Q.

Draw both aortic root and a radial artery pressure wave forms on the same
axes. Explain the differences between them
Aorta pressure-time curve
• X axis;
• Y axis;

Radial artery pressure-time curve

• X axis;
• Y axis;

Overview
Causes of radial pulse
• Pressure transmission
• Wave & flow

Recording
• Occlusion & wave

Mechanism of radial waves

• mechanical activity
• electrical activity
• absence

Difference
1. Delay in onset
• Onset & pressure rise
• Reason

2. Systolic peak
• Height
• Effect to systolic pressure
• Shape
• Causes

3. Presence of dicrotic notch

• presence
• Aortic curve & notch
• Causes

4. Shape
• Distorted shape
• Causes

4. Presence of diastolic hump

• presence;
• Causes

5. Pulse pressure
• Comparison
• Mean pressure
8. Duration
• Relative duration

Efffect of age on radial artery pressure contour

Physiological changes in elderly
• Decrease compliance of the aorta; due to aortic atheroscerosis & loss of aortic fibre
• Decrease myocardial performance

Changes in arterial contour

Aortic curve shape
• Slower upstroke than young ptn

Aortic curve height

• Higher peak ; due to low aortic compliance

Clinical significant
• Note; if this systolic peak is persistently elevated then; ptn has systolic hypertension

Summary;
• The low aortic compliance causes the pressure wave to travel faster and less
distorted from the contour of aortic curve
• Ie sama jer bentuknye

Differences with young

• Changes in elderly ; difference in pressure curve found in young patient
• The difference between aortic and radial curves in the elderly are less than found in
young ptn.

Causes of difference
• The differences between the waves are due to the decreased compliance which gave
rise to the steeper upstroke in the radial wave form.
• The higher systolic radial arterial pressure is due to reflection and summation,
tapering and faster transmission of pressure waves.
• Whilst damping in the radial wave causes the loss of anacrotic and dicrotic notches;
• whereas reflection and resonance lead to a diastolic hump on the radial wave form.
• In elderly patients, pulse wave may be transmitted unchanged from the ascending
aorta to the periphery because of the less compliant vessels

Short answer question

Overview
Aorta pressure-time curve

Radial artery pressure-time curve

Overview
Causes of radial pulse
• Transmission of pressure wave peripherally
• The pressure wave travel faster than flow of blood

Recording
• The wave can be measured eventhough there is occlusion at distal part

Mechanism of radial waves

• Heart is pumping ---mechanical activity
• Heart is generating electricity --- has electrical activity
• If absence ---no radial wave

Difference
1. Delay in onset
• Radial artery has---- delay in the time of onset of the initial pressure rise
• This is due to--- time taken to travel distally

2. Systolic peak
• Radial artery curve is taller
• Effect ---higher systolic pressure
• Narrower peak
• Due to higher velocity of higher pressure peak

3. Presence of dicrotic notch

• Radial aretry doesnt has diacrotic notch as aortic wave
• Reason--its high pressure components is dampened
• Dicrotic notch---which at aortic arch is the incisura
• due to closing of the aortic valve) becomes delayed and slurred

4. Presence of diastolic hump

• Radial artery pressure -time traces--has diastolic hump;
• this is due to reflection and resonance

5. Pulse pressure
• The radial pulse pressure is higher than aortic pressure,
• But the mean pressure ; not much difference from the mean pressure recorded
centrally
• peak and pulse pressures of the radial artery pressure wave to be greater than the
aortic root pressure wave.

8. Duration
• the radial wave pressure should show a steeper upstroke and a shorter duration than
the aortic trace

Efffect of age on radial artery pressure contour

Physiological changes in elderly
• Decrease compliance of the aorta; due to aortic atheroscerosis & loss of aortic fibre
• Decrease myocardial performance

Changes in arterial contour

 • Slower upstroke than young ptn
• Higher peak ; due to low aortic compliance
• Note; if this systolic peak is persistently elevated then; ptn has systolic hypertension

Summary;
• The low aortic compliance causes the pressure wave to travel faster and less
distorted from the contour of aortic curve
• Ie sama jer bentuknye
• Changes in elderly ; difference in pressure curve found in young patient
• The difference between aortic and radial curves in the elderly are less than found in
young ptn.

Causes of difference
• The differences between the waves are due to the decreased compliance which gave
rise to the steeper upstroke in the radial wave form.
• The higher systolic radial arterial pressure is due to reflection and summation,
tapering and faster transmission of pressure waves.
• Whilst damping in the radial wave causes the loss of anacrotic and dicrotic notches;
• whereas reflection and resonance lead to a diastolic hump on the radial wave form.
• In elderly patients, pulse wave may be transmitted unchanged from the ascending
aorta to the periphery because of the less compliant vessels

Q. Write short note on measurements of end tidal CO2

Overview
• End tidal CO2 & capnograph
• Capnograph
• Capnograph

Capnogram
• CO2 & time

Capnograph
• Device
• Continous
• Capnogram wave form

Principal
• absorbtion of IR light
• dissimilar atom
• CO2 - best at 4.3 um

Sample
• End tidal CO2-& --exhaled CO2
• System interaction

Measurements of end tidal CO2

Overview
• Components
• Tungsten wire---source of infrared light after heated to 1500-4000K
• Monochromatic filter----filtered only infrared to pass through
• Sapphire windows --not glas because glass absorbtion of infrared
• Sampling catheter ---either side streams or main streams
• Reffence chamber ---known concentration of CO2
• Focus optic -----that focus the beam to a detector
• Detector---that display the CO2 concentration based on CO2 absorbtion

Principal
• Lamber law principal
• It= Ii e - A
• It= intensity of transmitted light
• Ii= intensity of incident light
• e=natural base logarithm
• A= product of gas absorbtion coefficients , the distance the beam travel & molar
concentration of gas

Sampling catheter
• side stream & main stream
• Side strea-location , advanatages
• main stream -location , advandtages

Infrared light
• Composition & infrared light spectrometer
• Tungsten wire & heat
• Infrared light production

Filter
• Filter & monochromator
• Filter & specific wavelength & values
• Filter & beam

Focus
• Beam & sapphire windows

Sample gas chamber & reffence chamber

• Emerge light from sapphire windows & sample of expired gas & refference chamber
• Reffence chamber & known CO2 concentration
• Sample chamber & measured CO2

Absorbtion
• IR light will be absorbed by CO2 in reffence chamber & measured chamber

Absorbtion & CO2 concentration

• the amount of absorbed light is proportional to CO2 concentration

Measurements
• The beam than pass through focussing optic and finally to detectors
• The detector display CO2 concentration based on degree of IR absorbtion by CO2

Normal CO2 waveform

• End tidal CO2 & pCO2

Phases of capnogram
Phase 1
• a-b---inspiratory baseline

phase 2
• b-c---expiratory upstroke

phase 3
• c—d---expiratory plataeu

phase 4
• d-e----ispiratory downstroke

End expiration
• d

Start of expiration
• b

Start of inspiration
• E

Normal values
• d= 38 mmhg
• a,b,e= 0 mmhg

Capnograph
• oesophagus intubation
• Complete airway disconnection
• Ventilation malfunction
• Obstructed airway
• Cardiac arrest
• Graph
Capnograph
• Loss of pulmonary perfusion
• Pulmonary embolism
• Graph

Capnograph
• Rising body temperature
• Hypoventilation
• MH

Capnograph of soda lime exhaustion with breathing spontaneous

• Elevated inspiratory baseline
• Plateau phase limited by increased ventilation

Capnograph of soda lime exhaustion with controlled ventilation

• Elevated inspiratory baseline
• Plateau phase rise because limited ventilation

Errors
COAD
• Sloping of capnograph
• Due to V/Q mistmatch

Pediatric
• High RR
• Small Vt
• Difficult analysis

System leak & disconnection

• Low traces

Nitrous oxide
• Nitrous oxide may absorb infrared---inaccuracy
• Collision broadening --the external forces that result from the interaction between CO2
that has wavelength 4.2-4.4 um & nitrous wavelength - 4.4- 4.6

Calibration
• In vitro with known concentration of CO2 or with calibrated sample cells

Short answer question

Overview
• End tidal CO2 can be measured by capnograph
• Capnograph will display a capnogram

Capnogram
• Plot of concentration of carbon dioxide as function of time

Capnograph
• Device that continuosly record and display CO2 concentration in form of capnogram
wave form
• Based on principal of absorbtion of IR light by 2 dissimilar atom

End tidal CO2 can be measured by capnogram

• End tidal CO2---from exhaled CO2 at the end of expiration
• It represent ---dynamic interaction between pulmonary , cardiovascular , and metabolic
system

Measurements of end tidal CO2

• End tidal CO2 is sampled by channeling CO2 via sampling catheter
• Sampling catheter----either side stream or main stream channel CO2 to CO2 analyser
• CO2 then will be measured by IR analyser

CO2 analyser
• CO2 analyser ---comprised of infrared light spectrometer
• The system consist of IR light source that passing through filter
• The filter then yield the desired wavelength
• The beam then passing through a sample gas chamber
• IR light will be absorbed and the amount of absorbed light is proportional to CO2
concentration
• The beam than pass through focussing optic and finally to detectors
• The detector display CO2 concentration based on degree of IR absorbtion by CO2

Measurements of end tidal CO2

Components
• Tungsten wire---source of infrared light after heated to 1500-4000K I
• Monochromatic filter----filtered only infrared to pass through I
• Sapphire windows --not glass because glass absorbtion of infrared I
• Sampling catheter ---either side streams or main streams I
• Reffence chamber ---known concentration of CO2 I
• Focus optic -----that focus the beam to a detector I
• Detector---that display the CO2 concentration based on CO2 absorbtion I
Principal
• Lamber law principal
• It= Ii e - A
• It= intensity of transmitted light
• Ii= intensity of incident light
• e=natural base logarithm
• A= product of gas absorbtion coefficients , the distance the beam travel & molar
concentration of gas

Sampling catheter
• side stream & main stream
• Side strea-location , advanatages
• main stream -location , advandtages

Infrared light
• Composition & infrared light spectrometer
• Tungsten wire & heat
• Infrared light production

Filter
• Filter & monochromator
• Filter & specific wavelength & values
• Filter & beam

Focus
• Beam & sapphire windows

Sample gas chamber & reffence chamber

• Emerge light from sapphire windows & sample of expired gas & refference chamber
• Reffence chamber & known CO2 concentration
• Sample chamber & measured CO2

Absorbtion
• IR light will be absorbed by CO2 in reffence chamber & measured chamber

Absorbtion & CO2 concentration

• the amount of absorbed light is proportional to CO2 concentration

Measurements
• The beam than pass through focussing optic and finally to detectors
• The detector display CO2 concentration based on degree of IR absorbtion by CO2
Normal CO2 waveform
• Normal end expired CO2 content +/- 5% of paCO2

Phases of capnogram
Phase 1
• a-b---inspiratory baseline

phase 2
• b-c---expiratory upstroke

phase 3
• c—d---expiratory plataeu

phase 4
• d-e----inspiratory downstroke
Capnograph
• oesophagus intubation
• Complete airway disconnection
• Ventilation malfunction
• Obstructed airway
• Cardiac arrest
• Graph

Capnograph
• Loss of pulmonary perfusion
• Pulmonary embolism
• Graph

Capnograph
• Rising body temperature
• Hypoventilation
• MH

Capnograph of soda lime exhaustion with breathing spontaneous

• Elevated inspiratory baseline
• Plateau phase limited by increased ventilation

Capnograph of soda lime exhaustion with controlled ventilation

• Elevated inspiratory baseline
• Plateau phase rise because limited ventilation

Errors
COAD
• Sloping of capnograph
• Due to V/Q mistmatch

Pediatric
• High RR
• Small Vt
• Difficult analysis

System leak & disconnection

• Low traces

Nitrous oxide
• Nitrous oxide may absorb infrared---inaccuracy
• Collision broadening --the external forces that result from the interaction between CO2
that has wavelength 4.2-4.4 um & nitrous wavelength - 4.4- 4.6

Calibration
• In vitro with known concentration of CO2 or with calibrated sample cells

Factor affect capnograph

Inhalational Agents
• Inhalational agents do not affect CO2 measurement
• The low concentrations of halogenated anaesthetic agents used during anaesthesia
absorb IR energy at different wave lengths (around 3.3 milli microns)
• their interference is not considered to be important

Atmospheric pressure
• Increases in atmospheric pressure result in an increase in the PETCO2 values by
increasing number of IR absorbing molecules
• and increasing intermolecular forces
• the CO2 read high
• minimize error by Calibrating with a known concentration of CO2 as partial pressure
at the site of measurement

Nitrous oxide
• nitrous oxide absorbs IR (IR absorption spectra of N20 = 4.5 µm whereas C02 = 4.3
µm),
• the presence of N20 therefore can give falsely high C02 readings.
• This problem can be eliminated by using a narrow band IR filter that only transmits
the the wavelength most strongly absorbed by C02 (about 4.3 µm). Another problem
relates to N2O concerns the interaction between N20 molecules and C02
molecules.
• This produces a "collision broadening effect" that affects the sensitivity of the IR
analyzer and causes an apparent increase in C02 reading
Q. Describe how the partial pressure of oxygen in a blood sample is measured using a Clark electrode
Overview
• partial pressure of oxygen
• blood gas analysers & O2 tension & clark electrode
• polarographic electrode.
Clark electrode
• electrode & oxygen & platinum surface
Principal
• reaction:
Component of clark electrode
Overview
• Electrode --cathode & anode
Cathode
• platinum cathode & glass rod
• Solution
Anode
• silver/silver chloride anode
• Solution

Temperature
• electrode is kept at 37 degrees.
Accuracy
• has accuracy of +/- 2 mmHg

Calibration
• calibration occurs via use of standardised gas mixtures

solution/electrolyte
• NaCl
• KCL

Function
• 2 electrodes are held within this solution

voltage
• voltage of 700 mv
• polarising voltage is supplied to the electrodes
ammeter
• reading the electrical potenatial generated

O2 permeable membrane
Components

• whole cell & plastic membrane,

Character
• To gases
• To liquids or solids

Function
• Electrode & blood
• prevent deposition
• Oxygen equilibrium

Diagram

Mechanism of action
AT ANODE:
• Reaction
• Product
• Equation

AT CATHODE:
 • O2 & electrons & water
• Equation
Process
• eletron & cathode
• Process & electric potential
• Effect of process

Problems & limitations

Electrode
• O2 electrode must be clean/ uncontaminated.

Electrode wrapper
• intact.

Sample
• Anaerobically
• heparinised.
Sampling time
• Prompt
• Reason

Short answer question

Overview
• Partial pressure: pressure a gas would exert if it alone occupied a space.
• blood gas analysers allow measurement of the O2 tension in blood using the clark electrode (
• also called polarographic electrode.
Clark electrode
• electrode
• measures oxygen
• on a catalytic platinum surface
• using the reaction: O2 + 2 e- + 2 H2O → H2O2 + 2 OH-
Component of clark electrode
electrode
• platinum cathode ----- kept in glass rod
• silver/silver chloride anode----- kept in AgCl gel.
• electrode is kept at 37 degrees.
• has accuracy of +/- 2 mmHg
• calibration occurs via use of standardised gas mixtures
solution/electrolyte
• sodium chloride eletrolyte solution ---
• KCL is alternative ---
• 2 electrodes are held within this solution

voltage
• voltage of 700 mv---- polarising voltage is supplied to the electrodes
ammeter
• reading the electyrical potenatial generated

O2 permeable membrane ------

• whole cell is wrapped in a plastic membrane, permeable to gases but not liquids or solids
• separate the electrode from blood -----
• prevent deposition of protein ----
• allow oxygen tension in the blood to equilibrate with electrolyte solution

Diagram

Mechanism of action
AT ANODE:
• Ag reacts with KCl creating AgCl and free electrons
• Ag + Cl -------> AgCl + e-

AT CATHODE:
• O2 combines with electrons and water (
• O2 + 4e +2H2O makes 4(OH)-
Process
• eletron ----taken up at the cathode-platinum
• the current is generated that proportional to oxygen tension

Problems & limitations

• O2 electrode must be clean/ uncontaminated.
• plastic membrane must be intact.
• blood sample must be taken anaerobically and heparinised.
• analysis must be prompt as O2 falls with time, especially at room temp due to O2 consumption by cells, ice
storage of samle helps to slow this).
Q. Briefly explain the principles of Doppler ultrasound used to measure cardiac
output.
[edit]

Examiner's Report
[edit]
2005

52 % of candidates passed this question.

Important points:

• Nature of ultrasound waves and working frequencies

• Piezoelectric effect
• Doppler effect
• Doppler equation relating velocity and Doppler shift in frequency
• Components of the Doppler equation, particularly the incident angle
• Cardiac output measurement
• Measurement of flow from cross sectional area and velocity
• Integrated flow over time to give stroke volume
• Heart rate
• Advantages/disadvantages

The most common mistake was to equate velocity or a single flow rate with cardiac output;
not accounting for the pulsatile nature of cardiac output.

[edit]
1998

Only thirty-three percent (33%) of candidates achieved a pass standard in this question.
Many candidates were obviously taken by surprise by the question and had no knowledge of
even basic Doppler principles. However, of those who passed, a number wrote excellent
answers. The better papers included a discussion of:

• The phenomenon of Doppler Shift (frequency shift and velocity of target)

• The measurement of Aortic Red Cell velocity
• The measurement of Aortic cross sectional area (M mode echocardiography)
• The relationship between velocity (mean vs. peak of profile), cross sectional area,
and flow (cardiac output)
• The effect of the angle of incidence of ultrasound beam on velocity measurement
(cosine q)
• The relative accuracy of the measurement

One answer included a correct formula of target velocity (knowing frequency shift, speed of
sound in tissue, frequency of ultrasound wave, and the angle between ultrasound and
target).

A surprising number of candidates chose not to answer the question at all and wrote
nothing, or chose to answer their own question (eg. "Compare and contrast the different
methods of measuring cardiac output" or "write notes on clinical use of transoesophageal
echocardiography")

Q.Briefly describe the potential causes of a difference between measured end-

tidal and arterial partial pressure of carbon dioxide.

Overview
• the difference is attributed into
• 1. patient factors
• 2. measurement error

Patient factors
overview
• patient factor are:
• increase alveolar dead space,
• delayed alveolar emptying ,
• smoker,
• pulmonary embolism

Graph

alveolar dead space

Overview
• alveolar dead space is volume of inspired gas that passed through anatomical dead
space but not participate in gas exchange

Mechanism that causes difference

• the failure of gas exchange
• result in reduction of transfer of CO2 from arterial blood to alveolar
• resulting in the show arterial to end expiratory pCO2 gradient
Delayed alveolar emptying
Overview
• delayed alveolar emptying
• slow rise of alveolar air
• may cause low expired CO2 detected by capnograph

Causes
• may be due to air trapping in airway secondary to airway obstruction

smoker
• smoking may cause increase in dead space – resulting lung dysfunction
• it may cause arterial to end expiratory pCO2 gradient

increasing age
• elderly patient show arterial to end expiratory pCO2 gradient

increased anatomical dead space

Overview
• anatomical dead space is volume of gas exhaled before CO2 concentration rises to its
alveolar plateau

Causes of anatomical dead space

• increasing antomical dead space for example ---with;
• neck extended and jaw protruded ,
• bronchodilator agent such as inhlational agent
• – result in increase anatomical dead space

Physiological effect of dead space

• that may cause a difference between measured end-tidal and arterial partial pressure of
carbon dioxide.

lung pathology
• pulmonary embolism may cause failure of transfer of CO2 from arterial to alveoli
Measurement error
Overview
• CO2 in end- tidal is measured by infrared analyser/capnograph to measure CO2 levels
continously.
• CO2 in arterial blood is measured by CO2 sensitive electrode via arterial sample

Causes of errors
• any measurement error involving this equipment may result in difference between
measured end-tidal and arterial partial pressure of carbon dioxide.

measurement error of end tidal CO2

Machine error
• Inadequate calibration of infrared sensor
Sampling errors
• Inadequate tidal volume
• Blockage of sampling line
sample error
• Air entrainment into sampling line (leaks)

Measurement error of arterial CO2

Machine errors
• Not calibrated to pressure and temperature

Electrode errors
• Damage to Severinghaus electrode - damage to semi-permeable membrane
Sampling errors
• Delay of 2-3 minutes while CO2 diffuses for measurement
• Delay of sample being measured
• not placed on ice
Sample errors
• Air bubble in blood sample
• Excess heparin (acid) resulting in reduced measure PCO2
• Venous sample taken instead of arterial sample
Q. Draw an expiratory flow volume curve for a forced expiration from total lung
capacity. Describe its characteristics in people with normal lungs,as well as those
with obstructive and restrictive lung disease. Briefly explain the physiological
mechanisms involved in the concept of flow limitation

Overview
Normal.
Overview
• Inspiratory limb of loop is symmetric and convex.
• Expiratory limb is linear.

Curve
• Y Axis; flow in l/sec
• X axis; volume in l
• Plots -- TLC, FRC, RV
• Shape ---slightly triangular
Values of flow
Overview
• Maximal inspiratory flow at 50% of forced vital capacity (MIF 50%FVC) is greater than
maxi-mal expiratory flow at 50% FVC
• you see

Causes of maximal inspiratory flow

• (MEF 50%FVC)
• because dynamic compression of the air-ways occurs during exhalation.
• Therefore ---it restrict the airflow during expiration

Effort dependent and effort independent

Effort dependent
Overview
Location
• Effort dependent is the airflow from maximal inspiration (TLC) to expiratory volume of
half of the lung volume,

Relationship
• in which the greater the effort the higher the flow rate
Mechanism
• When subject exhaled from maximal inspiration --->higher lung volume
• the greater the effort to exhaled the air ---the higher the flow rate
• Therefore airflow ---the flow rate is effort dependent.
Slope of PV loop
• Greater the effort---greater positive intrapleural pressures ----result in higher flow
rates.
• Submaximal effort produced lower flow rates and flattened peak of flow volume
curve.

Effort independent flow

Overview
• Effort independent flow is the expiration of air from mid lung volume to the lowest
possible lung volume or RV,

Relatioship
• in which the flow rate doesn't increased despite greater effort of exhalation
Mechanism
• As expiration progresses, mid lung volumes are reached
• there is a subsequent progressive reduction in flow rate which continues through low
lung volume until full expiration complete -----(lung in RV).
Slope of effort independent
• Slope generated following peak flow rate until RV is the plateau.
• At mid to low lung volumes, flow rates gradually decline as air is expelled.
• It is not possible to increase flow rates even with greater intrathroacic pressures.
• Flow is therefore effort independent at this point.
Causes of effort independent pat
• Effort independent part of the curve is a result of dynamic compression of the
airways.

From graph
• The effort independent part includes most of the descending part of expiration curve
Dynamic airway compression
 • During a forceful expiration, the intrathoracic or pleural pressure (Pit) rises

• The intrathoracic pressure causes the alveolar pressure (Palv) to exceed the
downstream pressure at the airway openings (PB).
• As flow resistance dissipates the driving energy along the bronchial tree, the driving
pressure of the cartilaginous bronchi falls towards zero at the mouth
• At a certain point the forces that expand the airway equal the forces that tend to
collapse.
• This is the equal pressure point.
• Beyond the equal pressure point the driving pressure falls below the external
pressure, and the bronchi are compressed .
• At this point the person cannot voluntarily increase the rate of expiratory airflow,
because increased effort also increases the external pressure.
• This phenomenon is called dynamic airway compression with airway collapse.

Factor affect dynamic airway compression

Airway resistance

Lung volume

Flow-volume loop in severe obstructive disease

Overview

• In obstructive diseases, the flow rate is very low in relation to lung volume,

Example
• Asthma

effect to volume
• residual volume is above normal due to air trapping
• the VC below normal

Shape of flow-volume curve

• scooped in (concave)appearance
• The patient inspires maximally and starts a maximal expiration,
 • However ,due to the high airway resistance, the flow rate become very low in relation
to lung volume

Mechanism
• The airway resistance is high because of the inflammed airways that are obstructed
by secretion and smooth muscle contraction.
• The number of airways are reduced as is the pulmonary elastic recoil with loss of
alveolar walls and traction causing the airways to collapse.

Flow volume curve in severe restrictive lung disease

Overview
 • Restrictive lung disease is characterized by small lung volumes

Effect to lung volume

• TLC is small,
• all volumes are often proportionally decreased.
• RV is below the normal
• The TLC is below normal

Effect to airflow velocity

• The airflow velocity and relative forced expiratory volume in 1 s is typically normal.
• One way or the other, the normal expansion of the lungs is restricted or the
pulmonary compliance is decreased
• In restrictive diseases, the maximum flow rate is reduced, as is the total volume
expired.
• The flow is abnormally high in the latter part of expiration because of increased
recoil.

Shape
• Scooped out
• Convex
Q. Briefly explain how oximetry can be used to estimate the partial pressure of
oxygen in a blood sample

Overview
• Partial pressure of oxygen & definition
• Oxymetry & paO2

Oxymetry & Spectrophotometric

• Source & radiation & beam & sample & absorbtion of radiation & extent of absorbtion
• Extent of absorbtion & concentration of gas

Application of laws
• Extent of absorbation of radition & concentration of gas

Principle of application
• Beer lambert law----It = Ii ´e- DCa
• where,
• It = the intensity of the transmitted light
• Ii = intensity of the incident light
• D = the distance through the medium the light passed
• C = the concentration of the solute
• a = the extinction coefficient of the solute

Extinction coefficients
• the extinction coefficient & specific solute & specific wavelength of light

Components of pulse oximetry

Light emiting diode
• 2 LED
• One LED transmit red light with wavelength of 660 nm,
• other transmit infrared light with wavelength of 940 nm.

Photocell

• Photocell or photodiode absorbed the extent of light absorbences

• The light absorbences produce voltage that depends on light absorbtion
• Light absorbtion depend on oxygen saturation

Miscroprocessor
• Calculate ratio of absorbtion by pulsatile tissue
•

Note
• The point at which the absorbences for the two forms of hemoglobin are identical =
isobestic points
• The isobestic point only dependent on hemoglobin concentration
Mechanism of pulse oximetry
Light transmission
• Infrared & light red transmitted through tissue , to venous blood , then finally pulsatile
arteriole

Light absorbtion
• Light beam onto red cell
• Red cell---oxyhemoglobin & deoxyhemoglobin
• Difference absorbtion & difference wavelength
• therefore from the ratio of the absorption of the red and infrared light the
oxy/deoxyhemoglobin ratio can be calculated.

Measured variables
• Pulsatile tissue & non-pulsatile tissue

Pulsatile tissue
• absorbtion of red light by deoxyhemoglobin
• absorbtion of red light by oxyhemoglobin
• Absorbtion of infrared light by deoxyhemoglobin
• Absorbtion of infrared light by oxyhemoglobin

Non-pulsatile tissue
• absorbtion of red light by deoxyhemoglobin
• absorbtion of red light by oxyhemoglobin
• Absorbtion of infrared light by deoxyhemoglobin
• Absorbtion of infrared light by oxyhemoglobin

Miscroprocessor
• comparison of the absorbances at these wavelength -----calculate oxygen saturation

Method
• Ratio of absorbtion of AC 660 of pulsatile arterial deoxyhemoglobin / DC 660 non
pulsatile venous deoxyhemoglobin / AC 940
• Ratio of absorbtion of AC 940 of pulsatile arterial oxyhemoglobin / AC 940 non pulsatile
oxyhemoglobin
• SaO then measured by logarithm

Isobestic point
• point at which the absorbances for the two form of hemoglobin are identical
• isobestic point---only depend on hemoglobin concentration

Calibration

Short answer question

Overview
• Partial pressure of oxygen & definition
• Oxymetry & paO2

Oxymetry & Spectrophotometric

• Source & radiation & beam & sample & absorbtion of radiation & extent of absorbtion
• Extent of absorbtion & concentration of gas

Application of laws
• Extent of absorbation of radition & concentration of gas

Principle of application
• Beer lambert law----It = Ii ´e- DCa
• where,
• It = the intensity of the transmitted light
• Ii = intensity of the incident light
• D = the distance through the medium the light passed
• C = the concentration of the solute
• a = the extinction coefficient of the solute

Extinction coefficients
• the extinction coefficient & specific solute & specific wavelength of light

Components of pulse oximetry

Light emiting diode
• 2 LED
• One LED transmit red light with wavelength of 660 nm,
• other transmit infrared light with wavelength of 940 nm.

Photocell

• Photocell or photodiode absorbed the extent of light absorbences

• The light absorbences produce voltage that depends on light absorbtion
• Light absorbtion depend on oxygen saturation

Miscroprocessor
• Calculate ratio of absorbtion by pulsatile tissue
•

Note
• The point at which the absorbences for the two forms of hemoglobin are identical =
isobestic points
• The isobestic point only dependent on hemoglobin concentration

Mechanism of pulse oximetry

Light transmission
• Infrared & light red transmitted through tissue , to venous blood , then finally pulsatile
arteriole

Light absorbtion
• Light beam onto red cell
• Red cell---oxyhemoglobin & deoxyhemoglobin
• Difference absorbtion & difference wavelength
• therefore from the ratio of the absorption of the red and infrared light the
oxy/deoxyhemoglobin ratio can be calculated.

Measured variables
• Pulsatile tissue & non-pulsatile tissue

Pulsatile tissue
• absorbtion of red light by deoxyhemoglobin
• absorbtion of red light by oxyhemoglobin
• Absorbtion of infrared light by deoxyhemoglobin
• Absorbtion of infrared light by oxyhemoglobin

Non-pulsatile tissue
• absorbtion of red light by deoxyhemoglobin
• absorbtion of red light by oxyhemoglobin
• Absorbtion of infrared light by deoxyhemoglobin
• Absorbtion of infrared light by oxyhemoglobin

Miscroprocessor
• comparison of the absorbances at these wavelength -----calculate oxygen saturation

Method
• Ratio of absorbtion of AC 660 of pulsatile arterial deoxyhemoglobin / DC 660 non
pulsatile venous deoxyhemoglobin / AC 940
• Ratio of absorbtion of AC 940 of pulsatile arterial oxyhemoglobin / AC 940 non pulsatile
oxyhemoglobin
• SaO then measured by logarithm

Isobestic point
• point at which the absorbances for the two form of hemoglobin are identical
• isobestic point---only depend on hemoglobin concentration

Calibration

Error
nail
• coloured nail varnish, especially blue varnish absorn at 660
• affect Sat , false reduction

dye
• idocyanine, methylene blue in thyroid surgery, fluorescein causes decrease in
saturation
• fluorescein no significant effect
• effect last 5-10 minutes

methaemoglobin
• erroneoly read high despite having low sat
• absorb same red light at 660
• also absorb infrared light at 940
Carboxyhemoglobin
• erroneoly read high despite having low sat
• smaller absorbtion of red light at 660
• also absorb infrared light at 940
• but the ratio of absorbances is preserved

HbF
• same absorbtion spectrum as HbA
• no effect on pulse oximetry

HbS
• no significant effect
Anemia
• may be smaller underestimation
Polycythemia
• no effect

Other sources of error

• Excessive movement & malpositioning
• fluoresecent ambient light
• high airway pressure, hypoperfusion , vasoconstriction, valsalva decrease venous
return

Short answer question

Spectrophotometric
Definition
• Technique of measurement that involve shining the radiation through a sample and
determined the quantity of radiation absorbed
• The wavelength of radition that is absorbed by the studied compound is chosen

Principle of action
Two laws that becoame the basic of study:
1. Beer’s law
2. Bouguer law or Lambert’s law

Beer’s law :
• The absorbtion of radiation by a given thickness of a solution of a given concentration
is the same as that of a solution of a given concentration id the same as that of twice
the thickness of solution of half the concentration

Lambert law
• Each layer of equal thickness absorbs an equal fraction which passes through it
Application of laws
• The absorbation of radition by studied compound is increases when the concentration
increases
• At low concentration, the absorbtion is proportional to the concentration

Principle of application
• spectrophotometry was first used to determine the [Hb] of blood in the 1930's, by
application of the Lambert-Beer Law
• where, Ii = the incident light
It = the transmitted light
D = the distance through the medium
C = the concentration of the solute
a = the extinction coefficient of the solute
• the extinction coefficient is specific for a given solute at a given wavelength of light
• therefore, for each wavelength of light used an independent Lambert-Beer equation can
be written, and if the number of equations = the number of solute, then the
concentration for each one can be solved ,
• Lambert- Beer equation , It = Ii ´e- DCa

Oximeter
• Oximeter : the light that consists of various wavelength is transmitted through
hemolyzed blood sample
• Photocell absorbed the extent of light absorbences so that the oxygen saturation can be
calculated
• Latest model use various wavelength of light to give the direct reading of saturation and
also the total hemoglobin

Pulse oximeter
• A pulse oximeter is a medical device that indirectly measures the amount of oxygen in
a patient's blood and changes in blood volume in the skin, a photoplethysmograph.
• Oximeter : the light that consists of various wavelength is transmitted through
hemolyzed blood sample
• Photocell or photodiode absorbed the extent of light absorbences so that the oxygen
saturation can be calculated

Note
• The point at which the absorbences for the two forms of hemoglobin are identical =
isobestic points
• The isobestic point only dependent on hemoglobin concentration

Principle of action of pulse oximeter

• Typically it has a pair of small light-emitting diodes facing a photodiode through a
translucent part of the patient's body, usually a fingertip or an earlobe.
• One LED is red, with wavelength of 660 nm, and the other is infrared 940 nm.
• Absorption at these wavelengths differs significantly between oxyhemoglobin and its
deoxygenated form,
• therefore from the ratio of the absorption of the red and infrared light the
oxy/deoxyhemoglobin ratio can be calculated.
• comparison of the absorbances at these wavelength -----calculate oxygen saturation
Isobestic point
• point at which the absorbances for the two form of hemoglobin are identical
• isobestic point---only depend on hemoglobin concentration

Pulse oximeter
Principles of Pulse Oximetry Technology:
• The principle of pulse oximetry is based on the red and infrared light absorption
characteristics of oxygenated and deoxygenated hemoglobin.
• Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass
through.
• Deoxygenated (or reduced) hemoglobin absorbs more red light and allows more infrared
light to pass through.
• Red light is in the 600-750 nm wavelength light band.
• Infrared light is in the 850-1000 nm wavelength light band.
Q.Explain how cardiac output is measured by thermodilution technique.
Overview
• Definition of CO
• Definition & formula

Measurements of CO
• Two technique
• principal

Indicators dilution technique

Overview
• Definition & invasive
Principle
• stewart hamilton & fick principal
• Injection

Setting
• Cold water
• Thermistor
Measurements of CO
• CO & AUC.
Stewart hamilton equation

Limits of indicator dilution technique

Flow
1. Assumes constant flow.
Heart
1. Assumes structurally normal heart (eg. normal valves)
Measured parameter
1. Measures global function; no information on regional abnormalities.
2. When measuring preload it cannot differentiate between a change in LV Compliance and
a change in LVEDV.
Technique
1. Risk of injury on insertion / flotation of PAC.
2. Minimal evidence of improved mortality with use of PAC to guide therapy.

Fick Principle:

Simple version of Stewart Hamilton Equation:

The Fick principle

• Fick relationship:
• Q = M / (V - A)
• Where Q is the volume of blood flowing through an organ in a minute,
• M the number of moles of a substance added to the blood by an organ in one minute,
• and V and A are the venous and arterial concentrations of that substance.
• This principle can be used to measure the blood flow through any organ that adds
substances to, or removes substances from, the blood.
CO & pulmonary blood flow
• The heart does not do either of these but the
• CO equals the pulmonary blood flow,
• lungs add oxygen to the blood and remove carbon dioxide from it.
• The concentration of the oxygen in the blood in the pulmonary veins is 200 ml/L
• Concentration of oxygen in pulmonary artery is 150 ml/L,
• so each litre of blood going through the lungs takes up 50 ml.
• At rest, the blood takes up 250 ml/min of oxygen from the lungs and this 250 ml must be
carried away in 50 ml portions;
• therefore, the CO must be 250/50 or 5 L/min.

Dilution techniques

Dye dilution:

Methods
• amount of dye & injection
• Calculations of concentration
Characteristic of dye
• Toxicity
• Halflife
• Alternative
Technique
• Injection site
• Measurements

Measurements
• Electrode & radial arterial cannula.

Formula and calculations

• Plot
• CO &(AUC)
Graph
• Y axis; dye concentration
• X axis; time
Thermodilution
Overview
• Amount , injection , site
• Measurements
Measurements
• A plot
• Stewart-Hamilton equation.
• CO=( initial blood temperature - injectate temp ) x computation costant x injectate
volume / integral of temperature changes over time
Graph
• Y axis; temperature decrease as per voltage
• X axis; time
Assumption of the technique
• 1. Mixture
• 2. Loss
• 3. flow

Formula

• The amount of indicator (n) is related to its mean concentration (c),

• cardiac output (Q)
• and the time for which it is detected (t2 - t1).

Advanatages
Patients
• Safe
Doctors
• Rapid
• Frequent

Disadvantage
Doctors
• accuracy
• Reliability
• cost
• Overestimation
Patients
• cvs
• Temperature
• valve
Overview
• CO---volume of blood pumped each minutes by each ventricle
• CO--product of stroke volume & heart rate

Measurements of CO
• CO---can be measured indirectly by dye dilution technique & thermodilution technique
• Both technique uses Fick principal

Indicators dilution technique

Overview
• Invasive indirect technique to measure cardiac output
Principle
• Uses stewart hamilton indicator dilution technique that is derived from fick principal
• It applies bolus

Setting
• Cold water injected down Pulmonary Artery Catheter.
• Thermistor on the end measures temperature change.
Measurements of CO
• Flow rate (CO) is the Amount of Indicator injected divided by the AUC.
Stewart hamilton equation

Limits of indicator dilution technique

Flow
1. Assumes constant flow.
Heart
1. Assumes structurally normal heart (eg. normal valves)
Measured parameter
1. Measures global function; no information on regional abnormalities.
2. When measuring preload it cannot differentiate between a change in LV Compliance and
a change in LVEDV.
Technique
1. Risk of injury on insertion / flotation of PAC.
2. Minimal evidence of improved mortality with use of PAC to guide therapy.

Alternative Techniques
1. MRI with velocity encoded phase contrast
2. Dye Dilution (indiocyanine)
3. Doppler
4. PICCO
Fick Principle:

Simple version of Stewart Hamilton Equation:

The Fick principle

• Fick relationship:
• Q = M / (V - A)
• Where Q is the volume of blood flowing through an organ in a minute,
• M the number of moles of a substance added to the blood by an organ in one minute,
• and V and A are the venous and arterial concentrations of that substance.
• This principle can be used to measure the blood flow through any organ that adds
substances to, or removes substances from, the blood.
CO & pulmonary blood flow
• The heart does not do either of these but the
• CO equals the pulmonary blood flow,
• lungs add oxygen to the blood and remove carbon dioxide from it.
• The concentration of the oxygen in the blood in the pulmonary veins is 200 ml/L
• Concentration of oxygen in pulmonary artery is 150 ml/L,
• so each litre of blood going through the lungs takes up 50 ml.
• At rest, the blood takes up 250 ml/min of oxygen from the lungs and this 250 ml must be
carried away in 50 ml portions;
• therefore, the CO must be 250/50 or 5 L/min.

Dilution techniques

Dye dilution:

Methods
• A known amount of dye ie 10 mls of 25 mg idiocyanine green is injected into venous
circulation in RA
• its concentration is measured peripherally after one complete circulation ---30-40 second
• The mean concentration of the dye is calculated
Characteristic of dye
• Indocyanine green is suitable due to its low toxicity and short half-life.
• Lithium has also been used as an alternative to indocyanine green.
Technique
• It is injected via a central venous catheter
• measured by a lithium-sensitive electrode

Measurements
• Theidiocyanine green is measured by lithium-sensitive electrode
• lithium-sensitive electrode incorporated into the radial arterial cannula.

Formula and calculations

• Plot the curve of idiocyanine green concentration versus time
• CO is calculated from the injected dose, divided by the area under the curve (AUC) and
its duration.
Graph
• Y axis; dye concentration
• X axis; time
Thermodilution
Overview
• 5-10 ml cold saline injected through the proximal injection port of a pulmonary artery
catheter.
• Temperature changes are measured by a distal thermistor.
Measurements
• A plot of temperature change against time gives a similar curve to the dye curve (but
without the second peak).
• Calculation of CO is achieved using the Stewart-Hamilton equation.
• CO=( initial blood temperature - injectate temp ) x computation costant x injectate
volume / integral of temperature changes over time
Graph
• Y axis; temperature decrease as per voltage
• X axis; time
Assumption of the technique
• Application of this equation assumes three major conditions;
• 1. complete mixing of blood and indicator,
• 2. no loss of indicator between place of injection and place of detection and
• 3. constant blood flow.
• The errors made are primarily related to the violation of these conditions.

Formula

• The amount of indicator (n) is related to its mean concentration (c),

• cardiac output (Q)
• and the time for which it is detected (t2 - t1).

Advantages
Patients
• Safe
Doctors
• Rapid
• Frequent

Disadvantage
Doctors
• Not as accurate as fick and indicators dilution technique
• Unreliable if > 10% variations
• Expensive
• Overestimation of CO---highest at end expiration
Patients
• Arrythmia if rapid injection
• Hypothermia
• Tricuspid regurgitation

•
Q. Briefly describe the measurement of blood pressure using an automated
oscillometric non-invasive blood pressure monitor. Briefly outline the problems of
this kind of monitor.
Overview
• LV contraction
• blood ejection
• vascular system
• Pulsation
• systolic pressure
• diastolic pressure
• Pulse pressure

Automated oscillometry
• Definition of automated
• Definition of oscillometry
• DINAMAP

Site of measurement
• Relative to artery
• Arm

Size of cuff
• bladder length ---80% of width
• 40% of arm circumfererence
• L:W

Inflation of pressure
• Inflation
• Oscillation
• Cuff pressure
• Transducer
• next
• Cuff pressure
• hold
• Cuff release
 • Pulsation
• Next
• Cuff pressure
• repeated

Blood pressure
• systolic pressure point
• diastolic pressure point
• Mean Arterial Pressure = Diastolic Arterial Pressure + 1/3 pulse pressure
Relaibllity
• most reliable pressure measurement
Error
Devices factors
• Size
• Calibration
Patients factors
• Obesity
• CO
• Rhythm

Short answer question

Overview
• Rhythmic LV contraction>>>blood ejection enter>>>vascular system>>> pulsatile
arterial pressure
• Peak pressure during systolic --------systolic blood pressure
• Trough pressure during diastolic pressure----------diastolic blood pressure
• Pulse pressure: difference between systolic & diastolic pressure
• Mean arterial pressure: systolic pressure + 2 diastolic pressure X 1/3
• Mean arterial pressure : diastolic pressure + 1/3( pulse pressure)

Measurements of arterial blood pressure

• ABP depend sampling site:
• As pulse move peripherally>>>> wave reflection distort the pressure
waveform>>>exaggeration of arterial blood pressure

Principle of measurement
• based on oscilllometry
• eq; DINAMAP= device for indirect non-invasive automatic mean arterial pressure

Oscilometry
• Def : technique of measuring BP by measuring oscillation produced by arterial
pulsation

Technique:
Site of measurement
• measure above artery
• upper arm over brachial artery
Size of cuff
• bladder length ---80% of width ,
• 40% of arm circumfererence
• length to width ratio----1:2

Inflation of pressure
• Cuff inflated above systolic
• >>> small oscillation produced
• Cuff pressure-----monitored by machine pressure transducer
• Cuff pressure---decreased by small amount ----then held for a period of time
• Cuff released >>>pulsation transmitted to entire cuff----the oscillation /pulsation
detected by transducer
• Then cuff further decerased by small amount of pressure
• Process repeated as above

Measurement of oscillation
• Use automated blood pressure>>> to monitor changes of oscillation amplitude
• Then : microprocessor derives / calculate the values by algorithm
• when samll oscillation in pressure rise significantly---the baseline pressure---measure
as systolic
• as cuff pressure continue to decrease in series of small steps-----machine determine
size of oscillation above baseline pressure
• Oscilation initially increase---then decrease
• the baseline pressure at the point when the oscillation are maximum size---is mean
arterial pressure

Blood pressure
• systolic pressure ---- when samll oscillation in pressure rise significantly---the baseline
pressure
• mean aretrial pressure ---- the baseline pressure at the point when the oscillation are
maximum
• diastolic pressure calculated as variations of Mean Arterial Pressure = Diastolic
Arterial Pressure + 1/3 pulse pressure
Relaibllity
• most reliable pressure measurement
error
• inappropriate cuff size, ----cuff too small or too large, more error with cuff to small
• irregular heart rhythms (particularly atrial fibrillation), ---- bllod pressure varies with
every contraction----no reliable determination of pressure
• patient movement including shivering,
• low output states,
• inaccurate calibration.
• obese----large arm circumference with short upper arm length