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pulse oximetry -> bibliography
last modified: September 10, 2002

Bibliography

  • Conventional Pulse Oximeters

  • New Generation (Motion Resistant) Pulse Oximeters

    • Peer Reviewed Articles

    • Informative Articles

    • Abstracts


Conventional Pulse Oximeters (in chronological order)

  1. Yoshiya I, Shimada Y, Tanaka K. Spectrophotometric monitoring of arterial oxygen in the fingertip. Med Biol Eng Comput 1980;18:27-32
  2. Sarnquist F, Todd C, Whitcher C. Accuracy of a new non-invasive oxygen saturation monitor. Anesthesiology 1980;53:S163
  3. Yelderman M, New W. Evaluation of Pulse Oximetry. Anesthesiology 1983; 59:349-352
  4. Brooks TD, Paulus DA, Winkle WE. Infrared heat lamps interfere with pulse oximeters [Letter]. Anesthesiology 1984; 61:630
  5. Kim SK, Baidan BS, Petty TL. Clinical evaluation of a new finger oximeter. Crit Care Med 1984;12:910-912
  6. Shippy MB, Petterson MT, Whitman RA, Shivers CR. A clinical evaluation of the Biox II ear oximeter. Respir Care 1984;29:730-735
  7. Brodsky JB, Shulman MS, Swan M, Mark JBD. Pulse oximetry during one-lung ventilation. Anesthesiology 1985;63:212-214
  8. New W. Pulse Oximetry. J Clin Monit. 1985 Apr;1(2):126-129
  9. Cecil WT, Petterson MT, Lamoonpun S, Rudolph CD. Clinical evaluation of the Biox IIA ear oximeter in the critical care environment. Respir Care 1985; 30:179-183
  10. Mihm FG, Halperin BD. Noninvasive detection of profound arterial desaturation using a pulse oximetry device. Anesthesiology 1985;62:85-87
  11. Ries AL, Farrow JT, Clausen JL. Accuracy of two ear oximeters at rest and during exercise in pulmonary patients. Am Rev Respir Dis 1985;132:685-689
  12. Severinghaus JW, Astrup PB. History of blood gas analysis. VI. Oximetry. J Clin Monit 1986;2:270-288
  13. 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;65:1333-1339
  14. Severinghaus JW, Honda Y. History of blood gas analysis. VII. Pulse oximetry. J Clin Monit 1987 Apr;3(2):135-138
  15. Block FE Jr. Interference in a pulse oximeter from a fiberoptic light source. J Clin Monit 1987;3:210-211
  16. Barker SJ, Tremper KK. The Effect of Carbon Monoxide Inhalation on Pulse Oximetry and Transcutaneous PO2. Anesthesiology 1987;66:677-679
  17. Anderson JV. The accuracy of pulse oximetry in neonates: Effects of fetal hemoglobin and bilirubin. J Perinatol 1988;7:323
  18. Pologe JA, Raley DM. Effects of fetal hemoglobin on pulse oximetry. J Perinatol 1988;7:324-326
  19. Pologe, J. Pulse Oximetry: Technical Aspects of Machine Design. Int Anesthesiol Clin 1987 Fall;25 (3):137-153
  20. Cecil WT, Thorpe KJ, Fibuch EE, Tuohy GF. A clinical Evaluation of the Accuracy of the Nellcor N-100 and Ohmeda 3700 Pulse Oximeters. J Clin Monit 1988;4:31-36
  21. Ridley SA. A comparison of two pulse oximeters. Assessment of accuracy at low arterial saturation in paediatric surgical patients. Anaesthesia 1988; 43:136-140
  22. Wukitsch MW, Petterson MT, Tobler DR, Pologe JA. Pulse Oximetry: Analysis of Theory, Technology, and Practice. J Clin Monit 1988;4:290-301
  23. Fanconi S. Reliability of pulse oximetry in hypoxic infants. Pediatrics 1988;112:424-427
  24. Marks JB. Systolic Venous Waves Cause Spurious Signs of Arterial Hemoglobin Desaturation. Anesthesiology 1989;71:158-160
  25. Kelleher JF. Pulse oximetry. J Clin Monit 1989;5:37-62
  26. Hay WW, Brockway JM, Eyzaguirre M. Neonatal Pulse Oximetry: Accuracy and Reliability. Pediatrics 1989;83(5):717-722
  27. Kelleher JF, Ruff RH. The Penumbra Effect: Vasomotion-dependent Pulse Oximeter Artifact due to Probe Malpostion. Anesthesiology 1989;71(5):787-791
  28. Tremper KK, Barker SJ. Pulse Oximetry. Anesthesiology 1989:70:98-108
  29. Barker SJ, Tremper KK, Hyatt J. Effects of Methemoglobinemia on Pulse Oximetry and Mixed Venous Oximetry. Anesthesiology 1989 70:112-117
  30. Choe H, Tashiro C, Fukumitsu K, Yagi M, Yoshiya I. Comparison of recorded values from six pulse oximeters. Crit Care Med 1989; 17:678
  31. Severinghaus JW, Spellman MJ Jr. Pulse Oximeter Failure Thresholds in Hypotension and Vasoconstriction. Anesthesiology 1990;73:532-537
  32. Freund PR, Overland PT, Cooper J, Jacobson L, Bosse S, Walker B, Posner KL, Cheney FW. A prospective study of intraoperative pulse oximetry failure. J Clin Monit 1991;7:253-258
  33. Ralston AC, Webb RK, Runciman WB. Potential errors in pulse oximetry III: Effects of interference, dyes, dyshaemoglobins and other pigments. Anaesthesia 1991;46:291-295
  34. Valko, Campbell JP, McCarty DL, Martin D, Turnbull J. Prehospital use of pulse oximetry in rotary-wing aircraft. Prehospital Disaster Med 1991 Oct-Dec;6(4):421-428
  35. Stewart KG, Rowbottom SJ. Inaccuracy of pulse oximetry in patients with severe tricuspid regurgitation. Anaesthesia 1991;46:668-670
  36. Talke PO. Measurement of systolic blood pressure using pulse oximetry during helicopter flight. Crit Care Med 1991;19:934
  37. Rajadurai VS, Walker AM, Yu VYH, Oates A. Effect of fetal haemoglobin on the accuracy of pulse oximetry in preterm infants. J Paediatr Child Health 1992;28:43-46
  38. Severinghaus JW, Kelleher JF. Recent Developments in Pulse Oximetry. Anesthesiology 1992;76:1018-1038
  39. Barker SJ, Hyatt J, Shah NK, Kao YJ. The effect of sensor malpostioning on pulse oximeter accuracy during hypoxemia. Anesthesiology 1993;79(2):248-54
  40. Thilo EH, Anderson D, Wasserstein ML, Schmidt J, Luckey D. Saturation by pulse oximetry: Comparison of the results obtained by instruments of different brands. J Pediatr 1993;122:620-626
  41. Bucher HU, Keel M, Wolf M, von Siebenthal K, Duc G. Artifactual pulse-oximetry estimation in neonates. Lancet 1994;343:1135-1136
  42. Trivedi NS, Ghouri AF, Shah NK, Lai E, Barker SJ. Effects of motion, Ambient Light, and Hypoperfusion on Pulse Oximeter Function. J Clin Anesthesia 1997;9:179-183
  43. Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse Oximetry as a Fifth Pediatric Vital Sign. Pediatrics 1997;99:681-686
  44. Rahlfs TF, Ferson DZ, Law BK, Gokaslan Z, Arens JF. Pulse Oximeter Malfunction Caused by the Use of the StealthStation System during Neurosurgery. Anesthesiology 2002;96:A597 (http://www.asa-abstracts.com)

New Generation (Motion Resistant) Pulse Oximeters - Peer Reviewed Articles
(in chronological order)

  1. Dumas C, Wahr J, Tremper KK. Clinical evaluation of a prototype motion artifact resistant pulse oximeter in the recovery room. Anesthesia & Analgesia 1996;83(20:269-272
  2. Barker SJ, Shah NK. The effects of motion on the performance of pulse oximeters in volunteers. Anesthesiology 1997;86(1):101-108
  3. Bohnhorst B, Peter CS, Poets CF. Pulse oximeters' reliability in detecting hypoxemia and bradycardia: Comparison between a conventional and two new generation oximeters. Crit Care Med 200;28(5):1565-1568
  4. Malviya S, Reynolds PI, Voepel-Lewis T, Siewert M, Watson D, Tait AR, Tremper KK. False alarms and sensitivity of conventional pulse oximetry versus the Masimo SET technology in the pediatric postanesthesia care unit. Anesthesia and Analgesia 2000;90(6):1336-1340
  5. Durbin CG, Rostow SK. More reliable oximetry reduces the frequency of arterial blood gas analyses and hastens weaning after cardiac surgery: A prospective, randomized trial of the clinical impact of a new technology. Crit Care Med 2002; 30:1735-1740. 

New Generation (Motion Resistant) Pulse Oximeters - Informative Articles
(in chronological order)

  1. Goldstein MR. Left heart hypoplasia: a life saved with the use of a new pulse oximeter technology. Neonatal Intensive Care 1998;12(1):14-17
  2. Patel DS, Rezkalla R. Weaning protocol possible with pulse oximetry technology. Advance for Respiratory Care Managers 2000; 9(9):86
  3. Barker SJ. Standardization of the testing of pulse oximeter performance. Anesthesia and Analgesia 2002;94:S17-S20
  4. Brouillette RT, Lavergne J, Leimanis A, Nixon GM, Laden S, McGregor CD. Differences in pulse oximetry technology can affect detection of sleep disorders in children. Anesthesia and Analgesia 2002;94:S47-S53
  5. Durbin CG, Rostow SK. Advantages of new technology pulse oximetry with adults in extremis. Anesthesia and Analgesia 2002;94:S81-S83
  6. Miyasaka K. Pulse oximetry in the management of children in the PICU. Anesthesia and Analgesia 2002;94:S44-S46
  7. Urschitz MS, Von Einem V, Seyfang A, Poets CF. Use of pulse oximetry in automated O2 delivery to ventilated infants. Anesthesia and Analgesia 2002;94:S37-S40
  8. Ogino MT. The advantages of a new technology pulse oximeter in neonatal care. Neonatal Intensive Care 2002;15(1):24-27

New Generation (Motion Resistant) Pulse Oximeters - Abstracts
(in chronological order)

  1. Lichtenthal PR, Wade LD. Evaluation of signal extraction technology (SET) in preventing false alarms when using pulse oximetry in the recovery room. Anesthesiology 1996;86(2S):S278
  2. Goldstein MR, Martin GI, Sindel BD, Cunningham MD. Novel pulse oximeter technology resistant to noise artifact and low perfusion. American Journal of Respiratory and Critical Care Medicine 1997;155(4):A712
  3. Barker SJ, Novak S, Morgan S. The performance of three pulse oximeters during low perfusion in volunteers. Anesthesiology 1997;87 (3A):A409
  4. Barnum PT, Taschuk RD, Goldstein MR, Vogt G, Gangitano E, Stephenson CG, Liberman, RL. Novel pulse oximetry technology capable of reliable bradycardia monitoring. Respiratory Care 1997;42(11):1072
  5. Goldstein MR, Liberman RL, Taschuk RD, Thomas A, Vogt JF. Pulse oximetry in transport of poorly perfused babies. Pediatrics 1998;102(3):818
  6. Goldstein MR, Barnum PT, Vogt J, Gangitano ES, Stephenson CG, Liberman RL. Conventional pulse oximetry can give spurious data in a neonatal population at risk for retinopathy of prematurity (ROP). Pediatric Research 1998; 43(4):216A
  7. Holmes M, Thomas A, Vogt J, Gangitano E, Stephenson C, Liberman R. CO-oximetry validation of a new pulse oximeter in sick newborns. Respiratory Care 1998;43(10):860
  8. Thomas a, Holmes M, Vogt J, Gangitano E, Stephenson C, Liberman R. Useful life of pulse oximeter sensors in a NICU. Respiratory Care 1998; 43(10): 860
  9. Witucki PJ, Bell SJ. Comparison of three new technology pulse oximeters during recovery from extreme exercise in adult males. Critical Care Medicine 1999;27(12):A224
  10. Gangitano ES, Taschuk RD, Liberman RL. Near continuous pulse oximetry during newborn ECLS ASAIO Journal 1999;45(2):125
  11. Harrington S, Henderson D, Burton GG. Reliable pulse oximetry during exercise testing. Respiratory Care 1999;44(10):1226
  12. Liberman R, Holmes M, Taschuk R, Snelling L. Accuracy of pulse oximeters during neonatal motion. Respiratory Care 1999;44(12);1499
  13. Sahni R, Gupta A, Rosen TS. Motion-resistant pulse oximetry during circumcision in neonates. Pediatric Research 2000;47(4):430A(2544)
  14. Villareal D, Kukreja S. Masimo SET has major advantages for testing of infant apnea. Respiratory Care 2000;45(8):1009
  15. Trang H, Leske V, Boureghda S, Gaultier C. Masimo SET pulse oximetry improves detection of sleep apnea-related hypoxemia. American Journal of Respiratory and Critical Care Medicine 2001;163(5):A298
  16. Barker SJ. The effects of motion and hypoxemia upon the accuracy of 20 pulse oximeters in human volunteers. Sleep 2001;24:A406-7
  17. Whitman RA, Garrison ME. Comparison of the new Masimo SET V3 technology with a conventional pulse oximeter during polysomnography. Sleep 2001;24:A412
  18. Irita K, Kai Y, Takahashi S. Performance evaluation of Masimo SET pulse oximeter during mild hypothermic cardiopulmonary bypass. Anesthesiology 2001;95:A551. (http://www.asa-abstracts.com)
  19. Shah N, Clack SL, Hoang TD. Is there a difference in the recovery time for the accurate display of oxygen saturation (SpO2) and pulse rate (PR) after motion induced failure of pulse oximeters (PO) during low perfusion and normoxemia or hypoxemia in human volunteers? Anesthesiology 2001;95:A552 (http://www.asa-abstracts.com)
  20. Shah N, Clack SL, Hoang TD. Is there a difference in the recovery time for the accurate display of oxygen saturation (SpO2) and pulse rate (PR) after motion induced failure of pulse oximeters (PO) during low perfusion and normoxemia or hypoxemia in human volunteers? Anesthesiology 2001;95:A552 (http://www.asa-abstracts.com)
  21. Clack SL, Shah N, Hoang TD, Gupta B. A comparison of four major brands of pulse oximeters (PO) with Masimo SET PO during motion and low perfusion under normoxic and hypoxic conditions in human volunteers. Anesthesiology 2001;95:A586 (http://www.asa-abstracts.com)
  22. Barker SJ. The performance of six "motion-resistant' pulse oximeters during motion, hypoxemia and low perfusion in volunteers. Anesthesiology, 2001; 95:A587. (http://www.asa-abstracts.com)
  23. Rostow SK, Durbin CG. Clinicians quickly learn to utilize improved accuracy and reliability of the new generation of pulse oximeters. Respiratory Care 2001;46(10):1104
  24. Noblet T. Cost reduction following conversion to Masimo SET pulse oximetry-experience in the NICU. Respiratory Care 2001;46(10):1130
  25. Bogy AT, Martinez D. Changing to Masimo SET improves patient outcome and staff satisfaction. Respiratory Care 2001;46(10):1140
  26. Noblet T. Patient safety and staff satisfaction following conversion to Masimo SET pulse oximetry- experience in the NICU. Respiratory Care 2001;46(10):1140
  27. Goldstein MR, Furman GI, Pernia ML, Lawas-Alejo P, Yang LL, Sindel BD, Ochikubo CG, Martin GI. Performance of motion-resistant pulse oximeters in tracking neonatal heart rate variability. Anesthesia and Analgesia 2002;94:S102(A5)
  28. Wischniewski E, Erler T, Avenarius S. Multicenter trial of neonatal pulse oximeter sensor usage: a difference between manufacturers. Anesthesia and Analgesia 2002;94:S110(A21)
  29. Torres A, Skender K, Wohrley J, Aldag J, Raff G, Geiss D. Assessment of 2 New Generation Pulse oximeters During Low Perfusion in Children. Critical Care Medicine 2002;29(12):A117
  30. Whitman RA, Garrison ME, Oestrich PJ. Influence of pulse oximeter technology on hypopnea diagnosis using the newly proposed definition of a respiratory hypopnea. Sleep 2002;25:A509
  31. Robertson F, Hoffman G. Effects of Signal Integrity and Saturation on Accuracy of Masimo SET and Nellcor N395 Pulse Oximeters. Anesthesiology 2002;96:A555 (http://www.asa-abstracts.com)
  32. Robertson F, Hoffman G. Clinical evaluation of Masimo SET and Nellcor N395 Oximeters during Optimal signal Conditions in Difficult-to-Monitor Neonates. Anesthesiology 2002;96:A556  (http://www.asa-abstracts.com)
  33. Kawagishi T, Kanaya N, Nakayama M, Namiki A. A Comparison of the Performance of Pulse Oximeters during Blood Pressure Cuff-Induced Hypoperfusion in Volunteers. Anesthesiology 2002;96:A559 (http://www.asa-abstracts.com)
  34. Lutter N, Kozma E, Meyer V, Schuettler J. Performance of Three Fourth-Generation Pulse Oximeters during Electro-Convulsive Therapy. Anesthesiology 2002;96:A560 (http://www.asa-abstracts.com)
  35. Lichtenthal PR, Barker SJ. An Evaluation of Pulse Oximetry-Pre, during, and Post-Cardiopulmonary Bypass. Anesthesiology 2002;96:A598 (http://www.asa-abstracts.com)
  36. Robertson F, Hoffman G. Effects of Signal Integrity and Saturation on Data Availability in Masimo SET and Nellcor N395 Pulse Oximeters. Anesthesiology 2002;96:A599 (http://www.asa-abstracts.com)

Yoshiya I, Shimada Y, Tanaka K. Spectrophotometric monitoring of arterial oxygen in the fingertip. Med Biol Eng Comput 1980;18:27-32

Researchers describe an early pulse oximeter that used a halogen lamp and fiberoptic fibers with filters at 605nm and 805nm. The authors found that the instrument was useful in their intensive care units for monitoring patients with respiratory failure; although they gave no clinical scenarios. They also mentioned it was susceptible to motion artifact such as shivering due to interruption of the light beam. Sarnquist F, Todd C, Whitcher C. Accuracy of a new non-invasive oxygen saturation monitor. Anesthesiology 1980;53:S163 These researchers report (in this abstract) the result of an accuracy study on a pulse oximeter (Minolta Oximeter Model 101). Using volunteers during breathing of hypoxic gas mixtures, they found that the device reported high values at the lower SaO2 levels. They suggest that the device should be corrected for this over reading. They do conclude that the ease of use, linearity and speed of response make the device a promising monitoring device for use in anesthesia.

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Yelderman M, New W. Evaluation of Pulse Oximetry. Anesthesiology 1983; 59:349-352

This is one of the first reports to use the term "pulse oximeter". The authors studied the use of Nellcor N-100 on 5 healthy volunteers during slow controlled desaturation from 100% to 70%. They found the pulse oximeter accurately measured the arterial oxygen saturation in the 70-100% range.

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Brooks TD, Paulus DA, Winkle WE. Infrared heat lamps interfere with pulse oximeters [Letter]. Anesthesiology 1984; 61:630

Brooks and coworkers reported that Nellcor and Biox pulse oximeter technologies were interfered with by infrared heating lamps. The Nellcor N-100 would report a falsely low pulse rate or SpO2 or blank the display. The BTI Biox III would indicate that the light from the diode was not being sensed by the photodetector. The authors suggest protecting the sensor (both emitter and photodetector) from bright light.

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Kim SK, Baidan BS, Petty TL. Clinical evaluation of a new finger oximeter. Crit Care Med 1984;12:910-912

The authors studied the accuracy of pulse oximeter readings (Minolta SM-32) in normal subjects (during normoxic and hypoxic gas breathing) and on critically ill patients in their ICU. They compared the device to the Hewlett-Packard ear oximeter, calculated and measured arterial saturation. They found the device comparable in accuracy to the HP ear oximeter, although smaller and easier to use. They did mention that Minolta zeroed out when the figure tip changed its position against the light beam. They suggest that the device had accuracy and utility of sufficient degree for a wide variety of clinical applications. 

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Brodsky JB, Shulman MS, Swan M, Mark JBD. Pulse oximetry during one-lung ventilation. Anesthesiology 1985;63:212-214

This is a clinical report of using pulse oximetry (Nellcor N-100) during one-lung ventilation (OLV). They studied the usefulness and accuracy (vs. CO-Oximetry) of pulse oximetry in 19 patients under going OLV. They concluded the pulse oximeter was helpful and accurate in this population.

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New W. Pulse Oximetry. J Clin Monit. 1985 Apr;1(2):126-129

This article describes some of the advantages of pulse oximetry compared to transcutaneous oxygen monitoring. Dr. New is a co-founder of Nellcor and does an excellent job of extolling the virtues of pulse oximeters compared to transcutaneous monitors. He lists numerous features and benefits of pulse oximetry. He does include a table on limitations of pulse oximetry.

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Mihm FG, Halperin BD. Noninvasive detection of profound arterial desaturation using a pulse oximetry device. Anesthesiology 1985;62:85-87

The authors studied pulse oximetry (Nellcor) versus CO-Oximetry in 18 patients in respiratory distress or being weaned from mechanical ventilation. They obtained 131 measurements in the range of 56.2% to 99.9%. In addition, they reported that the pulse oximeter picked up clinically significant arterial desaturation that occurred in three of the patients. They did note that the pulse oximeter had occasional signal failure from poor perfusion in four of the patients due to "a history of vascular disease" or dopamine infusions. The authors suggest that pulse oximetry can reduce the number the arterial blood gases and also improve care by providing continuous information of arterial oxygenation.

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Ries AL, Farrow JT, Clausen JL. Accuracy of two ear oximeters at rest and during exercise in pulmonary patients. Am Rev Respir Dis 1985;132:685-689

These researchers studied the accuracy of two ear oximeters (Hewlett-Packard 47201A and Biox II) at rest and during exercise in 116 pulmonary patients. Both instruments demonstrated comparable accuracy when compared to simultaneously measured arterial blood samples. They found the oximeters more accurate in measuring a change in saturation than the absolute reading of saturation. They also found that COHb levels > 4% and dark skin pigmentation appeared to decrease the accuracy of measurement. They conclude that both units may be useful for clinical exercise testing in pulmonary patients.
NOTE: The HP ear oximeter was an 8 wavelength non-pulsatile oximeter, and the Biox II utilized pulse oximetry technology.

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Severinghaus JW, Astrup PB. History of blood gas analysis. VI. Oximetry. J Clin Monit 1986;2:270-288

This is the classic article that describes the beginning of non-invasive oximetry in the 1930s to pulse oximetry's origins in the 1970's. This is must reading for those interested in the history of non-invasive oximetry and pulse oximetry. In addition to this article, please read the follow up article by Severinghaus and Honda in 1987. There are several major corrections about the "invention" of pulse oximetry covered in the 1986 article.

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Severinghaus JW, Honda Y. History of blood gas analysis. VII. Pulse oximetry. J Clin Monit 1987 Apr;3(2):135-138

This is the classic article that attributes the invention of pulse oximetry to Takuo Aoyagi. The authors detail how Mr. Aoyagi, a Japanese physiological bioengineer, was working on cardiac output measurement using ear oximetry. The transmitted light signal exhibited pulsatile variations, which made it nearly impossible to compute cardiac output. He devised a method to cancel out the pulsatile variations by electronically subtracting a pulse signal detected at 900 nm (infrared), where the cardiogreen dye is transparent, from the dye-sensing 630 nm red signal. However, this cancellation process didn't work well with changes in arterial saturation.. He knew of the work of other researchers in oximetry and thought his method might get rid of previous calibration problems. His company, Nihon Kohden, produced an instrument that was used clinically in 1974. The authors discuss later developments from Biox and Nellcor that helped to commercialize pulse oximetry.

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Block FE Jr. Interference in a pulse oximeter from a fiberoptic light source. J Clin Monit 1987;3:210-211

In this case report, the author found that a pulse oximeter sensor could be interfered with by the strobe light effect from a fiberoptic light source. Light from the internal light source of a cystoscope, interrupted by the spinning blades produced an erroneous pulse rate on the pulse oximeter. In a later experiment on himself, he found that he could produce any value of SpO2 (even down to 0%) just by varying the position of the light source and the finger sensor. In addition, he found that the pulse oximeter sensor just dangling in the air could report a 100% SpO2 reading with pulse rate of 250 bpm from the incident light. He suggested that care should be taken to protect pulse oximeter sensors from incident light.

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Barker SJ, Tremper KK. The Effect of Carbon Monoxide Inhalation on Pulse Oximetry and Transcutaneous PO2. Anesthesiology 1987;66:677-679.

These researchers studied the effects of increased levels of COHb on pulse oximetry using anesthetized dogs. COHb levels were varied slowly from 0 to 75% in each animal. As the COHb level increased and the oxyhemoglobin decreased, the pulse oximeter continued to read an SpO2 greater than 90%. Their conclusion was that in the presence of COHb, the SpO2 is approximately the sum of the COHb and the HbO2. They also add caution about using the pulse oximeter as a sole measure of oxygenation in patients with recent carbon monoxide exposure.

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Anderson JV. The accuracy of pulse oximetry in neonates: Effects of fetal hemoglobin and bilirubin. J Perinatol 1988;7:323

The author presents clinical data on 18 neonates in whom fetal hemoglobin had been measured (range 17% -82%). He found that both the Nellcor N-100 and Ohmeda Biox 3700 pulse oximeters were unaffected by fetal hemoglobin.

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Pologe JA, Raley DM. Effects of fetal hemoglobin on pulse oximetry. J Perinatol 1988;7:324-326

Pologe and Raley, both research engineers at Ohmeda, presented theoretical data based on the extinction curves of HbA and HBF obtained from Dr. Zijlstra of the University of Groningen. They calculated the theoretical effects HbF on pulse oximetry and found that the maximum effect of HbF would be 0.41% at an SaO2 of 100% and 1.12% at an SaO2 of 50%. Thus, they concluded that any effect would be clinically insignificant.

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Pologe, J. Pulse Oximetry: Technical Aspects of Machine Design. Int Anesthesiol Clin 1987 Fall;25 (3):137-153

The author, an employee of Ohmeda, reviews the principles of pulse oximetry in detail. Mr. Pologe, an electrical engineer, has an easy to read writing style, which is helpful as he explains some of the more technical aspects of pulse oximetry. This often cited article includes an excellent section on light emitting diodes (LEDs) and LED cycling in pulse oximetry. 

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Ridley SA. A comparison of two pulse oximeters. Assessment of accuracy at low arterial saturation in paediatric surgical patients. Anaesthesia 1988; 43:136-140

This researcher studied the accuracy of two pulse oximeters, the Ohmeda Biox 3700 and the Nellcor N-100E, during surgery performed on 25 hypoxemic children with congenital heart disease. The SpO2 values from the two pulse oximeters were compared with arterial blood measurement using a Radiometer OSM-2 CO-Oximeter. The pulse oximeters differed significantly from the CO-Oximeter measurement and were outside of the manufacturers' accuracy claims. However, both pulse oximeters appeared to reflect changes in saturation accurately in the same patient.

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Wukitsch MW, Petterson MT, Tobler DR, Pologe JA. Pulse Oximetry: Analysis of Theory, Technology, and Practice. J Clin Monit 1988;4:290-301

The authors, all employees of Ohmeda, describe in detail how the Ohmeda 3700 pulse oximeters works. They describe the electronics of their pulse oximeter: 1) LED timing and probe control; 2) analog signal conditioning and/or processing; 3) data acquisition; 4) digital conditioning and/or processing; 5) display and control system; 6) internal system diagnostic functions. In additional, they discuss the effects of interfering substances, such as, dyes, COHb and MetHb on pulse oximetry.

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Fanconi S. Reliability of pulse oximetry in hypoxic infants. Pediatrics 1988;112:424-427

This researcher studied the accuracy of pulse oximetry at SaO2 values < 65% in hypoxic infants. His 20 patients included 13 with congenital heart disease. He collected 8 samples per patient and compared SpO2 (Nellcor N-100) vs. measured SaO2 (Radiometer OSM 2 Hemoximeter). He excluded patients with hypotension or poor peripheral perfusion ( inadequate signal strength on the pulse oximeter). Linear regression analysis of SpO2 vs. SaO2 produced an r value of 0.91 with a regression equation of y = 23.6 + 0.71x. The bias between the measured SaO2 and SpO2 was -4.53%, with a precision of 7.86% (range -35.0% to +12.0%). Thus, he found that the results indicate a large, variable, and unpredictable error of pulse oximetry at low saturations. He concluded that in patients with severe arterial desaturation pulse oximetry is unreliable and cannot substitute for invasive blood gas measurements.

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Kelleher JF. Pulse oximetry. J Clin Monit 1989;5:37-62

Excellent review of the literature concerning the accuracy, limitations and clinical uses of pulse oximetry. He cites 220 references.

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Hay WW, Brockway JM, Eyzaguirre M. Neonatal Pulse Oximetry: Accuracy and Reliability. Pediatrics 1989;83(5):717-722

The authors report the accuracy of the Ohmeda Biox 3700 pulse oximeter in the neonatal population. They found that SpO2 was highly correlated with arterial blood oxygen saturation (r= .99) measured on arterial (catheter) blood using a two-wavelength Radiometer OSM2 Hemoximeter. In addition, they report that when compared to PaO2, SpO2 values of 92% 3% excluded all of the measured PaO2 values less than 45 mm Hg and greater than 100 mm Hg. They also discuss some of the differences between transcutaneous PO2 and pulse oximeter monitoring in this clinical population.

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Kelleher JF, Ruff RH. The Penumbra Effect: Vasomotion-dependent Pulse Oximeter Artifact due to Probe Malpostion. Anesthesiology 1989;71(5):787-791

The authors present a case report where a dislodged sensor (hidden under a surgical drape) caused an erroneous decrease in SpO2. They then studied the effect of sensor malposition and the error it causes at two different room temperatures (13 C and 21 C) both on a volunteer and then on actual surgical patients. They found this effect is more pronounced at warmer room temperatures. They suggest that the mechanism of this effect probably involves some combination of optical shunt, a weak pulse signal, and flow through cutaneous arteriovenous anastomoses.

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Tremper KK, Barker SJ. Pulse Oximetry. Anesthesiology 1989:70:98-108

The authors review the historical development of pulse oximetry, as well as the physics and engineering principles upon which it is based. They also review selected studies that discuss pulse oximetry accuracy, limitations, and clinical applications. They cite 53 references.

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Barker SJ, Tremper KK, Hyatt J. Effects of Methemoglobinemia on Pulse Oximetry and Mixed Venous Oximetry. Anesthesiology 1989 70:112-117

These researchers studied the effects of methemoglobin (MetHb) on pulse oximetry using anesthetized dogs. Methemoglobin levels of up to 60% were induced by intratracheal benzocaine. They found that as MetHb gradually increased the SpO2 overestimated the SaO2 by an amount proportional to the concentration of MetHb until it reached approximately 35%. At this level of MetHb, the SpO2 values reached a plateau of 84% to 86%. These researchers concluded that pulse oximetry should be used with caution in the presence of MetHb.

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Choe H, Tashiro C, Fukumitsu K, Yagi M, Yoshiya I. Comparison of recorded values from six pulse oximeters. Crit Care Med 1989; 17:678

The authors studied the accuracy of six pulse oximeters on eight nonsmoking volunteers with SaO2 values in the range of 70% to 100%. The difference between SaO2 and HbO2 was 2.3 0.3 (SD)% with 1.4 0.1% HbCO and 0.9 0.1% MetHb. They found that the SpO2 value in two of the pulse oximeters were close to HbO2, while the others correlated with SaO2. The greatest SpO2 difference among the instruments was 2.7 1.9%. They suggest that under normal dyshemoglobin levels, some of the pulse oximeters are calibrated to estimate SaO2 and the others to estimate HbO2. They suggest that the manufacturers should establish a standard calibration method.

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Severinghaus JW, Spellman MJ Jr. Pulse Oximeter Failure Thresholds in Hypotension and Vasoconstriction. Anesthesiology 1990;73:532-537

In a unique set of experiments, the authors studied the degree of systolic hypotension causing failure and recovery of pulse oximeters. They tested three pulse oximeters in nine normal male volunteers. Perfusion of the test hand was slowly reduced and restored by 1) elevation of the hand plus hypotension with nitroprusside (if needed); 2) clamp compression of the brachial artery; 3) brachial cuff inflation; and 4) intraarterial norepinephrine. They report the systolic pressure at which the pulse oximeters failure and then recover. They also studied these effects at lower SpO2 (70%). In normoxic subjects, SpO2 decreased at threshold to 88.8 11.5%, suggesting that arterial O2 was lost to the tissue by pulsatile movement in and out of capillaries, or by transarterial diffusion. In addition, to this observation it was noted that the response to a desaturation event was prolonged due to markedly decreased peripheral blood flow by as much as 6 minutes in one case.

Dr. Severinghaus also presented a case report of a patient in the OR who had a progressive hypotension to 60 mm Hg systolic due to blood loss. Rapid crystalloid administration was begun while awaiting blood, and 10 mg ephedrine was administered. While arterial blood pressure rose to 70 mm Hg, SpO2 fell from 97-100% (Nellcor N-200) over the next 5 minutes to 45%. An arterial blood sample from the radial artery of the same hand with the pulse oximeter sensor revealed a PaO2 of 550 mm Hg. When blood was administered and the ephedrine induced vasoconstriction wore off, the SpO2 value returned to > 95% over the next 15 minutes. 

They summarize that pulse oximeters are so sensitive that they may detect pulses when pressure is too low to provide adequate tissue blood flow, that is, SpO2 may decrease due to O2 consumption by the finger of the pulsing but stagnant arterial blood at low pressure or with vasoconstriction. They suggest that it may be counterproductive to increase pulse oximeter sensitivity in an effort to obtain SpO2 data during severe hypotension or vasoconstriction, since the data would often severely underestimate arterial oxygen saturation.

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Ralston AC, Webb RK, Runciman WB. Potential errors in pulse oximetry III: Effects of interference, dyes, dyshaemoglobins and other pigments. Anaesthesia 1991;46:291-295

This is a review of the limitations of pulse oximetry. The authors discuss interference caused by electrosurgery, patient motion and some types of lighting. They conclude that carboxyhemoglobin (COHb) overestimates the fractional saturation by an amount less than, but close to, the percent of COHb present. They conclude that methemoglobin (MetHb) cause the SpO2 to tend to 85%. Fetal hemoglobin and Bilirubin introduce no significant error, although they comment that increased levels may cause interference with in vitro measurement (CO-Oximetry). Skin pigmentation was shown to cause increased inaccuracy. Nail polish may cause under reading and it was suggested that the sensor could be placed sideways to eliminate that effect. They cite 50 references.

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Valko, Campbell JP, McCarty DL, Martin D, Turnbull J. Prehospital use of pulse oximetry in rotary-wing aircraft. Prehospital Disaster Med 1991 Oct-Dec;6(4):421-428

The authors conducted a prospective study of pulse oximetry (Ohmeda 3740) on 200 patients during rotary-wing aircraft transport. Thirty-four patients (17%) were found to have significant hemoglobin desaturation to less than 90%. These desaturations often were noted prior to alterations in vital signs or clinical appearance. In 32 of the 34 hypoxemic patients, therapeutic interventions corrected the low SpO2. They conclude that pulse oximetry is a practical and valuable adjunct for monitoring critically ill patients transported by rotary-wing aircraft.

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Talke PO. Measurement of systolic blood pressure using pulse oximetry during helicopter flight. Crit Care Med 1991;19:934

Systolic blood pressure (BP) measured by pulse oximetry (Ohmeda Biox 3740) was compared with systolic BP measurement by the direct intra-arterial and the arterial occlusion methods intraflight on 10 critically ill patients. Systolic BP by pulse oximetry was measured by observing the return of the plethysmographic waveform of the pulse oximeter as the BP cuff ipsilateral to the pulse oximeter sensor was slowly deflated. Arterial occlusion pressure was measured by observing the return of the intra-arterial waveform as the BP cuff ipsilateral to the arterial cannula was slowly deflated. The indirect methods correlated better with each other than with the direct intra-arterial measurements. The author found that the noise and vibrations of the helicopter did not significantly interfere with the operation of the pulse oximeter. He concluded that a pulse oximeter that displays a plethysmographic waveform can accurately measure systolic BP intraflight.

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Rajadurai VS, Walker AM, Yu VYH, Oates A. Effect of fetal haemoglobin on the accuracy of pulse oximetry in preterm infants. J Paediatr Child Health 1992;28:43-46

These researchers studied the effects of fetal hemoglobin (HbF) on pulse oximeter measurements on 22 infants with HbF range of 0% - 100%. They found no significant influence on SpO2 for any level of HbF present for the Nellcor N-200 in the SpO2 range of 78% - 98%.

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Severinghaus JW, Kelleher JF. Recent Developments in Pulse Oximetry. Anesthesiology 1992;76:1018-1038

The authors perform an excellent review of the pulse oximetry articles between mid 1988 and October 1,1991. During this time they state that there were more than 500 publications that describe methods, uses, problems, progress and effects of pulse oximetry. They cite over 240 references.

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Barker SJ, Hyatt J, Shah NK, Kao YJ. The effect of sensor malpostioning on pulse oximeter accuracy during hypoxemia. Anesthesiology 1993;79(2):248-54

These researchers studied the effects of sensor malpositioning on pulse oximeters from different manufacturers, used on hypoxemic subjects. Early studies had shown that improperly positioned sensors could read erroneously low on normoxemic subjects. 12 healthy volunteers were studied. Each had a radical artery cannula inserted and 5 of the 8 sensors applied were malpositioned. The subjects breathed a mixture of N2 and O2 sufficient to vary SaO2 slowly from 100% to 70%. Five stable levels of SaO2 were measured for each subject. The researchers found that the pulse oximeters varied greatly with their behavior depending on both the SaO2 and the manufacturer. One oximeter underestimated saturation at all SaO2 levels, while three others underestimated at high SaO2 and overestimated at low SaO2. The researchers recommended that sensor position be checked frequently and that inaccessible sensor locations be avoided whenever possible.

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Thilo EH, Anderson D, Wasserstein ML, Schmidt J, Luckey D. Saturation by pulse oximetry: Comparison of the results obtained by instruments of different brands. J Pediatr 1993;122:620-626

The authors studied the difference in the reported SpO2 by two major brands of pulse oximeters in their neonatal population. They found the Nellcor N-100 SpO2 was consistently higher than the Ohmeda 3700 pulse oximeter by a mean of 1.61% 2.69%. When running the arterial blood sample on a Radiometer OSM-3 CO-Oximeter, they found the Nellcor SpO2 correlated best with functional SaO2 (oxyhemoglobin (HbO2)/(HbO2 + reduced hemoglobin)) x 100); the Ohmeda SpO2 correlated best with fractional SaO2 ((HbO2/(HbO2 + reduced hemoglobin + carboxyhemoglobin + methemoglobin)) x 100). They also commended that to keep the PaO2 in a range of 50 to 100 mm Hg; the SpO2 range should be from 90% to 96% for the Ohmeda and 92% to 98% for the Nellcor.

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Bucher HU, Keel M, Wolf M, von Siebenthal K, Duc G. Artifactual pulse-oximetry estimation in neonates. Lancet 1994;343:1135-1136

These researchers report an incident of unexplained hypoxemia (SpO2 in the 80-82% range) being resolved by readjustment of the sensor. They then performed a series of experiments with 20 infants studying the effect of venous congestion (impaired venous return) at the sensor site. Each infant had a sensor placed on both feet. One foot was used as the control the other was the test site. A blood pressure cuff was wrapped around the test sensor site. As the pressure was slowly raised the difference in the control versus test SpO2 was recorded. They found that at 50 mm Hg pressure the test difference from the control exceeded 3% in 5 infants. With increasing pressure between 25 to 30% of the infants had a difference >3% up to total failure due to inadequate pulsatile signal. In a second set of experiments, the blood pressure cuff was placed around the lower leg (to study the effects of venous congestion). At an occlusion pressure of 30 mm Hg, 3 infants had a DSpO2 >3%, and at 40 and 50 mm Hg, 6 and 7 infants respectively, had DSpO2 >3%. In a separate study they measured the amount of pressure that 26 nurses used to apply sensors (to a device with built-in pressure transducer). Forty-two (42)% of the nurses exceeded 50 mm Hg. They conclude that when the tissue pressure increases or venous return is impeded, the venous blood may become pulsatile and thus, become included in the calculation and cause the SpO2 to be erroneously low. This can occur without affecting accurate pulse detection.

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Mower WR, Sachs C, Nicklin EL, Baraff LJ. Pulse Oximetry as a Fifth Pediatric Vital Sign. Pediatrics 1997;99:681-686

This is a prospective study using pulse oximetry to measure oxygen saturation in children presenting to emergency department triage.SpO2 values were disclosed to clinicians only after they had completed evaluations and were ready to discharge or admit each child. The study included 2127 children. They measured the changes in medical treatment and diagnoses initiated after the disclosure of the SpO2 values. They found that using pulse oximetry resulted in important changes in the treatment of a small proportion of pediatric patients.

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Rahlfs TF, Ferson DZ, Law BK, Gokaslan Z, Arens JF. Pulse Oximeter Malfunction Caused by the Use of the StealthStation System during Neurosurgery. Anesthesiology 2002;96:A597 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Rahlfs" and press Go

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Dumas C, Wahr J, Tremper KK. Clinical evaluation of a prototype motion artifact resistant pulse oximeter in the recovery room. Anesthesia & Analgesia 1996;83(20:269-272

This study compares the frequency and nature of spurious pulse oximetry readings between a conventional pulse oximeter (Nellcor N-200) and a motion resistant pulse oximeter (Masimo SET prototype) under various patient motion conditions seen in the recovery room. They authors studied fifty (50) adult surgical patients post operatively selected from a group of patients that typically experienced a high alarm rate with conventional pulse oximetry. Alarm frequency, defined as SpO2 < 90% or complete signal loss was evaluated. For 1400 min. of monitoring, the conventional pulse oximeter was falsely alarming for 75 min. vs. 11 min. for the Masimo SET prototype. This represents a sevenfold decrease in audible false alarming for the motion resistant pulse oximeter. 

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Barker SJ, Shah NK. The effects of motion on the performance of pulse oximeters in volunteers. Anesthesiology 1997;86(1):101-108

The effect of motion on three different pulse oximeters (Nellcor N-200, Nellcor N-3000 and Masimo SET prototype) was studied in ten healthy volunteers. Sensors were placed on digits 2,3,and 4 of the test hand (which was strapped to a motion generator). The other hand was kept motionless and was monitored with same pulse oximeters and an arterial cannula. Arterial oxygen saturation was varied from 100% to 75% by changing the inspired O2 concentration. While the SpO2 was both constant and changing, the oximeters were connected before and during motion. These researchers found that if the oximeter was functioning before the motion began, the following were the percentages of time the instrument displayed an SpO2 value within 7% of control: N-200 = 76%, N-3000 = 87%, and Masimo = 99%. When the oximeter sensor was connected after the beginning of motion, the values were N-200 = 68%, N-3000 = 47%, and Masimo = 97%. They concluded that the error and dropout rate of the Masimo was superior to that of the other two instruments during all test conditions.

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Bohnhorst B, Peter CS, Poets CF. Pulse oximeters' reliability in detecting hypoxemia and bradycardia: Comparison between a conventional and two new generation oximeters. Crit Care Med 200;28(5):1565-1568

The authors evaluated three different pulse oximeters for their ability to track hypoxemia and bradycardia in a neonatal population. They wanted to study whether the newer generation pulse oximeters (Masimo SET and Nellcor N-3000) achieved their lower false alarm rate at the expense of missed or delayed detection of hypoxemia or bradycardic events. Seventeen (17) unsedated, preterm and spontaneously breathing infants were monitored for ECG heart rate, transcutaneous PO2, SpO2 and pulse rate from three pulse oximeters (Nellcor N-200, Nellcor N-3000, and Masimo SET). For 220 hours of monitoring, there were 185 hypoxic and 54 bradycardic events. For the hypoxic events, the N- 200 failed to report 15 (8%), the N-3000 failed to report 14 (7%), and the Masimo failed to report 2 (1%). For the bradycardic events, the N-3000 failed to report 37 (69%), the N-200 failed to report 17 (31%) and the Masimo failed to report 4 (7%). The authors concluded that the N-3000 reduced alarm rate was achieved at the expense of an unreliable and/or delayed identification of hypoxemia and bradycardia. On the other hand, they found that the low false alarm rate of the Masimo SET pulse oximeter was accomplished without loss of the ability to detect hypoxemia and bradycardia in their neonatal population.

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Malviya S, Reynolds PI, Voepel-Lewis T, Siewert M, Watson D, Tait AR, Tremper KK. False alarms and sensitivity of conventional pulse oximetry versus the Masimo SET technology in the pediatric postanesthesia care unit. Anesthesia and Analgesia 2000;90(6):1336-1340

This is a prospective study comparing the incidence and duration of false alarms and the sensitivity of conventional pulse oximetry (CPO) with Masimo Signal Extraction Technology (Masimo SET) in children in the postanesthesia care unit. 75 children were monitored via ECG and SpO2 and pulse rate via CPO (Nellcor N-200) and Masimo SET pulse oximeters. All data were collected via computer. Patient motion, respiratory, and other events were simultaneously documented. SpO2 tracings conflicting with clinical observation and/or documented events were considered false. These were defined as 1) Data dropout; 2) False negative, failure to detect SpO2 < 90% detected by another pulse oximeter or based on observation/intervention; 3) False alarm, SpO2 < 90% considered artifactual; and 4) True alarm, SpO2 < 90% considered valid. For the 42 hours of monitoring there were 27 true alarms, all identified by Masimo SET and 16 (59%) by the N-200. The Masimo SET pulse oximeter had 4 false alarms compared to 10 for the N-200. Data dropout was equal for the two devices. The authors conclude that the Masimo SET pulse oximeter reduced the incidence and duration of false alarms and identified more frequent incidence of true alarms compared with a conventional pulse oximeter.

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Durbin CG, Rostow SK. More reliable oximetry reduces the frequency of arterial blood gas analyses and hastens weaning after cardiac surgery: A prospective, randomized trial of the clinical impact of a new technology. Crit Care Med 2002; 30:1735-1740

The authors report on a methodology and results of comparing the clinical impact of two pulse oximeters: one older generation conventional oximeter and one newer generation Masimo oximeter. They describe a methodology of blinding the output of one or the other device and evaluating clinicians utilization of the pulse oximetry data, by measuring the time to wean oxygen concentration to a predetermined safe level and the number of blood gases obtained to confirm the patient's clinical condition. They report that the group of patients monitored with the Masimo were weaned in half of the time and that the number of blood gases were reduced by 50% compared to the group monitored with the conventional oximeter.

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Goldstein MR. Left heart hypoplasia: a life saved with the use of a new pulse oximeter technology. Neonatal Intensive Care 1998;12(1):14-17

This is a case report of a prototype motion resistant pulse oximeter (Masimo SET) being used in the resuscitation of an infant in the emergency department. The author, a neonatologist, describes the compassionate use of a prototype pulse oximeter when a conventional pulse oximeter (Nellcor N-200) had failed to give readings. The author was able to use the initial data from the prototype Masimo pulse oximeter to follow the clinical course of the infant during the early course of the resuscitative efforts. The author felt the steady rise in SpO2 and pulse rate values from the Masimo pulse oximeter aided in the decision to continue the successful resuscitative efforts.

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Patel DS, Rezkalla R. Weaning protocol possible with pulse oximetry technology. Advance for Respiratory Care Managers 2000; 9(9):86

The authors report on the results of the initiation of a weaning protocol at their hospital facilitated by improved pulse oximetry technology. The authors felt the weaning protocol was easier to implement due to confidence in their newly acquired Masimo SET pulse oximeters. Trial of this new technology had shown it to acquire data on patients who were poorly perfused, combative or frequently moving where their older conventional pulse oximeters had failed. The authors state that initially with the new protocol, the clinical staff was cautious in the weaning of patients. They confirmed the ventilator changes with an arterial blood gas (ABG). They state that because the ABGs consistently correlated with the Masimo pulse oximeter, the respiratory therapists grew confident with the readings. The number of ABGs declined, and weaning times became faster. In reviewing the data over a nine-month period they found evidence of decreased costs and improved patient outcomes. They found a 40% reduction in total hours of ventilator time. In addition, they report a significant reduction in ABGs, as well as, a decrease in length of hospital stay for their ventilator patients.

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Barker SJ. Standardization of the testing of pulse oximeter performance. Anesthesia and Analgesia 2002;94:S17-S20

This researcher discusses the pros and cons of laboratory testing (volunteer studies) of pulse oximetry technology. He raises the issues that also accompany the clinical testing of pulse oximetry. He discusses metrics of performance for laboratory testing including bias, precision, dropout rate, performance index, and ROC curves. He describes the protocol that he has used in his laboratory evaluations of twenty (20) different pulse oximeters. He suggests that laboratory studies need to be followed by clinical studies. When the user is faced with determining what device to purchase he suggests that a combination of the published laboratory studies and clinical case studies be used. However, he states these studies need to be interpreted with an understanding of their limitations as well as their advantages.

Brouillette RT, Lavergne J, Leimanis A, Nixon GM, Laden S, McGregor CD. Differences in pulse oximetry technology can affect detection of sleep disorders in children. Anesthesia and Analgesia 2002;94:S47-S53

These researchers studied several motion resistant pulse oximeters compared with a conventional pulse oximeter (Nellcor N-200) in a pediatric sleep lab setting. Their study consisted of three series: 1) N-200 in mode 2 ( 2 to 3 second averaging) vs. Masimo Q400 in 4 second averaging in 24 patients; 2) N-200 in mode 2 vs. Masimo Radical in 2 second averaging in 22 patients; and 3) Nellcor N-395 (averaging time not user selectable) vs. Masimo Radical in 2 second averaging in 5 patients. Through this series of tests they found that the Masimo pulse oximeters register markedly less false desaturations due to motion artifact than the other pulse oximeters. Using a 4 second averaging, a Masimo oximeter detected significantly fewer SaO2 dips than the N-200 but using the 2-second averaging, a Masimo oximeter detected more dips than the N-200. They found the N-395 had too many false desaturations and too slow a response time (missed true desaturation events) to be recommended for the pediatric sleep lab setting. They concluded that use of a Masimo pulse oximeter with a very short averaging time could significantly reduce workload and improve reliability of desaturation detection.

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Durbin CG, Rostow SK. Advantages of new technology pulse oximetry with adults in extremis. Anesthesia and Analgesia 2002;94:S81-S83

The authors studied New Generation pulse oximetry technology (Masimo SET) in thirteen critically ill patients in whom conventional pulse oximetry had failed. They found the Masimo SET was able to obtain a signal and the SpO2 compared accurately to actual arterial saturation in 12 of the patients (92.3%). In one patient, the Masimo SET pulse oximeter also failed. However, in this patient they were also unable to obtain an arterial blood gas sample and the patient expired shortly thereafter. They concluded that this series of patients demonstrates the value of the new Masimo SET technology in the most critically ill and demanding clinical situations in which other techniques had failed. They further suggested that a significant improvement in patient safety resulted from use of this improved oximetry.

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Miyasaka K. Pulse oximetry in the management of children in the PICU. Anesthesia and Analgesia 2002;94:S44-S46

The author reviewed data from an alarm study conducted yearly in his PICU. He found that the frequency of pulse oximeter alarms were reduced more than half with introduction of Masimo SET V2 in his 9 bed PICU compared with data from a prior year when conventional pulse oximeters were in use. With introduction of Masimo SET V3 in 2001, there was a more than threefold decrease in frequency of false alarms (compared with Masimo V2). In addition, he presented results from a 1998 study of measurement of false alarms during induction of anesthesia on 50 consecutive healthy infants undergoing repair for inguinal hernias. Sensors were placed on the toes of the infants and connected to a conventional pulse oximeter and a Masimo SET V2 pulse oximeter. The studies were videotaped and data digitally recorded. The data from the data recorder and videotapes were analyzed for the events occurring outside the alarm limits from the time the sensors were placed to right after the child was immobilized. He found the conventional pulse oximeter falsely alarmed 36.0% of the time. The Masimo SET V2 falsely alarmed 3.7%. He concluded this was a 90% decrease in false alarm conditions.

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Urschitz MS, Von Einem V, Seyfang A, Poets CF. Use of pulse oximetry in automated O2 delivery to ventilated infants. Anesthesia and Analgesia 2002;94:S37-S40

The authors reviewed the history of close-loop O2 titration in neonates, which has been linked to undesirable change in therapy (largely due to poor pulse oximetry). 126 hours of Masimo SET SpO2 recordings obtained in 10 preterm infants were used to test their new artificial intelligence controller. The same recordings were used to determine what a clinician would have done given the same pulse oximetry values and condition of the child. All of the controller and clinician based adjustments were inspected critically and independently by an NICU nurse and two neonatologists. They found their controller-based system was more accurate than older controller techniques thereby reducing the risk of over and undershooting oxygen delivery.

These researchers also studied the possibility of using the Signal IQ value from the Masimo pulse oximeter to warn of erroneous data. They evaluated 223 desaturation events from the 10 preterm infants to determine the specificity for a signal quality threshold predictive of false desaturations. 217 of the 223 desaturations (97.3%) were determined to be real (raw data analysis of red and infrared waveforms). All six false desaturation episodes were associated with a Signal IQ < 0.3. For these 223 desaturation episodes there were 8 associated with Signal IQ < 0.3. Thus, the use of the Signal IQ value < 0.3 showed a high specificity (75%). They concluded that they confirmed the validity of using a Signal IQ value < 0.3 to warn of potentially unreliable measurement conditions.

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Ogino MT. The advantages of a new technology pulse oximeter in neonatal care. Neonatal Intensive Care 2002;15(1):24-27

The author reviews the recent literature supporting the use of a motion resistant pulse oximeter, Masimo SET, in the neonatal care settings. He comments on research performed with the new technology in the areas of the NICU, delivery room, transport, sedation, extracorporeal life support, and sleep studies. He concludes that the use of pulse oximetry containing Masimo SET has been associated with reduced costs, fewer errors in patient care and improved outcome in neonates.

Lichtenthal PR, Wade LD. Evaluation of signal extraction technology (SET) in preventing false alarms when using pulse oximetry in the recovery room. Anesthesiology 1996;86(2S):S278
These researchers compared a new prototype motion resistant pulse oximeter (Masimo SET) to a conventional pulse oximeter (Nellcor N-200) in their post-operative recovery room. They studied 21 patients with the two pulse oximeters attached to the same hand. They used blood pressure cuff inflation (that still allowed some blood flow) to induce a low perfusion state. They found that the Masimo SET markedly reduced the number of alarms compared to the Nellcor N-200.

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Barker SJ, Novak S, Morgan S. The performance of three pulse oximeters during low perfusion in volunteers. Anesthesiology 1997;87 (3A):A409

The authors studied the effects on accuracy caused by reduced perfusion and hypoxemia for three generations of pulse oximeters in volunteers. The pulse oximeters studied were the Nellcor N-200, Nellcor N-3000 and a Masimo SET prototype. For six healthy volunteers, low perfusion was induced by wrapping the test arm in a cooling blanket at 5 C and elevating it up to 75 degrees in the air. Hypoxemia to 80% was then induced via breathing a hypoxic gas mixture. The abilities of the pulse oximeters to track the desaturation and resaturation event were studied. Both the N-200 and N-3000 failed to detect two of the six hypoxemic events; Masimo tracked all six. They found the total error, or percentage of time with either no display of greater than 7% error, was Masimo: 2.3%, N-3000: 10.6% and N-200: 19.7%. 

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Barnum PT, Taschuk RD, Goldstein MR, Vogt G, Gangitano E, Stephenson CG, Liberman, RL. Novel pulse oximetry technology capable of reliable bradycardia monitoring. Respiratory Care 1997;42(11):1072

The authors studied the abilities of a conventional pulse oximeter (Nellcor N-200) and a motion resistant pulse oximeter (Masimo SET prototype) to accuracy track bradycardia in neonates. Sensors from the pulse oximeters were attached to the feet of each infant and switched midway in each test to the opposite foot. A low pulse rate alarm of 100 bpm was set to define an event. A total of 65.3 hours of monitoring time was accumulated and examined for true and false bradycardic events. They found that there were16 true events (ECG) of which the Masimo caught 100% while the N-200 captured 9 (68%). In addition they found the N-200 reported 96 false events while the Masimo reported 5. They conclude that the data suggests that the Masimo SET pulse rate algorithm minimizes false alarms seen in the NICU and captures more true bradycardic events when compared to a conventional pulse oximeter. 

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Goldstein MR, Liberman RL, Taschuk RD, Thomas A, Vogt JF. Pulse oximetry in transport of poorly perfused babies. Pediatrics 1998;102(3):818

The authors studied a motion resistant pulse oximeter (Masimo SET prototype) versus conventional pulse oximetry (Nellcor N-200) during interhospital ground and rotary aircraft transport of five sick infants. All infants were intubated, had cardiac shunting due to Persistent Pulmonary Hypertension of the Newborn, and were referred for Extracorporeal Membrane Oxygenation or Nitric Oxide therapy. One N-200 was place pre-ductal (right wrist) while another was placed on one of the feet (post-ductal). The Masimo was always connected to the opposite foot. They found that both Nellcors failed 100% of the time during rotocraft takeoff and landing, and during periods of high road vibration and patient motion; whereas, the Masimo had no failures. Shunting reduced post-ductal (peripheral) perfusion with associated pulse oximeter failures: 5% with Masimo; 74% with Nellcor. They conclude that Masimo SET pulse oximetry has dramatically fewer failures than conventional pulse oximetry during interhospital transport of poorly perfused infants.

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Holmes M, Thomas A, Vogt J, Gangitano E, Stephenson C, Liberman R. CO-oximetry validation of a new pulse oximeter in sick newborns. Respiratory Care 1998;43(10):860

The authors studied the accuracy of a new motion resistant pulse oximeter (Masimo SET) and a conventional pulse oximeter (Nellcor N-200) during non-motion in sick newborns. Sixty-eight (68) samples of arterial blood were analyzed (CO-Oximetry) from 18 sick newborns. They found a bias of 0.9% and precision of 2.4% for the Masimo; and a bias of 1.0 and precision of 5.1 for the N-200. The Nellcor N-200 findings included a spurious point of 63% (97% SaO2 and 99% SPO2 Masimo) where the Nellcor pulse rate matched the ECG. In addition, three N-200 zero outs (due to poor perfusion) were excluded from the calculations. They conclude that Masimo SET accurately reflects the SaO2 in sick infants.

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Thomas a, Holmes M, Vogt J, Gangitano E, Stephenson C, Liberman R. Useful life of pulse oximeter sensors in a NICU. Respiratory Care 1998; 43(10): 860

The authors studied the life cycle of two different brands of disposable sensors (Masimo Neonatal and Nellcor N-25) in their NICU. The start time, and the time a sensor was replaced or remove, along with the reason for replacement or removal were recorded. Both sensors were removed, the site assessed and the sensors repositioned every 12 hours. For sixteen infants, 56 sensors were used for a total of 211 days. The Masimo sensors had a significantly longer useful life than the Nellcor: 11.1 vs. 5.7 days (range of 5 to 22.5 and 4 to 7.5 days respectively). 13/16 times (81%) the original Masimo sensor applied to the neonate was used until monitoring was discontinued, compared to 1/16 (6%) with Nellcor. They conclude that if the sensor cost to the hospital was identical, a nearly twofold savings could be realized with the Masimo sensors.

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Liberman R, Holmes M, Taschuk R, Snelling L. Accuracy of pulse oximeters during neonatal motion. Respiratory Care 1999;44(12);1499

These researchers studied the effect of induced motion on the accuracy of three pulse oximeters in their neonatal population. Sensors from Masimo SET and Nellcor N-295 pulse oximeters were attached to the opposing feet of an infant, whose feet were secured to a motion generator. The motion generator provided neonatal movement and was configured to stimulate a kicking infant in frequency and amplitude. An additional pulse oximeter (N-200) was attached to the infant's right hand, which served as a stationary reference site. A blood gas specimen was drawn after 30 - 120 seconds of motion. The sensors on the feet were then switched, motion again applied, and another blood sample taken. 122 ABG samples were analyzed from 14 newborns. The SaO2 ranged from 82.7% to 95.8%. The ECG heart rate ranged from 83 to 200 bpm. The SpO2 bias and precision for the pulse oximeters were: -0.9 2.3 for Masimo SET, 5.1 8.1 for Nellcor N-295, and 0.3 4.6 for Nellcor N-200. The pulse rate bias and precision for the pulse oximeters were: -0.1 3.0 for Masimo SET, -3.4 18.0 for Nellcor N-295, and 5.2 20.9 for Nellcor N-200. They state that motion adversely affects most pulse oximeters and spurious values can lead to inappropriate care. They conclude that Masimo SET pulse oximetry reflected SaO2 and ECG heart rate accurately during motion and that broad use should improve care.

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Whitman RA, Garrison ME. Comparison of the new Masimo SET V3 technology with a conventional pulse oximeter during polysomnography. Sleep 2001;24:A412

This study compared the saturation profile of patients undergoing polysomnography using the new Masimo V3 technology compared with a commonly used conventional pulse oximeter (Nellcor N-200). Three pulse oximeters were attached to each patient: a Quartz Medical Q-400 (Masimo SET V3) in 2 second SpO2 averaging, a Nellcor N-200 in mode 1 (5 to 7 second SpO2 averaging), and a Nellcor N-200 in mode 2 (2 to 3 second SpO2 averaging). Data from the all night recordings from the pulse oximeters were downloaded into ProFox oximetry analysis software. Data from 13 patients showed no difference in mean saturation between the three oximeters: 95.8 1.5% for Masimo, 96.2 1.4% for Nellcor mode 2, and 96.4 1.6% for Nellcor mode 1. There was a large difference in the number of desaturations > 4% between the Masimo and the Nellcor pulse oximeters. The mean number of desaturations were 78 102 for Masimo, 51 93 for Nellcor mode 2, and 51 92 for Nellcor mode 1. These researchers concluded that this finding suggests the Masimo SET V3 technology has higher signal fidelity relative to actual physiologic changes in saturation than conventional pulse oximetry, which should lead to improved diagnostic capabilities.

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Irita K, Kai Y, Takahashi S. Performance evaluation of Masimo SET pulse oximeter during mild hypothermic cardiopulmonary bypass. Anesthesiology 2001;95:A551. (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "Masimo, Irita" and press Go 

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Shah N, Clack SL, Hoang TD. Is there a difference in the recovery time for the accurate display of oxygen saturation (SpO2) and pulse rate (PR) after motion induced failure of pulse oximeters (PO) during low perfusion and normoxemia or hypoxemia in human volunteers? Anesthesiology 2001;95:A552 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Shah" and press Go

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Shah N, Clack SL, Hoang TD. Is there a difference in the recovery time for the accurate display of oxygen saturation (SpO2) and pulse rate (PR) after motion induced failure of pulse oximeters (PO) during low perfusion and normoxemia or hypoxemia in human volunteers? Anesthesiology 2001;95:A552 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Shah" and press Go

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Clack SL, Shah N, Hoang TD, Gupta B. A comparison of four major brands of pulse oximeters (PO) with Masimo SET PO during motion and low perfusion under normoxic and hypoxic conditions in human volunteers. Anesthesiology 2001;95:A586 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Clack" and press Go

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Barker SJ. The performance of six "motion-resistant' pulse oximeters during motion, hypoxemia and low perfusion in volunteers. Anesthesiology, 2001; 95:A587. (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Barker" and press Go

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Rostow SK, Durbin CG. Clinicians quickly learn to utilize improved accuracy and reliability of the new generation of pulse oximeters. Respiratory Care 2001;46(10):1104

The authors found that during a prospective study on the impact of new pulse oximetry technology, that caregivers more rapidly weaned cardiac surgery patients from a high FiO2 and obtained fewer ABGs when using the new technology. In this report they measured the change in weaning time that occurred during the study. 86 adults patient were followed immediately after cardiac surgery. Upon arrival in the ICU, a conventional pulse oximeter (Ohmeda 3740) and a new generation pulse oximeter (Masimo SET) were attached to the same hand of the patient and the output of both monitors recorded continuously. Patients were randomly assigned to have the display of only one of the devices available to the bedside caregivers with the other device covered (blinded). No other clinical interventions were altered. No information about the expected or actual performance of the new generation pulse oximeter was provided to the caregivers at any time. In the first 30 patients, there was a small difference with the Masimo pulse oximeter monitored patients who weaned in 83% of the time of the conventional pulse oximeter. Of the last 30 patients, those with the Masimo pulse oximeter weaned in 32% of the conventional pulse oximeter weaning time. There were fewer ABGs during weaning with the Masimo compared to the Ohmeda 3740 over the entire study (2.7 1.2 vs. 4.1 1.6), but this difference did not change with time.

The authors conclude that clinicians learned to identify better monitoring technology. They suggest this experimental design (randomized patients and blinded clinicians) is a powerful method to evaluate the impact of new technology.

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Torres A, Skender K, Wohrley J, Aldag J, Raff G, Geiss D. Assessment of 2 New Generation Pulse oximeters During Low Perfusion in Children. Critical Care Medicine 2002;29(12):A117

This group studied two new generation pulse oximeters' accuracy in children in the operating room post cardiopulmonary bypass surgery. 25 children who underwent surgery for congenital heart defect repair had a total of 61 SaO2 measurements recorded. The median SaO2 was 98% (62-100), with 17/61 (28%) being < 90%. SpO2 failures were 40% (25/61) for the N-395 vs. 10% (6/61) for the Masimo Radical. SpO2 - SaO2 (bias) for SaO2 90% was 1.3 1.6% for Masimo and 1.4 1.6% for Nellcor. SpO2 - SaO2 (bias) for SaO2 < 90% was 4.1 2.9% for Masimo and 4.9 4.7% for Nellcor. They found the Nellcor N-395 failed significantly more than the Masimo Radical. They also concluded that the absolute difference between SaO2 and SpO2 was significantly greater for both pulse oximeters when SaO2 was < 90% compared to SaO2 90%.

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Whitman RA, Garrison ME, Oestrich PJ. Influence of pulse oximeter technology on hypopnea diagnosis using the newly proposed definition of a respiratory hypopnea. Sleep 2002;25:A509

Citing new Medicare guidelines for coverage of nasal CPAP therapy, this group of researchers studied the fidelity of different pulse oximeters to measure a 4% change (desaturation) in arterial oxygenation during sleep disordered breathing testing. Twenty-nine (29) patients undergoing testing were instrumented with three different pulse oximeters: a Masimo Radical V3, a Nellcor N-395, and a Nellcor N-200. The Masimo and N-200 were set in their fastest SpO2 average time (N-395 not user selectable). Data from all three pulse oximeters were downloaded into ProFox oximetry analysis software. There were no differences found in mean saturation between the Masimo, Nellcor N-395, and Nellcor N-200 (95.8 1.7%, 95.9 1.8%, 95.9 1.5% respectively). There was a large difference in the number of desaturations 4% between the three oximeters. The mean number of desaturations were 81 89, 48 55, and 31 35 for the Masimo, N-395, and N-200 respectively. The Masimo Radical detected 69% more desaturations 4% than the Nellcor N-395 and 161% more than the N-200. The Nellcor N-395 detected 55% more desaturations 4% than the Nellcor N-200. They conclude that this difference between pulse oximeter technologies in detecting the degree of desaturation from baseline could have an important impact on qualifying patients for nasal CPAP coverage under the new Medicare reimbursement rules.

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Robertson F, Hoffman G. Effects of Signal Integrity and Saturation on Accuracy of Masimo SET and Nellcor N395 Pulse Oximeters. Anesthesiology 2002;96:A555 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Robertson" and press Go

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Robertson F, Hoffman G. Clinical evaluation of Masimo SET and Nellcor N395 Oximeters during Optimal signal Conditions in Difficult-to-Monitor Neonates. Anesthesiology 2002;96:A556. (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Robertson" and press Go

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Kawagishi T, Kanaya N, Nakayama M, Namiki A. A Comparison of the Performance of Pulse Oximeters during Blood Pressure Cuff-Induced Hypoperfusion in Volunteers. Anesthesiology 2002;96:A559 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Kawagishi" and press Go

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Lutter N, Kozma E, Meyer V, Schuettler J. Performance of Three Fourth-Generation Pulse Oximeters during Electro-Convulsive Therapy. Anesthesiology 2002;96:A560 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Lutter" and press Go

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Lichtenthal PR, Barker SJ. An Evaluation of Pulse Oximetry-Pre, during, and Post-Cardiopulmonary Bypass. Anesthesiology 2002;96:A598 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Lichtenthal" and press Go

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Robertson F, Hoffman G. Effects of Signal Integrity and Saturation on Data Availability in Masimo SET and Nellcor N395 Pulse Oximeters. Anesthesiology 2002;96:A599 (http://www.asa-abstracts.com)

This abstract is available online at www.asa-abstracts.com. Just go to the Quick Search Abstract Archive box and type in "pulse oximeter, Robertson" and press Go

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