Vol. 20 •Issue 11 • Page 13
Standard of Care Has Some Drawbacks
From health fairs to heart surgery suites, everyone is using a pulse ox these days. But are they using them correctly and do they really understand what they are using?
In the hands of untrained or unresponsive staff, pulse oximetry can provide false security and even deadly consequences. The truly sad thing is we can’t just sit back and blame the EMT or out-of-hospital practitioner for being unskilled.
A recent Australian study reviewed data from 14 trials that examined clinicians’ knowledge of pulse oximetry and found that nurses, doctors and allied health professionals (all of whom frequently used pulse oximetery—many in the critical care setting) had significant knowledge deficits about proper and safe usage.
And it wasn’t just the new grads who didn’t understand how to use it or what the readings meant. Senior staff had problems too.
As a beginning point, we should note there is a difference between a pulse oximeter reading and an arterial blood gas finding.
Look at Some Differences
Let’s look at some of the differences between pulse oximetry and ABGs.
Pulse oximeters measure the oxygen saturation of circulating hemoglobin.
An ABG measures the dissolved oxygen tension in the arterial blood.
They are related, and it could be argued they are indirect measures of each other. But they are different. An 80 mm Hg on a blood gas is normal for an adult; an 80 percent reading on a pulse ox is something else.
Next let’s review how transmission pulse oximetry works. This is the kind most of us are familiar with. The oximetry probe is placed on a finger tip or earlobe. The probe sends beams of red then infrared light from one side of the sensor/probe to the other. The light is sent at two wavelengths (650nm and 805nm).
Amounts of light absorbed by the hemoglobin differ, depending on whether it is saturated or desaturated with oxygen. The microprocessor in the pulse ox calculates the absorption of the two wavelengths of light to determine the proportion of hemoglobin which is oxygenated.
Advances in Technology
Recent advances in microprocessor technology include time division multiplexing in which the lights are sent several times per second. This helps to reduce artifact. Quadrature division multiplexing is another technique in which the red and infrared signals are separated in phases rather than time sequences.
They are recombined in a later phase, and the microprocessor can differentiate the variances between the two and provide a reading that is less susceptible to artifact.
The saturation values provided by the pulse oximeter are averaged and reported over five to 20 seconds, depending on the machine. But remember pulse oximetry cannot distinguish among normal oxygen saturated, carboxyhemoglobin or methemoglobin. Other variables that can affect the function of a pulse oximeter include bright ambient light; pulse rate and rhythm; and vasoconstriction and cardiac function.
Reflection pulse oximetry works a little bit differently. The basic technology is the same as transmission pulse oximetry. But in this format, the light is transmitted and recorded by a single-sided monitor/sensor. It can be used on the forehead, abdomen or other flat body surface. There are mixed data on the effectiveness of reflective pulse oximetry.
Some reports suggest there is faster response time and fewer effects related to vasoconstriction. Other data find unstable readings and falsely low values are a concern. Perhaps the biggest concern is that while the underlying technology is the same, the systems themselves work a little differently than the ones we usually see.
So a word of caution needs to be given here. If you are running short of pulse oximeters in the ICU and you borrow one from anesthesia, make sure the staff—all the staff—knows how to use it.
And this brings us to perhaps the final point. We generally cannot fault the technology when an error occurs. The problem is the user. It is amazing how many people know how to turn off the alarms on a pulse ox. A lot of times, even the environmental services people know how to change and just plain shut off the alarms. I am not just talking about hitting the alarm silence button but turning the lower alarm limit down to a level that would be consistent with the patient being clinically dead.
The safe, effective use of a pulse oximeter in any setting boils down to education. We pretty much take for granted that the staff we are working with understand and know how to properly and safely use these machines. After all, they have been around forever. But the data suggest that they do not.
In many facilities, RCPs are responsible for providing the pulse ox; but we also have a responsibility to provide proper training and ensuring the equipment is used safely.
For a list of references, visit our Web Site at www.advanceweb.com/rcp.
Margaret Clark is a Georgia practitioner.