Fetal transmission pulse oximetry: is it accurate?
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Fetus↗
Biomedical subjects
R Nijland
Publications and source records attributed to R Nijland.
Metabolic information from the human fetal brain obtained with proton magnetic resonance spectroscopy.
OBJECTIVE: To study the feasibility of proton magnetic resonance spectroscopy for the examination of human fetal brain metabolism. STUDY DESIGN: Proton magnetic resonance spectroscopy was performed from a selected volume of brain tissue of 21 single normal fetuses of 36 to 41 weeks' gestational age. Absolute brain metabolite tissue levels were estimated by using the brain water content as an internal reference. RESULTS: Proton magnetic resonance spectra showed resonances for four dominating brain metabolites. Inositol, choline, creatine, and N-acetylaspartate could be detected with average tissue levels of 7.42 mmol/L, 3.31 mmol/L, 4.16 mmol/L, and 5.03 mmol/L, respectively. The resonance for N-acetylaspartate could not always be resolved from contaminating lipid signals. CONCLUSION: Proton magnetic resonance spectroscopy of the human fetal brain is feasible and can provide useful information about the fetal condition. The metabolite tissue levels for the fetal brain obtained in this study were in the range observed for neonates of similar gestational age.
Aspartic Acid↗
Hypoxia in fetal lambs: a study with (1)H-MNR spectroscopy of cerebrospinal fluid.
In fetal lambs, severe hypoxia (SH) will lead to brain damage. Mild hypoxia (MH) is thought to be relatively safe for the fetal brain because compensating mechanisms are activated. We questioned whether MH, leading to mild acidosis, induces changes in cerebral metabolism. Metabolites in cerebrospinal fluid (CSF) samples, as analyzed by proton magnetic resonance spectroscopy, were studied in two groups of seven anesthetized near-term fetal lambs. In group I, SH leading to acidosis with an arterial pH <7.1 was achieved. In group II, MH with an intended pH of 7.23--7.27 was reached [start of MH (SMH)], and maintained during 2 h [end of MH (EMH)]. During SH, choline levels in CSF, a possible indicator of cell membrane damage, were increased. Both during SH and at EMH, CSF levels of lactic acid, alanine, phenylalanine, tyrosine, lysine, branched chain amino acids, and hypoxanthine were increased compared with control values and with SMH, respectively. At EMH, the hypoxanthine CSF-to-blood ratio was increased as compared with SMH. These results indicate that prolonged MH leads to energy degradation in the fetal lamb brain and may not be as safe as assumed.
Animals↗
Databases and the statistical usage of (perinatal) results--reply.
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Databases as Topic↗
Accuracy of fetal pulse oximetry and pitfalls in measurements.
Pulse oximetry is a technique for estimating arterial oxygen saturation continuously and non-invasively. Reflectance pulse oximetry might become useful for monitoring the fetus during labour but it is much more susceptible to all kinds of physiological variations than the well-established transmission pulse oximetry for neonatal or adult monitoring. This review focuses on the accuracy of reflectance pulse oximetry. Results of human, animal, in vitro and theoretical models indicate that factors such as; blood volume fraction differences, haematocrit, and blood flow differences are major sources for inaccurate pulse oximetry readings in the fetal arterial oxygen saturation range of 10-80%. These factors cannot be overcome by systems using two wavelengths sensors with the 660/890 or 940 nm combination. Reported precision values (S.D. of difference between pulse oximeter and blood sample saturation) range between 2.5 and 12.9% for various 660 nm sensors. Most sensors were tested only once with a limited number of animals. A new 735/890 nm sensor (Nellcor Puritan Bennett) demonstrates a promising accuracy (precision around 5%) in two studies. Various other sensors have also been developed, but are not or scarcely evaluated. Without thorough establishment of the reliability of this technique, clinical fetal oxygen saturation data are still of limited value.
Animals↗
Validation of reflectance pulse oximetry: an evaluation of a new sensor in piglets.
OBJECTIVE: A new reflectance pulse oximetry sensor, developed for intrapartum estimation of arterial oxygen saturation (SaO2), was calibrated and evaluated. The sensor contains two light emitting diodes of 735 and 890 nm, and a photodetector at a distance of 14 mm from both light emitting diodes. METHODS: In seven Yorkshire/Hampshire piglets, the reflectance sensor (Nellcor Puritan Bennett Inc.) was calibrated using blood sample SaO2 values. The resulting calibration line was evaluated in four Dutch piglets, by comparing pulse oximetry saturation readings (SpO2) with blood sample and intravascular fiberoptic oximetry SaO2 values. Several reflectance sensors were fixed on each animal. Desaturation levels were obtained by changing the gas mixture of oxygen/ nitrous oxide via a tracheal catheter. RESULTS: In the Yorkshire/ Hampshire piglets, the standard deviation of difference (SpO2-SaO2) was 4.7% (n = 364), over an SaO2 range of 17% to 100%. In the Dutch piglets, the mean difference (SpO2-SaO2) was -1.6% and the standard deviation of difference was 5.4%, over the same SaO2 range (n = 254). Comparisons of continuous recordings of reflectance SpO2 and fiberoptic SaO2 revealed variation in individual regression lines. CONCLUSIONS: This new 735/890 nm reflectance sensor demonstrates acceptable accuracy in piglets. A further evaluation during labor should assess its feasibility for fetal surveillance.
Animals↗
Ins(1,4,5)P3 receptors in cerebral arteries: changes with development and high-altitude hypoxia.
We and others have shown that adrenergic-mediated contractile responses in cerebral vessels in vitro differ with vessel segment, with developmental age, and with high-altitude, long-term hypoxia. This is associated with significant differences in alpha 1-adrenergic receptor density and norepinephrine (NE)-induced response of the second messenger inositol 1,4,5-trisphosphate [Ins(1,4,5)P3]. To test the hypothesis that vessel-specific, developmental, and hypoxic-associated contractility changes are mediated, in part, by changes in Ins(1,4,5)P3-receptor [Ins(1,4,5)P3-R] density or affinity, we performed the following study. In common carotid (Com), circle of Willis, and main branch anterior, middle, and posterior cerebral arteries (MBC) from normoxic fetal (approximately 140 days), newborn (3-5 days), and adult sheep and fetal and adult sheep acclimatized to high altitude, we quantified Ins(1,4,5)P3-R with [3H]Ins(1,4,5)P3. In normoxic Com, Ins(1,4,5)P3-R density values (fmol/mg protein) in fetus, newborn, and adult were 8 +/- 53, 150 +/- 18, and 357 +/- 21, respectively (P < 0.05). In normoxic MBC cerebral arteries, the receptor density values in the three age groups were 115 +/- 15, 105 +/- 9, 99 +/- 5 fmol/mg protein, respectively. For fetal and adult Com, high-altitude, long-term hypoxemia was associated with decreases in Ins(1,4,5)P3-R density of 32 (to 58 +/- 5) and 70% (to 109 +/- 12), respectively, from control values (P < 0.01). In MBC cerebral arteries of fetus and adult, hypoxic-associated decreases in Ins(1,4,5)P3-R density from control were 80 (to 23 +/- 3) and 47% (to 53 +/- 7), respectively (P < 0.01). Ins(1,4,5)P3 binding affinity to the receptor averaged 11.8 +/- 0.5 nM and did not vary significantly as a function of vessel type, developmental age, or hypoxia. In Com, but not in MBC, Ins(1,4,5)P3-R density increased dramatically with developmental age. This suggests that differences in Ins(1,4,5)P3-R density values may account, in part, for differences in contractile responses of the two artery types in the several age groups. In response to long-term, high-altitude hypoxia, Ins(1,4,5)P3-R density values in both fetal and adult Com and MBC decreased significantly, as did their NE-induced contraction. This suggests a cellular basis for changes in cerebrovascular contractility in response to long-term hypoxia and that Ins(1,4,5)P3-R may play a role in acclimatization responses to high altitude.
Aging↗
Reflectance pulse oximetry in fetal lambs: subcutaneous vessels and vasoconstriction affect its reliability.
OBJECTIVE: Reflectance pulse oximetry (RPOX) has been introduced for intrapartum fetal surveillance. The purpose of this study was to describe two possible effects on the reliability of RPOX, namely the effect of the presence of a subcutaneous vein and the effect of vasoconstriction by adrenaline, both at fetal SaO2 levels. METHODS: In four anesthetized fetal lambs, a prototype 660/890 nm reflectance sensor (Nellcor Inc.) was placed on the fetal head, with the photodiode of the sensor precisely over a superficial subcutaneous vein. Measurements were made before and after coagulation of the vein. In five anesthetized fetal lambs, one or two reflectance sensors were placed on the fetal head and/or neck and adrenaline was administered in doses of 0.02 to 0.04 mg via a brachial artery. Pulse oximeter saturation readings (SpO2) were compared with continuous arterial oxygen saturation (SaO2) values obtained using a fiberoptic catheter (Opticath, Abbott) in the carotid artery. RESULTS: When the sensor was placed over the vein, the pulse oximeter read 18% to 24% too low at a SaO2 level of 20% to 50%. After coagulation of the vein, SpO2 readings were in agreement with fiberoptic SaO2 values. Administration of adrenaline resulted in a large overestimation of the SaO2 in 6 of the 7 measurements. CONCLUSIONS: Subcutaneous veins and vasoconstriction can affect the reliability of reflectance pulse oximetry. As comparable situations may occur during labor, SpO2 readings should be interpreted with caution when this kind or comparable types of RPOX sensors are used at low SaO2 levels.
Animals↗
Neonatal complications in newborns with an umbilical artery pH < 7.00.
OBJECTIVE: Our purpose was to determine the significance of an umbilical artery pH < 7.00 in relation to neonatal morbidity and mortality. STUDY DESIGN: Between 1986 and 1993 acid-base assessment of the umbilical artery was performed routinely in 10,699 deliveries. In a retrospective cohort study 84 nonanomalous neonates with an umbilical artery pH < 7.00 were individually matched with 84 neonates with an umbilical artery pH > 7.24. Matched variables included year of delivery, gender, parity, maternal age, delivery mode, fetal presentation, gestational age, and birth weight. Differences in morbidity between the two groups during the neonatal period (until 28 days after delivery) were investigated. RESULTS: Neonates with an umbilical artery pH < 7.00 versus > 7.24 showed significant differences in the following: neonatal condition directly post partum; neurologic, respiratory, cardiovascular, and gastrointestinal complications; and neonatal intensive care unit admissions. No significance was found in renal dysfunction and mortality rate. The proportion of premature infants (< 37 weeks) was 17% in both groups. In the acidotic group a 1-minute Apgar score < or = 3 and a 5-minute Apgar score < 7 was predictive for neonatal complications. CONCLUSIONS: Severe intrapartum asphyxia, quantified by an umbilical artery pH < 7.00, poses a threat to the neonate's health.
Acidosis↗
Transmission pulse oximetry in the fetal lamb: is there a universal calibration?
Transmission pulse oximetry is widely used for oxygen monitoring. The use of pulse oximeters is steadily expanding toward situations with low arterial oxygen saturation (Sao2) values. Therefore, we evaluated transmission pulse oximetry in the unanesthetized fetal lamb at low Sao2 levels. In seven fetal lambs, fetal hypoxemia was induced by occlusion of the maternal common iliac artery, four days after the instrumentation of the animal. Two Nellcor prototype transmission Y-sensors (light emitting diodes: 660 and 890 nm) were applied, one around a forelimb muscle and one around a skinfold in the neck, and were connected to Nellcor pulse oximeters. The pulse oximeter was calibrated for the skin measurements. Pulse oximeter saturation readings (Spo2) were compared with sample Sao2 values, over an Sao2 range of 13 to 63%. For the neck sensor the SD of the difference was 5.0% (n = 101). For the muscle sensor the mean difference was 19.5% and the SD of the difference was 5.9% (n = 206). Regression analysis showed a different calibration line for the muscle sensor with the equation: Spo2 = 0.92 x Sao2 + 21.90. Continuous recordings were obtained both from the forelimb muscle and from the neck, but the recordings from the neck showed a substantial loss of signal during the hypoxemia period. We conclude that transmission pulse oximetry is less accurate below an Sao2 of 70% in fetal lambs than above 70% Sao2. At these low levels of Sao2, pulse oximeters may need to be constructed with different calibration lines for various application positions of the body.
Animals↗
Reflectance pulse oximetry: accuracy of measurements from the neck of fetal lambs.
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Animals↗
The effect of pulsating arteries on reflectance pulse oximetry: measurements in adults and neonates.
OBJECTIVE: The objective of our study was to describe the results from human experiments during normoxia that demonstrate the effect of pulsating arteries on the measured arterial oxygen saturation (SpO2) using a reflectance pulse oximeter sensor. METHODS: In 6 healthy adults and 7 healthy neonates, a Nellcor reflection sensor (FS-10 oxisensor, Nellcor, Inc., Pleasanton, CA) was placed in three different positions: (1) on the forehead, (2) on the temporal area, with the photodiode placed over the superficial temporal artery, and (3) on the temporal area, with the light-emitting diodes (LEDs) placed over the superficial temporal artery. RESULTS: Placement of the sensor in position 2 resulted in a significantly lower SpO2 reading, compared to sensor position 1: 5.8% (p < 0.01) lower for adults and 7.5% (p < 0.01) lower for neonates. Placement of the sensor in position 3 resulted in significantly larger plethysmographic signals, compared to sensor position 1; but, the Spo2 readings were alike. CONCLUSIONS: Pulsating arteries can affect the reliability of reflection pulse oximetry. Depending on the position of the sensor, a falsely low Spo2 value can be observed.
Adult↗
Arterial oxygen saturation in relation to metabolic acidosis in fetal lambs.
OBJECTIVE: We studied the relationship between preductal arterial oxygen saturation and metabolic acidosis in 18 chronically instrumented fetal lambs (gestational age 119 to 133 days) in two experimental designs. In the first group the onset of metabolic acidosis was determined. In the second group the progression of metabolic acidosis was studied as was the cardiovascular and hormonal changes resulting from hypoxemia. STUDY DESIGN: In nine fetal lambs maternal fraction of inspired oxygen was lowered stepwise by increasing flows of nitrogen delivered into the trachea through a small indwelling catheter (group 1), and in nine fetal lambs maternal blood flow was reduced stepwise by means of a vascular occluder (group 2). RESULTS: Baseline arterial oxygen saturation values ranged from 26% to 67% with normal pH and extracellular fluid base excess values in both groups 1 and 2. In both groups pH and extracellular fluid base excess started to decrease below 30% arterial oxygen saturation, with a progressive decrease below 20% arterial oxygen saturation to an end value for pH of 7.14. In some fetal lambs pH and extracellular fluid base excess decreased initially at 20% to 30% arterial oxygen saturation and then stabilized at the lower level. Fetal heart rate in group 1 increased during hypoxemia from 155 to 179 beats/min. In group 2 baseline fetal heart rate was 153 beats/min and fell with every step change in arterial oxygen saturation but subsequently increased to 172 beats/min by the end of the period of hypoxemia. Baseline values for epinephrine, norepinephrine, dopamine, cortisol, and mean arterial pressure were not related to baseline arterial oxygen saturation levels, and each of these variables was increased at the end of hypoxemia in group 2. CONCLUSION: Preductal arterial oxygen saturation can reach values between 20% and 30% before anaerobic metabolism starts. During the progressive acidosis blood pressure was increased, which can be attributed to a strong rise in catecholamines.
Acidosis↗
Notes on the apparent discordance of pulse oximetry and multi-wavelength haemoglobin photometry.
Multi-wavelength photometers, blood gas analysers and pulse oximeters are widely used to measure various oxygen-related quantities. The definitions of these quantities are not always correct. This paper gives insight in the various definitions for oxygen quantities. Furthermore, the possible influences of dyshaemoglobins and fetal haemoglobin on the accuracy of pulse oximetry are discussed. As pulse oximeters are constructed for the determination of arterial oxygen saturation, they should be validated with sample oxygen saturation values and not with the oxyhaemoglobin fraction. The influence of carboxyhaemoglobin is insubstantial over an oxygen saturation range of 0% to 100%. Through the presence of methaemoglobin, pulse oximetry will give an underestimation above 70% and an overestimation below 70% oxygen saturation. The influence of fetal haemoglobin is insignificant in the neonatal use of pulse oximetry, in the range of 75% to 100% arterial oxygen saturation. However, a pulse oximeter underestimates the arterial oxygen saturation at the 25% level with 5%, if the pulse oximeter has been calibrated in human adults. Such a low level of arterial oxygen saturation can be present in the fetus during labor.
Adult↗
The accuracy of a fiberoptic oximeter over a wide range of arterial oxygen saturation values in piglets.
A piglet model was used to evaluate the accuracy of a fiberoptic oximeter over a wide range of arterial oxygen saturation (SaO2) values. In eight anaesthetized piglets, the inspired oxygen concentration was varied from 30% to 6% resulting in a SaO2 range from 100% to 15%. Paired data of the Opticath fiberoptic catheter, which was placed in the descending aorta, and blood sample SaO2 values assessed by a multiwavelength oximeter, were analysed. After in vitro calibration according to the manufacturer's instruction, the fiberoptic catheter started to underestimate the SaO2 below 78%, worsening towards lower SaO2 values. The overall bias was -3.4% and the precision 3.8%. An off-line fit with a non-linear model resulted in a standard deviation of residuals of 2.6%. After several in vivo calibration adjustments when the fiberoptic oximeter deviated more than 4% from the blood sample value, the bias was eliminated over the total SaO2 range and the precision was 3.7%. The Opticath fiberoptic oximeter could have an accuracy for the whole SaO2 range between 15-100% close to the accuracy of the multiwavelength oximeter, when the fiberoptic oximeter is adapted for the underestimation below 78% SaO2.
Anesthesia, General↗
The ductus arteriosus, pre- and post-ductal oxygen saturation measurements in fetal lambs.
In the fetus, the arterial oxygen saturation (SaO2) in the ascending aorta is higher than in the descending aorta. We questioned whether this difference over the ductus arteriosus (delta SaO2) would change during hypoxaemia. Therefore, six chronically instrumented fetal lambs (119-126 days of gestation) were studied, by changing the inspired oxygen (FIO2) via a tracheal tube to the ewe. The SaO2 was measured intermittently every 15 min with blood samples obtained from the ascending and descending aorta, and continuously with 2 pulse oximeters at both sides of the ductus arteriosus. delta SaO2 was at a level of 3.4-5.3% and had a tendency to decrease at preductal SaO2 levels of 10-20% and at pH levels below 7.25. The precision of the pulse oximeters, expressed as standard deviation of the differences between sample SaO2 and pulse oximeter SaO2, was around 5.0% for the individual calibration curves. This precision was not enough to show details of the course of delta SaO2 between the blood samples. Our results show that there is no change in delta SaO2 across the ductus arteriosus.
Animals↗
Measurement of oxygen saturation by multiwavelength analyzer influenced by interspecies differences.
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Adult↗
Intrapartum fetal surveillance of congenital heart block with pulse oximetry.
BACKGROUND: In cases of fetal congenital heart block, the fetal heart rate (FHR) pattern is uninterpretable, often leading to an operative delivery. Reflectance pulse oximetry, a new technique that continuously measures the fetal arterial oxygen saturation (SaO2) during labor, is potentially useful in intrapartum monitoring of fetuses with this condition. CASES: Two fetuses with congenital heart block were monitored with reflectance pulse oximetry and fetal scalp blood sampling. The first patient delivered spontaneously. Adequate signal quality was achieved during 73% of the study time. Mean +/- standard deviation (SD) SaO2 was 53 +/- 14%. Fetal outcome was good. The second patient was delivered by cesarean because of arrest of labor. Oxygen saturation values were obtained during 89% of the study time. The mean SaO2 was 42 +/- 13%. There was a period of 8 minutes with SaO2 values below 20%. Capillary blood pH dropped from 7.33 to 7.25; SaO2 values then returned to levels above 30% and the capillary blood pH normalized. The neonate was born in good condition. CONCLUSION: In fetal congenital heart block, adequate surveillance with FHR monitoring during labor is not possible; therefore, continuous information on fetal oxygenation may be valuable in assessing the fetal condition and may prevent unnecessary obstetric interventions.
Adult↗