p e e * s $ s s s * * £ t i s s j s s j j 3 s s e <££SSS5£;;5SSS£;;55S.5;;SS*#****S*S*S*a8S8S8S8 gfjfSSRSSSSCRasfcSRRSRPCPSStSJJJJSSBSSJSSSSSS < 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 * 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 8 |?PP P P P P P ^P P P P P P P P P ^P P S 8* 3 S 8S 8 * *8 * 88 S ^ p p Q p q p p q o p p q o q p o o o o p o q o p o p o o p p p o p o o d o o o o o SKNr»KKCl»KNNN>Kt^KKNKSNNNKNSNKr«kKHKKKKKr<NKr^SK H8 sa 8 S » S S 8 S 8 5 8 8 S 8 8 p 8 8 2 P ? P ? 5 S t5 a 8 |;R r!5 a S S S a 8 p3838888988S^SSSmSi«>«S>S>nny)«>StSmSiSS>S>S>«M>SiS>!>StS>m f> INFORMATION TO USERS This manuscript has been reproduced from the microfilm master. UMI films the text directly from the original or copy submitted. Thus, some thesis and dissertation copies are in typewriter face, while others may be from any type of computer printer. The quality of this reproduction is dependent upon the quality of the copy submit «d. Broken or indistinct print, colored or poor quality illustrations and photographs, prim bleedthrough, substandard margins, and improper alignment can adversely affect reproduction. In the unlikely event that the author did not send UMI a complete manuscript and there are missing pages, these will be noted. Also, if unauthorized copyright material had to be removed, a note will indicate the deletion. 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University of Southern California Dissertations and Theses
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Asset Metadata
Creator
Vu, Laura
(author)
Core Title
Pulse oximetry failure rates
School
Graduate School
Degree
Master of Science
Degree Program
Biomedical Engineering
Degree Conferral Date
1994-12
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
engineering, biomedical,OAI-PMH Harvest
Language
English
Contributor
Digitized by ProQuest
(provenance)
Advisor
D'Argenio, David B. (
committee chair
), Maarek, Jean-Michel (
committee member
), Yamashiro, Stanley M. (
committee member
)
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c18-5976
Unique identifier
UC11356902
Identifier
1376529.pdf (filename),usctheses-c18-5976 (legacy record id)
Legacy Identifier
1376529-0.pdf
Dmrecord
5976
Document Type
Thesis
Rights
Vu, Laura
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA
Tags
engineering, biomedical