Standing guard over the flame of life

Oxygen Monitoring in Acute Medicine

Dave Sainsbury
Staff Anaesthetist, Womens & Childrens Hospital Adelaide, South Australia

Entropy

Life

n n
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2nd law of thermodynamics Entropy is times arrow

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CO2

O2 CnHnOn
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159 150

149

100

50

I n s p i r e d

100

T ra c h ea

92
A r t e r y

A l v e o l u s

Tissue
40 2

Vein
40

Mitochondria
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Monitoring Oxygen As a Gas

Inspired Tracheal Alveolar

Oxygen analyser Calculated from FIO2 Calculated: Alveolar air equation End tidal oxygen analyser

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Ideal Oxygen Analyser

n n n n n

Rapid response Continuous Robust Low maintenance Do no harm

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Oxygen Analysers
n n n

Polarographic sensor Fuel cell Paramagnetic analyzer

Robust Rapid response time Low maintenance

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Paramagnetic Oxygen Analyser

Pressure transducer

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Oxygram
Inspired 30% 20% 10% 0% Expired

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Alveolar Air Equation

n

PAO2 = FIO2 * (Pb- 47) - PaCO2 PAO2 = FIO2 * (Pb- 47) - PaCO2 /R PAO2 = FIO2 * (Pb- 47) - PaCO2 /R(1-FIO2(1-R))

n n

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159 150

149

100

50

I n s p i r e d

100

T ra c h ea

92
A r t e r y

A l v e o l u s

Tissue
40 2

Vein
40

Mitochondria
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Oxygen saturation of haemoglobin (%)

100 90 80 70 60 50 40 30 20 10 0 10

20

Vein P50

15

10

20

40

60

80

Partial pressure of oxygen (mmHg)

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100

200

300

400

500

600

12

Oxygen content of blood (ml / 100 ml)

Artery

Ideal blood oxygen monitor

n n

Indicate oxygen tension Indicate oxygen supply

Haemoglobin concentration Haemoglobin saturation Blood flow

n n n n n n n
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Rapid response Continuous Safe

Non-invasive

Robust Low maintenance Stable calibration Affordable

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Monitoring blood oxygen

Arterial tension

Blood gas analyser Trans cutaneous Calculated from tension Co-oximeter Pulse oximeter

Arterial saturation

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Blood gas analyser

n n n n

Polarographic Measures tension Calculates saturation (functional) Problems

invasive intermittent

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Functional Saturation OxyHb (OxyHb+reducedHb)

7g OxyHb 1g reducedHb 2g metHb

Functional Saturation

= 7/(7+1) = 87%
16

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Transcutaneous gas analyser

n n

Polarographic Measures tension

persistent pulmonary hypertension diaphragmatic hernia

Problems
Delicate Heated Repositioning Recalibrating
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Co oximeters
n n

Measures haemoglobin types by absorption of light To measure 4 types of Haemoglobin measure absorption at 4 different wavelengths OHb reducedHb COHb metHb

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Fractional Saturation OHb (OHb+reducedHb+COHb +metHb)

7g OxyHb 1g reducedHb 2g MetHb

Fractional Saturation

= 7/(7+1+2) = 70%
19

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Oximeters

1875 vonVierordt 1972 Takuo Aoyagi - "Pulse Oximetry" 1980's Nellcor 1988 pulse oximetry mandatory in Australia

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Systole

Light absorption due to arterial blood

Diastole

Light absorption due to tissues Artery (pulsatile tissue) Non-arterial, (non-pulsatile) tissue

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10

Red

Infrared

Extinction coefficient

1.0

Oxyhaemoglobin
.1

Deoxyhaemoglobin

.01 600 640 680 720 760 800 840 880 920 960 1000

Light wavelength (NM)

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Oxygen saturation of haemoglobin (%)

100 90 80 70 60 50 40 30 20 10 0 0.4 1.0 2.0

Oxygen Monitoring

R=

Red absorption Infra-red absorption

3.0

3.4
23

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Oximeter errors
n n

Signal artefact Light absorption artefact

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Signal artefact
Ambient light Poor perfusion Movement artefact If R = 1 pulse oximeter shows 85%

n n n n

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Light absorption artefact

n n

carboxyHb metHb

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10

Red

Infrared

Extinction coefficient

1.0

Oxyhaemoglobin
.1

Deoxyhaemoglobin Carboxyhaemoglobin
720 760 800 840 880 920 960 1000

.01 600 640 680

Light wavelength (NM)

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10

Red

Infrared

Extinction coefficient

1.0

Methaemoglobin Oxyhaemoglobin

.1

Deoxyhaemoglobin

.01 600 640 680 720 760 800 840 880 920 960 1000

Light wavelength (NM)

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Light absorption artefact

n

carboxyHb
error showing low functional saturation error showing high fractional saturation

metHb
error toward 85%

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Light absorption artefact

n

carboxyHb
reads low functional, high fractional

metHb
error toward 85%

n n n n n
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fetal Hb dyes nail polish bilirubin skin pigment

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Monitoring oxygen

Tissue Venous tension Venous saturation

Cytochrome oximeters Blood gas analyser Optical fiber oximeter

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Monitoring Oxygen
Oxygen supply is critical No single monitor of oxygen supply Oxygen tension versus haemoglobin saturation Functional versus fractional saturation

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