1. Avery Foster, RRT Clinical Specialist afoster@masimo.com

2. Key Physiology and Laboratory Concepts

3. Hemoglobin Hemoglobin is a protein carried within the red blood cells.
Responsible for carrying oxygen to the tissues.
Four binding sites with Iron compound that binds to oxygen.
Each hemoglobin molecule can carry 4 oxygen molecules.
With four binding sites, each hemoglobin molecule can be 0%, 25%, 50%, 75% or 100% saturated.
Ask question of how do patients get saturations between these numbers?
Answer: blood is made up of huge numbers of hemoglobin molecules, some have 3 sites bound so those molecules are 75% saturated.
Some have two sites bound so those are 50% saturated. So the mixture leads to an average saturation which can be any percentage value.

4. Methemoglobin Oxyhemoglobin
Hemoglobin - species
Methemoglobin Oxyhemoglobin
Oxyhemoglobin
Deoxyhemoglobin
Dyshemoglobins
Carboxyhemoglobin
Methemoglobin
Sulfhemoglobin
Sickle Cell Hemoglobin
Genetically acquired hemoglobin abnormalities
Most clinicians are familiar with oxyhemoglobin and deoxyhemoglobin (or reduced hemoglobin).
A basic assumption of pulse oximetry is that the vast majority of the subject’s blood is only oxyhemoglobin and deoxyhemoglobin, with virtually no other forms of hemoglobin present.
However, it is important to remember that there are many other types of hemoglobin, all of which can cause problems with pulse oximetry if they are present in any significant quantity.
Carboxyhemoglobin and methemoglobin are the most commonly occurring dyshemoglobins but there are others including….
Point out the ‘chocolate brown’ color of blood in room air that has methemoglobinemia versus the bright red color you expect blood to look like in room air.
Only oxyhemoglobin can carry oxygen to the tissues.

6. Oxyhemoglobin Dissociation Curve
Left shift of the curve reduces the amount of oxygen delivered to the tissues
In order to fully understand the relationship between saturation and dissolved oxygen the oxyhemoglobin dissociation curve is taught in school and it always seemed to be a head scratcher to people.
But this is a very important thing to understand as this curve is what we base a blood gas on.
For saturations of around 90%, as long as pH is normal and CO2 is not increased, then we can be fairly certain the patient’s PO2 is at least 60 mm HG which is at the borderline of safe.
Clinically we tend to not let patients drop below 85% SpO2 except for specific situations like cyanotic infants.
Due to shape of curve as SpO2 drops below 85%, you are then on steep part of disassociation curve where small changes in PO2 result in very large changes in SpO2.
And in fact the disassociation curve is not static, but it shifts right or left depending on various things such as pH changes, temperature changes, etc.
Blood gas machines with CO-Oximetry modules measure the PO2 and take in to account any shift of the disassociation curve. Blood gas machines without CO-Oximetry modules assume the disassociation curve has not shifted when they estimate (or calculate) their oxygen saturation values. This is a big reason why blood gas machines without CO-Oximetry modules do not make accuracy claims about their calculated oxygen saturation values.
So, what is the point of showing the disassociation curve while talking about blood gas machines? There may be times when your Masimo pulse oximeter readings are different than your blood gas machine test results and you need to be knowledgeable. Temperature changes, CO, and Met levels can have the most dramatic influence on the accuracy of the readings. The other factors can also exert an effect on the readings. It is important to impress upon clinicians that with so many variables it is impossible to accurately predict, calculate or guess the correct saturation.
Turns out that perfusion differences between fingers can cause temperature variations between fingers large enough to shift curve left/right to cause SpO2 reading differences between fingers.

7. Blood Gas Machines with CO-Oximeters
The Gold Standard for measuring parameters from a patient’s blood
Blood Gas Machine Measures: Pa02, PaC02, pH
CO-Oximeter Measures: COHb, MetHb, RHb and HbO2
Most every hospital has a blood gas machine, but some blood gas machines DO NOT have the CO-Oximetry module
Radiometer OSM3
Blood Gas machines can only measure three parameters. All of the other parameters that are reported are calculated from these three measured values. Unless the Blood Gas machine is used with an additional machine called a CO-Oximeter. This can be as a module added to the blood gas machine or as a separate piece of equipment.
Instrumentation Lab, IL682

8. Basics of Pulse Oximetry

9. Basics of Pulse Oximetry Pulse Oximeter Components
SENSOR R IR
Emitter - shines Red (R) & Infrared (IR) light through patient
Photodetector
MONITOR
Monitor - analyzes signal and reports SpO2 and pulse rate
Most of us understand that a pulse oximeter takes a sensor and shines red and infrared light through a digit.
The part of the sensor producing the light is called the emitter, and the other side of the sensor that measures how much light made it through the digit is called the detector.
It is important that you also realize that light needs to only pass through the digit, not around the digit. Why? Different path length and different absorption.
Also the device must have a pulse, or pulsatile blood flow for the proper calculations to occur.
The cable transmits signals from the sensor to the monitor.
The monitor analyzes signals, calculates SpO2 and displays SpO2 and pulse rate.
CABLE
Patient cable - transmits signal to the monitor 6

10. Beer-Lambert Law I0 (rd,ir) = I1e- acl a = Extinction Coefficient
c = Concentration
l = Optical Path Length

11. Oxygenated Hb and Reduced Hb Absorb Different Amounts of Red (R) and Infrared (IR) Light10
(RED)
660nm
(INFRARED) nm
SpO2
~R/IR
2.5 0% % % % % % % % % %
HbO2
absorption Hb
Oxyhemoglolbin and deoxyhemoglobin absorb different amounts of red and infrared light.
This graph defines how much light is absorbed by oxyhemoglobin and reduced or deoxyhemoglobin at various light wavelengths of red and infrared light.
If you assume that oxyhemoglobin and reduced hemoglobin are the only variable light absorbers- and this is the second of three key assumptions of pulse oximetry- then you can calculate oxygen saturation.
Most pulse oximeters operate at around 640 nanometers and 905 nanometers.
In fact, the red wavelength is what you see when you look at a working pulse oximetry sensor, while the infrared light is beyond the human eye’s perception.
So by measuring how much red and infrared light passes through a finger (or toe) at each of these wavelengths and comparing the ratio of these absorbances we can compare this ratio to actual CO-oximetry data and display the oxygen saturation or the percent of oxyhemoglobin.
An interesting trivia question- the point at which the oxyhemoglobin and reduced hemoglobin curves cross is called the isobestic extinction point.
0.1
600
700
800
900
1000
Wavelength (nm)

12. Four Key Assumptions in Conventional Pulse Oximetry
The only absorbance that fluctuates is arterial blood
One experimental calibration fits all
No anemia
Nothing blocking sensor light path, i.e. dirt, blood, metallic fingernail polish
No bright external light sources
Correct size sensor on appropriate site with good alignment
Correct digit shape- no “clubbed digit” or swelling from hypervolemia
Emitter light goes through digit not around digit, no ‘penumbra effect’
Only two variable light absorbers- oxyhemoglobin and reduced hemoglobin
No dyshemoglobins
The sampled and measured sites are in equilibrium.
Reasonably good perfusion at monitoring site
No localized hypoxemia
So, let’s review these three key assumptions of pulse oximetry since understanding all three is critical to being able to troubleshoot common pulse problems in clinical settings.
The only absorbance that fluctuates is arterial blood- or said a different way, that the venous blood moves at a constant rate.
There are only two variable light absorbers- oxyhemoglobin and deoxyhemoglobin- and there are no dyshemoglobins present such as methemoglobin or carboxyhemoglobin.
One experimental calibration fits all people.
This third assumption encompasses many other assumptions:
Remember the data was collected on normal, healthy volunteers- none of which where anemic.
Another is the measurement site was clean and there was nothing to block the light from going through the digit- such as dirt or dried blood. Unfortunately published literature is not quite clear on the question of whether finger nail polish can effect pulse oximeter readings, but most articles seem to agree that metallic fingernail polish causes extra light scattering and can effect pulse oximeter accuracy.
Conventional pulse oximetry calibration data was collected on healthy volunteers with reasonably good perfusion. The better the perfusion the stronger the pulse oximetry signal; but the poorer the patient perfusion, the weaker the signal strength. Conventional pulse oximeters may not be able to accurately distinguish the red/infrared signal from the noise on patient’s with poor perfusion at the measurement site.
Correct sensor size for the patient’s weight range
Sensor on the correct site- i.e. a finger sensor is on the finger not the patient’s ear or forehead
And finally, it is assumed that there is proper alignment of emitter and detector to insure that light goes through the digit not around the digit. Malpositioned sensors will cause light to go around the digit, which in the literature is called the ‘penumbra effect’. It is well established in the literature that the penumbra effect causes erratic and inaccurate readings.

13. Model of Light Absorption At Measurement Site With Motion
AC Variable light absorption due pulsatile volume of arterial blood
DC Constant light absorption due to non-pulsatile arterial blood.
AC Variable light absorption due to moving venous blood
DC Constant light absorption due to venous blood.
DC Constant light absorption due to tissue, bone ...
Time
Absorption
IMPORTANT POINTS
Moving (AC) venous blood is the main contributor to motion artifact.
This was not predicted by the Aoyagi design.
This effect is significant in monitored patients and causes erroneous values.
Aoyagi’s model was correct as long as the patient did not move. But as soon as the patient proceeded with even normal daily activity the above moving venous blood (AC) was introduced and affected the reading.
Pulse Oximetry Assumption: The only absorbance that fluctuates is arterial blood

14. Influence of Perfusion on Accuracy of Conventional Pulse Oximetry During Motion
SpaO2=98
Good Perfusion
(Conventional PO)
SpO2=93
SpvO2=88
SpaO2=98
Poor Perfusion
(Conventional PO)
SpO2=74
SpvO2=50
IMPORTANT POINTS
Venous averaging is a significant clinical problem.
When the perfusion is good the effect is only slightly observed.
When perfusion is very poor, the effect can be dramatic and cause an inappropriate clinical response.
Common Cause of a False Alarm:
This effect can be demonstrated with a motion low perfusion ice water demonstration. By cooling the hand using a glass of ice water and then moving the cold hand with a conventional sensor attached, poor peripheral perfusion (the second example above) can be simulated. The moving venous blood causes a conventional oximeter to average the arterial and venous values together and report a value between arterial and venous. This erroneous value will set off alarms, bring the clinician to the bedside, and potentially waste caregiver time responding to the situation. If this situation persists, the caregiver may silence or turn off the alarms and put the patient at risk for a true desaturation event later.
[Venous Averaging]
Pulse Oximetry Assumption: The only absorbance that fluctuates is arterial blood

15. Four Key Assumptions in Conventional Pulse Oximetry
The only absorbance that fluctuates is arterial blood
One experimental calibration fits all
No anemia
Nothing blocking sensor light path, i.e. dirt, blood, metallic fingernail polish
No bright external light sources
Correct size sensor on appropriate site with good alignment
Correct digit shape- no “clubbed digit” or swelling from hypervolemia
Emitter light goes through digit not around digit, no ‘penumbra effect’
Only two variable light absorbers- oxyhemoglobin and reduced hemoglobin
No dyshemoglobins
The sampled and measured sites are in equilibrium.
Reasonably good perfusion at monitoring site
No localized hypoxemia
So, let’s review these three key assumptions of pulse oximetry since understanding all three is critical to being able to troubleshoot common pulse problems in clinical settings.
The only absorbance that fluctuates is arterial blood- or said a different way, that the venous blood moves at a constant rate.
There are only two variable light absorbers- oxyhemoglobin and deoxyhemoglobin- and there are no dyshemoglobins present such as methemoglobin or carboxyhemoglobin.
One experimental calibration fits all people.
This third assumption encompasses many other assumptions:
Remember the data was collected on normal, healthy volunteers- none of which where anemic.
Another is the measurement site was clean and there was nothing to block the light from going through the digit- such as dirt or dried blood. Unfortunately published literature is not quite clear on the question of whether finger nail polish can effect pulse oximeter readings, but most articles seem to agree that metallic fingernail polish causes extra light scattering and can effect pulse oximeter accuracy.
Conventional pulse oximetry calibration data was collected on healthy volunteers with reasonably good perfusion. The better the perfusion the stronger the pulse oximetry signal; but the poorer the patient perfusion, the weaker the signal strength. Conventional pulse oximeters may not be able to accurately distinguish the red/infrared signal from the noise on patient’s with poor perfusion at the measurement site.
Correct sensor size for the patient’s weight range
Sensor on the correct site- i.e. a finger sensor is on the finger not the patient’s ear or forehead
And finally, it is assumed that there is proper alignment of emitter and detector to insure that light goes through the digit not around the digit. Malpositioned sensors will cause light to go around the digit, which in the literature is called the ‘penumbra effect’. It is well established in the literature that the penumbra effect causes erratic and inaccurate readings.

16. Backwards and malpositioned Correct
So do you see any problems with this picture?
The top sensor was the first sensor which read 92%, while the bottom sensor was the third sensor which read 98%.
Correct

17. Pulsatile Red/Infrared
Signal and Noise
Signal:
Pulsatile Red/Infrared
Noise: unwanted signal that interferes with the red/infrared signal from the emitter.
Common sources of noise include:
(electrocautery)
(surgery or biliruben lights)
(decoupling from patient)
(triboelectric)
Increasing perfusion = increasing signal strength
(patient movement)

18. Conventional Pulse Oximeters Require Fairly Strong Perfusion to Read Signal Through the Noise
High Perfusion
High Noise
Low Perfusion
High Noise

19. Four Key Assumptions in Conventional Pulse Oximetry
The only absorbance that fluctuates is arterial blood
One experimental calibration fits all
No anemia
Nothing blocking sensor light path, i.e. dirt, blood, metallic fingernail polish
No bright external light sources
Correct size sensor on appropriate site with good alignment
Correct digit shape- no “clubbed digit” or swelling from hypervolemia
Emitter light goes through digit not around digit, no ‘penumbra effect’
Only two variable light absorbers- oxyhemoglobin and reduced hemoglobin
No dyshemoglobins
The sampled and measured sites are in equilibrium.
Reasonably good perfusion at monitoring site
No localized hypoxemia
So, let’s review these three key assumptions of pulse oximetry since understanding all three is critical to being able to troubleshoot common pulse problems in clinical settings.
The only absorbance that fluctuates is arterial blood- or said a different way, that the venous blood moves at a constant rate.
There are only two variable light absorbers- oxyhemoglobin and deoxyhemoglobin- and there are no dyshemoglobins present such as methemoglobin or carboxyhemoglobin.
One experimental calibration fits all people.
This third assumption encompasses many other assumptions:
Remember the data was collected on normal, healthy volunteers- none of which where anemic.
Another is the measurement site was clean and there was nothing to block the light from going through the digit- such as dirt or dried blood. Unfortunately published literature is not quite clear on the question of whether finger nail polish can effect pulse oximeter readings, but most articles seem to agree that metallic fingernail polish causes extra light scattering and can effect pulse oximeter accuracy.
Conventional pulse oximetry calibration data was collected on healthy volunteers with reasonably good perfusion. The better the perfusion the stronger the pulse oximetry signal; but the poorer the patient perfusion, the weaker the signal strength. Conventional pulse oximeters may not be able to accurately distinguish the red/infrared signal from the noise on patient’s with poor perfusion at the measurement site.
Correct sensor size for the patient’s weight range
Sensor on the correct site- i.e. a finger sensor is on the finger not the patient’s ear or forehead
And finally, it is assumed that there is proper alignment of emitter and detector to insure that light goes through the digit not around the digit. Malpositioned sensors will cause light to go around the digit, which in the literature is called the ‘penumbra effect’. It is well established in the literature that the penumbra effect causes erratic and inaccurate readings.

20. High Methemoglobin Reads ~85% On Two Wavelength Pulse Oximeters
Laboratory
CO-Oximeter Blood Sample
Similarly, additional data from the University of Arizona show that high methemoglobin levels cause conventional two wavelength pulse oximeters to read around 85% SpO2, even if the patient’s true oxygen saturation is below 60%!
Think back, have you ever had a patient that just looked awful; by looking at them you would say they were surely hypoxic but their pulse oximeter said their oxygen saturation wasn’t so bad, maybe 85%. Could easily have been an occult case of methemoglobinemia. Go visit a GI lab for a day that still uses benzocaine spray- you will see one or two cases of methemoglobinemia where the patient’s oximeter is reading 85% and yet the patient is blue.
[Blood]
Barker SJ, Tremper KK, Hyatt J. Effects of Methemoglobinemia on Pulse Oximetry and Mixed Venous Oximetry. Anesthesiology 1989;70:

21. High Carboxyhemoglobin Reads ~90% On Two Wavelength Pulse Oximeters
Laboratory
CO-Oximeter Blood Sample
As this data from Dr. Steven Barker from the University of Arizona shows, high COHb levels in patients cause conventional two wavelength pulse oximeters to read around 90% SpO2, even if the patient’s true oxygen saturation is below 50%!
[Blood]
Barker SJ, Tremper KK. The Effect of Carbon Monoxide Inhalation on Pulse Oximetry and Transcutaneous PO2. Anesthesiology 1987; 66:

22. Four Key Assumptions in Conventional Pulse Oximetry
The only absorbance that fluctuates is arterial blood
One experimental calibration fits all
No anemia
Nothing blocking sensor light path, i.e. dirt, blood, metallic fingernail polish
No bright external light sources
Correct size sensor on appropriate site with good alignment
Correct digit shape- no “clubbed digit” or swelling from hypervolemia
Emitter light goes through digit not around digit, no ‘penumbra effect’
Only two variable light absorbers- oxyhemoglobin and reduced hemoglobin
No dyshemoglobins
The sampled and measured sites are in equilibrium.
Reasonably good perfusion at monitoring site
No localized hypoxemia
So, let’s review these three key assumptions of pulse oximetry since understanding all three is critical to being able to troubleshoot common pulse problems in clinical settings.
The only absorbance that fluctuates is arterial blood- or said a different way, that the venous blood moves at a constant rate.
There are only two variable light absorbers- oxyhemoglobin and deoxyhemoglobin- and there are no dyshemoglobins present such as methemoglobin or carboxyhemoglobin.
One experimental calibration fits all people.
This third assumption encompasses many other assumptions:
Remember the data was collected on normal, healthy volunteers- none of which where anemic.
Another is the measurement site was clean and there was nothing to block the light from going through the digit- such as dirt or dried blood. Unfortunately published literature is not quite clear on the question of whether finger nail polish can effect pulse oximeter readings, but most articles seem to agree that metallic fingernail polish causes extra light scattering and can effect pulse oximeter accuracy.
Conventional pulse oximetry calibration data was collected on healthy volunteers with reasonably good perfusion. The better the perfusion the stronger the pulse oximetry signal; but the poorer the patient perfusion, the weaker the signal strength. Conventional pulse oximeters may not be able to accurately distinguish the red/infrared signal from the noise on patient’s with poor perfusion at the measurement site.
Correct sensor size for the patient’s weight range
Sensor on the correct site- i.e. a finger sensor is on the finger not the patient’s ear or forehead
And finally, it is assumed that there is proper alignment of emitter and detector to insure that light goes through the digit not around the digit. Malpositioned sensors will cause light to go around the digit, which in the literature is called the ‘penumbra effect’. It is well established in the literature that the penumbra effect causes erratic and inaccurate readings.

23. Differences in Measured Values
Measured Site- Pulse Oximetry
Sampled Site- ABG CO-oximetry

24. Undetected ‘Probe-Off’
In rare circumstances the pulse oximeter can continue to give erroneous readings within the normal physiological range during ‘probe off’
Serious limitation of pulse oximetry
No pulse oximetry manufacturer appears to be immune from the undetected probe-off condition
Any pulsatile interference at the sensor can produce a false signal that could be interpreted by the pulse oximeter as a true physiological signal

25. Types of Signal Interference That Can Produce an Undetected ‘Probe-Off’ Condition
Most Common is Ambient Light
Surgical lights, bilirubin lights and infrared radiant warmers
Light from the Emitter
Emitted light reflected by colored fabrics that are positioned in or near the photo emitter - detector path can also produce an SpO2 reading that is artifactual.

26. Who brought the cat?

27. Masimo Signal Extraction Technology Pulse Oximetry
This content is above and beyond basic user training and assumes each attendee has been through basic user training. This Super User Training is aimed at ‘super users’; those few people that others in the institution will look to for questions and troubleshooting. This class will also give these super users guidance on how to add/implement additional Masimo devices and to orient new staff to your Masimo devices.
The CS giving Super User Training should review this slide deck with the key person at the target hospital responsible for user training prior to scheduling the super user training. Once you and that person agree on the content to be covered, then let the person know how much time the super user training will require to cover the content the person wants covered. THEN schedule the training classes.
BE SURE to have all Super User trainees go through basic Masimo training prior to the Super User Training class.
The CS is to prepare a Masimo 3-ring binder or folder containing the following information and give a binder/folder to each participant of the Super User Training:
Color prints of all PowerPoint slides used during that customer’s Super User Training.
Device operators manuals (for each Masimo device customer is getting)
Device quick reference cards (for each device as available)
Device sell sheet (for each device)
LNCS application cards/posters
Whitepapers on PI, SIQ, APOD, FastSat, and PVI (include PVI even if customer didn’t purchase PVI)
SatShare Whitepaper if the customer is using SatShare
Rainbow sensor application card/poster if they are using Rainbow technology
SpCO and SpMet whitepapers if they are using any Rainbow parameters
Note: be sure to give the lead clinical educator for the institution a 3-ring binder of the above materials with the slides in clear plastic sheet protectors. It is acceptable to give the other participants the materials in a Masimo folder or 3-ring binder.
The CS will also create a sign in sheet and have each person attending the Super User Training sign the sign-in sheet to validate their attendance.
The CS will include a photocopy of the completed sign-in sheet in the binder/folder given to the lead clinical educator for the institution.
It is important that we not only complete the training, but that we document who was trained and that the hospital has documentation on who completed the training.

28. SET Doesn’t Make All Four Key Assumptions of Conventional Pulse Oximetry
The only absorbance that fluctuates is arterial blood - DST
One experimental calibration fits all – Good sensor placement
No anemia
Nothing blocking sensor light path, i.e. dirt, blood, metallic fingernail polish
No bright external light sources
Correct size sensor on appropriate site with good alignment
Correct digit shape- no “clubbed digit” or swelling from hypervolemia
Emitter light goes through digit not around digit, no ‘penumbra effect’
Only two variable light absorbers- oxyhemoglobin and reduced hemoglobin
No dyshemoglobins – Rainbow SET
The sampled and measured sites are in equilibrium – Perfusion Index
Reasonably good perfusion at monitoring site
No localized hypoxemia
So, let’s review these three key assumptions of pulse oximetry since understanding all three is critical to being able to troubleshoot common pulse problems in clinical settings.
The only absorbance that fluctuates is arterial blood- or said a different way, that the venous blood moves at a constant rate.
There are only two variable light absorbers- oxyhemoglobin and deoxyhemoglobin- and there are no dyshemoglobins present such as methemoglobin or carboxyhemoglobin.
One experimental calibration fits all people.
This third assumption encompasses many other assumptions:
Remember the data was collected on normal, healthy volunteers- none of which where anemic.
Another is the measurement site was clean and there was nothing to block the light from going through the digit- such as dirt or dried blood. Unfortunately published literature is not quite clear on the question of whether finger nail polish can effect pulse oximeter readings, but most articles seem to agree that metallic fingernail polish causes extra light scattering and can effect pulse oximeter accuracy.
Conventional pulse oximetry calibration data was collected on healthy volunteers with reasonably good perfusion. The better the perfusion the stronger the pulse oximetry signal; but the poorer the patient perfusion, the weaker the signal strength. Conventional pulse oximeters may not be able to accurately distinguish the red/infrared signal from the noise on patient’s with poor perfusion at the measurement site.
Correct sensor size for the patient’s weight range
Sensor on the correct site- i.e. a finger sensor is on the finger not the patient’s ear or forehead
And finally, it is assumed that there is proper alignment of emitter and detector to insure that light goes through the digit not around the digit. Malpositioned sensors will cause light to go around the digit, which in the literature is called the ‘penumbra effect’. It is well established in the literature that the penumbra effect causes erratic and inaccurate readings.

29. Masimo SET’s Parallel Algorithms for SpO2
R/IR (Conventional Pulse Oximetry)
Confidence Based Arbitrator
% % 97% 100%
SpO2%
Post Processor
Digitized, Filtered & Normalized
% Saturation
SSTTM
Proprietary Algorithm 4
DST
Masimo SET – 97%
DSTTM
FSTTM
MEASUREMENT
CONFIDENCE
R & IR
Here is where we get to the real secret sauce, Masimo SET software includes both adaptive filters and parallel algorithms (or parallel engines).
Where as conventional pulse oximetry uses one algorithm to turn the red over infrared value into an SpO2 value, Masimo SET is constantly calculating five different oxygen saturation values using five parallel algorithms, and then the Confidence Based Arbitrator chooses the algorithm it has the highest confidence in at that time and passes the output to the post processor for clean up and display.
So instead of looking at the signal in one way as in conventional oximetry, Masimo SET looks at the signals in 5 different ways simultaneously.
Why 5 different ways? Different algorithms work better under different conditions- low perfusion, motion, light interference, etc.
DST is Discrete Saturation Transform which is particularly effective during patient motion.

30. Masimo SET Discrete Saturation Transform (DST) Algorithm The Solution for Patient Motion
Without motion, the R/IR algorithm can accurately measure arterial oxygen saturation
DST makes only one assumption – that arterial blood has a higher oxygenation than venous – making it the most powerful pulse oximetry algorithm
Variable
Constant
% % % % 100%
SpO2%
% % % % %
SpO2%
Separates out venous saturation and reports true arterial saturation

31. SET Improvements Reduce Noise and Enable Highest Signal to Noise Ratio
Conventional Pulse Oximeter
SET During Normal Perfusion
SET During Low Perfusion
High signal to noise ratio is one of the reasons Masimo SET can read on patients with much poorer perfusion than conventional pulse oximeters

32. Rainbow SET

33. Perfusion Index (PI) Clinically Powerful, But Under Recognized and Under Utilized
During sensor placement, use Perfusion Index to quickly evaluate potential sites to determine which has the best perfusion
Monitor the trend for changes in physiologic conditions
PI may be a more sensitive and rapid measure than peripheral blood pressure for identifying patients with significant changes in peripheral perfusion
Peripheral blood pressure may remain unchanged while significant reductions in peripheral perfusion are occurring, as evidenced by a changing PI
A significant drop may indicate hypothermia, hypovolemia, shock, and/or sepsis
PI has been shown to be objective & accurate measure of acute illness in neonates
May help anesthesiologists confirm effectiveness of their anesthesia, epidural infusions and regional pain blocks in reducing patient pain
May be an objective, continuous indicator for patient pain increase/ decrease that doesn’t require conscious feedback from the patient
So what can you use Perfusion Index for, how can it help you?
Most common clinical use is to help users find the optimal pulse oximetry monitoring site, especially if you are having a hard time picking up readings on a patient.
You want to choose a monitoring site with as strong a perfusion index as possible since a strong PI means the site is characterized by good perfusion with oxygenated blood.
There are additional clinical applications for monitoring the perfusion index trend over time (read over the list for the class)
Conclusive studies for these potential clinical applications of PI have not been completed nor has the FDA cleared the use of PI for any of these indications.
The Perfusion Index whitepaper is included in your information folder and the whitepaper talks about each of these applications in more detail and gives references.

34. Signal IQ Signal Identification and Quality Indicator
Visual indicator of the system's confidence level in the displayed SpO2 and pulse rate measurements
Gives clinicians an objective way to know when to question displayed values, rather than interpreting a pleth morphology
The height of the spikes or LED bar indicates the confidence level of the reported oxygen saturation and pulse rate. The taller the spike, the higher the confidence level.
Even with "Low Signal IQ," the measurement has a high probability of being correct; otherwise the system would not display values at all
Another tool is Signal IQ which is a graphic or visual indicator of signal quality, rather like the strength bars on your cell phone: the more bars the stronger the wireless signal. Similarly, with Signal IQ, the taller the bar the better the signal quality.
Point to Signal IQ spikes on image from Radical-7. With each pulse the Radical-7 will display a Signal IQ ‘spike’- the better the signal quality the taller the spike; but as signal quality goes down the Signal IQ spike will get shorter. On a Masimo device without an LCD, like a Rad-5 or Rad-8, the Signal IQ will be displayed using a bouncing LED bar called SIQ. The higher the bounce the better the signal quality.
If signal quality gets very low then the spike (or bouncing bar) will virtually disappear and the SET device will display a ‘Low Signal IQ’ message (or LED devices will display two red bars at the bottom of the SIQ bar area) which tells the user that the Masimo device is only about 70% confident that the currently displayed readings are accurate.
Signal IQ pulse bar enables clinicians to easily determine if signal quality is trending better or worse
Signal IQ is a useful tool that works very differently than the ‘Interference’ and ‘pulse search’ lights on your Nellcor devices. Due to Nellcor’s inability to effectively read through motion and low perfusion a Nellcor device’s interference and pulse search lights are on so often that users become numb to them. In fact, many times users think the lights mean the Nellcor device is working when in reality they mean the device is struggling to get reliable readings.
However, research has shown that the Masimo Low Signal IQ message has good specificity during high motion and low perfusion and thus does not occur so frequently that it becomes useless.
Researchers evaluating Signal IQ and the Low Signal IQ message during desaturation events in neonates have found these parameters to be very sensitive for identifying erroneous data.
A Signal IQ whitepaper is also in your reference folder and the whitepaper goes in to more details and includes.
We will talk in more detail later about how to use Perfusion Index and Signal IQ when troubleshooting.
Signal IQ spikes

35. Only Masimo SET Offers User Selectable
Device Sensitivity
Full Signal Spectrum
Max
Sensitivity
Least
APOD
(best ‘sensor off’ detection, use in areas with high patient/nurse ratios or on patients with increased risk of sensor falling off such as peds or combative patients)
Normal Sensitivity
(care areas where patients are observed frequently)
Let’s talk reading sensitivity and probe off detection. In this case we not talking about the same ‘sensitivity’ we talked about earlier which is the ability to detect true events. Sensitivity in this case means the ability to read when the pulse (i.e. perfusion) is very weak.
It turns out that there are trade offs, or there is a balance, between the ability to read during very low perfusion and the ability to detect when a sensor has fallen off the patient.
First let’s talk about sensitivity or the ability to read during low perfusion.
In past your pulse oximeters had one sensitivity setting, regardless of your patient’s condition. So on well perfused patients that one setting was fine, but on patients with really poor perfusion what happened? The devices often would not pick up a reading.
So why do you think the manufacturer’s didn’t just amplify the signals and make their devices read at lower perfusion levels?
As perfusion goes down the pulse strength goes down, which means the signal to noise ratio gets worse, and it becomes harder to separate true signals from noise.
As the signal to noise ratio gets worse, the accuracy of conventional pulse oximeters gets worse. So at low perfusions the conventional pulse oximeters are not very sensitive and specific.
However, due to Masimo SET’s ability to reduce noise and separate signals from noise, SET devices can accurately read in much lower perfusion situations.
Masimo instruments offer 3 different user-selectable sensitivity settings- APOD, Normal and Max- with Max being able to read on signals 10x smaller than conventional pulse oximeters.
Who in the room is thinking “why doesn’t Masimo just use Max sensitivity all the time?”
Here is where we connect back to the question of probe off detection. It turns out that there is a trade off between the ability to read in low perfusion situations, and the ability to not read when the sensor has fallen off the patient.
It is well established in the literature that pulse oximeters can sometimes be fooled into displaying readings even when the sensor has fallen off the patient. When a sensor is laying on the white bed sheets and bathed in florescent lights, pulse oximeters will sometimes read the cycling of the florescent lights and mistakenly display readings.
All pulse oximeters have these limitations. The abilities and limitations vary from vendor to vendor but nobody has devised a concrete solution to totally robust probe off detection.
The most direct method to create more robust sensor off detection is to limit the low perfusion performance range of the pulse oximeter.
Most clinicians that have witnessed the advent of improved low perfusion would oppose sacrificing low perfusion performance for a more robust sensor off detection. They are used to troubleshooting “sensor off” but they cannot overcome low perfusion limitations.
And this is where we get back to the three user-selectable sensitivity modes in Masimo SET devices- APOD, Normal and Max.
APOD, or Advanced Probe Off Detection, offers our best probe off detection with reading sensitivity as good as most other pulse oximeters. We recommend using APOD in areas of higher patient to nurse ratios (such as med surg areas) and areas where you have greatest risk of the patient detaching the sensor (pediatrics, combative patients).
Normal sensitivity offers enhanced ability to read in lower perfusion situations with not quite as robust probe off detection. We recommend Normal sensitivity for patients that generally have less motion and in areas that have a lower patient to nurse ratio (hence the nurse looks in on the patient more often) such as in adult ICUs and PACU.
Max sensitivity is the most sensitive mode and offers unmatched reading capabilities during the poorest perfusion situations such as on neonates, patients on multiple ‘pressors, shock patients, or patients in the CTICU. However, we recommend that when using Max sensitivity clinicians provide close direct supervision of the measurement site as Max sensitivity offers limited probe off detection capabilities.
Each of these sensitivity modes demonstrate different sensor off thresholds that correspond to the immediate and critical needs of the end user in different care areas.
3 user-selectable sensitivity settings allow the clinician to address the unique physiological complications of their patients by making it possible to select a unique sensitivity mode that applies to that individual’s perfusion status and care-giver attention level.
At this point, highlight the APOD whitepaper in each person’s folder that you prepared and handed out.
Max Sensitivity
(close direct observation of measurement site is suggested to detect sensor off conditions)

36. Questions?

37. Troubleshooting
This content is above and beyond basic user training and assumes each attendee has been through basic user training. This Super User Training is aimed at ‘super users’; those few people that others in the institution will look to for questions and troubleshooting. This class will also give these super users guidance on how to add/implement additional Masimo devices and to orient new staff to your Masimo devices.
The CS giving Super User Training should review this slide deck with the key person at the target hospital responsible for user training prior to scheduling the super user training. Once you and that person agree on the content to be covered, then let the person know how much time the super user training will require to cover the content the person wants covered. THEN schedule the training classes.
BE SURE to have all Super User trainees go through basic Masimo training prior to the Super User Training class.
The CS is to prepare a Masimo 3-ring binder or folder containing the following information and give a binder/folder to each participant of the Super User Training:
Color prints of all PowerPoint slides used during that customer’s Super User Training.
Device operators manuals (for each Masimo device customer is getting)
Device quick reference cards (for each device as available)
Device sell sheet (for each device)
LNCS application cards/posters
Whitepapers on PI, SIQ, APOD, FastSat, and PVI (include PVI even if customer didn’t purchase PVI)
SatShare Whitepaper if the customer is using SatShare
Rainbow sensor application card/poster if they are using Rainbow technology
SpCO and SpMet whitepapers if they are using any Rainbow parameters
Note: be sure to give the lead clinical educator for the institution a 3-ring binder of the above materials with the slides in clear plastic sheet protectors. It is acceptable to give the other participants the materials in a Masimo folder or 3-ring binder.
The CS will also create a sign in sheet and have each person attending the Super User Training sign the sign-in sheet to validate their attendance.
The CS will include a photocopy of the completed sign-in sheet in the binder/folder given to the lead clinical educator for the institution.
It is important that we not only complete the training, but that we document who was trained and that the hospital has documentation on who completed the training.

38. Using Signal IQ and Perfusion Index Rather than the Pleth Waveform
Low Signal IQ
Typically sensor/patient interface issues. So insure
Proper sensor type for patient and condition
Proper sensor placement and emitter/detector alignment
Remove excessive environmental interference such as extremely bright light
Eliminate excessive motion
Low Perfusion Index
Check for mechanical/flow impedance at sensor site
Sensor on too tight
NIBP cuff inflated
Fingers bent
Arterial access on same extremity
Recognize any physiological flow impedance
Hypothermia, vasoconstriction
Abnormal physiology (AV shunt, anemia, peripheral vascular disease)
Hypovolemia
Remember, a corrupt pleth waveform is NOT an indication of unreliable readings on Masimo SET devices. Look at your Signal IQ and Perfusion Index to determine if your readings are suspect. When your Masimo SET device’s readings don’t seem to correlate with your clinical assessment of the patient and you have either low Signal IQ and/or Low Perfusion Index, follow these steps.

39. SpHb Method

40. Traditional Lab Hemoglobin: Intermittent, Invasive, Delayed40

41. Masimo SpHb: Continuous, Noninvasive, Immediate
Potential Benefits
Earlier and better clinical decisions
Improved patient safety
Decreased costs 41