The pulse oximeter is a device for non-invasive, continuous measurement of oxygen saturation. As such it is arguably one of the most important intraoperative monitors at the disposal of anaesthetists, and efforts are being made to make pulse oximeters available at all operating locations throughout the world [Walker et al. 2009]. Although the device measures oxygen saturation of arterial blood, which is the physiological end point of interest, it is not a replacement for monitoring all the events which may lead to hypoxaemia; in other words it does not replace an oxygen analyser at the common gas outlet of the anaesthetic machine. Depending on the site of the probe, usually ear lobe or finger, there is a variable delay between the onset of a causative hypoxaemic event and detection of hypoxaemia by the pulse oximeter, the delay being longer the more peripherally placed is the probe. Appropriate size and design of the probe for accuracy and safety in children is important [Howell et al. 1993] and finger probes are more accurate but slower to respond than ear probes [Webb et al. 1991]. Forehead reflectance probes have been used with good results [Casati et al. 2007]. It is also true that the human eye is notoriously bad at detecting cyanosis in the range of saturations 81–85%. For additional information on Monitoring Principles see Chapter 11. It is clear, however, that in a hierarchy of monitors for anaesthesia, the pulse oximeter is indispensable. A pulse oximeter uses two separate technologies: one is plethysmography, where reproduction of the pulsatile waveform takes place; the other is spectroscopy, where absorption of light of specific wavelengths by body tissues occurs and is analysed. The spectroscopic aspects depend on the laws of Beer and Lambert, which can be combined to state that the amount of light absorbed by a substance is proportional to the thickness of the substance sample (the path length of the light) and the concentration of the substance.
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