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Article

December 1998

The current status of transcutaneous blood gas analysis and monitoring*

by John W. Severinghaus
Blood gases/acid-base Neonatology Lactate
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The possibility of continuously monitoring arterial blood oxygen and carbon dioxide using heated surface electrodes on human skin was discovered in the early 1970s and made commercially available by 1976. 

These devices were applied initially to premature infants in an effort to reduce the incidence of blindness due to excessive oxygen administration. Subsequently they have been used in many different clinical and experimental situations. 

The accuracy of tcpO2 compared to pO2 in arterial blood, pO2(a), is of the order of 3-5 % up to pO2 = 80 mmHg, above which it reads substantially lower than arterial blood especially in adults. tcpCO2 tracks pCO2(a) with bias and SD = 1.3 ± 4.0 mmHg in both infants and adults, and if recalibrated in vivo to agree with pCO2(a), shows changes with less than 2 % error. 

Their use decreased at least temporarily with the widespread application of pulse oximetry in about 1985. The low noise level and ease of continuous monitoring without any invasive or annoying (nostril) devices makes transcutaneous analyzers useful in many arenas.

History and theory of transcutaneous blood oxygen monitoring

In 1951-52, the discovery of oxygen related blindness in premature infants created an urgent need for continuous noninvasive monitoring of blood oxygen. A new solution to the problem came from physiologists studying skin respiration. 

Human skin breathes, taking up oxygen and giving off CO2 to the air. If skin is covered (as by a flat unheated pO2 electrode) the surface pO2 falls to zero in a few minutes. 

However, in 1951, Baumberger and Goodfriend [1] showed that if skin blood flow is greatly increased by the highest tolerable heat (45 °C), the surface pO2 rises to about arterial blood, pO2(a).

Within a year after Clark’s invention [2,3] of the membrane covered platinum polarographic electrode, Rooth [4] used polarography to confirm the Baumberger report. 

Researchers tried unsuccessfully to use chemical vasodilators to make skin pO2 a monitor of pO2(a). Kwan and Fatt [5] noted that pO2 of the palpebral conjunctiva measured with an unheated tiny Clark electrode mounted facing outward on a contact lens over the cornea simulated pO2(a). 

This device was briefly marketed a decade later but was discontinued due to the danger of infection.

In 1972 in Marburg, Dietrich Lübbers and his students Renate Huch, Albert Huch and Patrick Eberhard showed that flat O2 electrodes heated to 43-44 °C recorded pO2 values close to pO2(a) [6,7]. 

The group found excellent correlation between pO2(a) and tcpO2 in normal infants and children [6,8,9]. tcpO2 was then shown [10] to be highly accurate in sick premature infants with a slope of 0.96 and correlation coefficient of 0.983, giving an approximate mean bias and SD of -2 ± 2 mmHg.

Development of methods and understanding of theory

By 1977 at least 3 commercial tcpO2 electrode systems were available (Hellige, Roche, RADIOMETERTM), with promising clinical data [11,12]. In November 1977, some 18 research teams joined for a workshop on transcutaneous blood gas methods in San Francisco, assessing the theory, problems, possibilities and progress [10,13-17]. 

The following summer (1978) many of these workers joined the Marburg team and others, for the first international congress on transcutaneous blood gas monitoring, establishing the technology as an essential tool in neonatology and as useful in many other fields [18,19].

The agreement of tcpO2 with pO2(a) proved to be due to a cancellation of two opposing effects [14,20].

  1. Heating of desaturated blood raises its pO2 by 7 %/°C, or 50 % at 43 °C, but in saturated blood, as in water, pO2 rises only 1.3 %/°C [21];
  2. Skin metabolism at the high temperature consumes O2 as it diffuses outward from capillaries through living cells, reducing the skin surface pO2 to about that of pO2(a).

The outward oxygen diffusion is facilitated by heat which proved to “melt” some skin diffusion barriers [20,22]. Skin O2 conductivity (C) at an adult volar forearm was determined by two groups, by comparing the flux with two membranes, teflon and mylar, of very high and low conductivities respectively. 

With a large gold cathode Clark electrode, C = 15 nL×cm-2×s-1×atm-1 [23] and with a mass spectrometer C = 10 nL×cm-2×s-1×atm-1 [24].

Skin O2 consumption (VO2) was determined after thermal vasodilation by the rate of fall of tcpO2 with circulatory occlusion (arm cuff) [14]. Relative skin blood flow under the heated electrode was estimated by measuring the required heating power [25]. 

Analysis of data collected at 2 levels of pO2 and 2 temperatures permitted calculation of blood flow, capillary temperature under a heated electrode, and diffusion gradient from capillary to surface [26]. 

Mean adult volar forearm skin VO2 was 4.2 ± 0.4 µL×g -1×min-1 at 44 °C and 2.8 ± 0.3 µL×g-1×min-1 at 37 °C. At 44 °C, skin blood flow averaged 0.64 ± 0.17 mL×g-1×min-1, capillary temperature was 43 °C and the diffusion gradient was 32 ± 7 mmHg.

Transcutaneous CO2

The success in transcutaneous measurement of oxygen led to design and testing of electrodes to measure tcpO2, by Beran et al [27,28], Huch et al [29] and my group [30,31]. Combined tcpO2 - tcpO2 electrodes were initially described by Parker et al [32] and Severinghaus [33]. 

A newly (1993) introduced solid state pH internal part of the CO2 electrode was said to be more stable [34]. Two other methods were found either too slow or too expensive: Infrared gas analysis of a tiny gas sample trapped over heated skin [35], and mass spectrometry using a heated flat probe covered with mylar [36].

Without correction, tcpCO2 is not similar to pCO2(a). Heating of blood (and water) raises pCO2 about 4.6 %/°C [21,37], metabolism adds about 3 mmHg pCO2, and the cooling by skin and blood of the electrode surface further raises the electrode reading. 

The fractional rise of blood pCO2 with temperature is: f= exp(0.046[T-37]) [38]. The net effect at 43 °C was found to be: tcpCO2 = 1.33 pCO2(a) + 4 mmHg [33,39] or tcpCO2 = 1.4 pCO2(a) [40]. 

Temperature dependent correction factors were later incorporated in most commercial transcutaneous blood gas monitoring apparatus. Although tcpCO2 appears to work at 42-43 °C, Tremper et al showed that 44 °C was better when blood pressure was or had been low [41]. tcpCO2 was better than pCO2(ET) in predicting pCO2(a) (bias and SD = -1.6 ± 4.3 mmHg) in anesthetized adults (n = 24) [42].

Special advantages of tcpCO2 are that it averages out breath by breath variations, and has almost no inherent “noise” or variability so that it often is found to be the best trend monitor for detecting small changes in pO2(a), such as those induced by experimental variations (anesthesia, ventilatory settings, posture, FO2(I), FCO2(I), blood pressure, pharmacologic agents, etc). After recalibration to equal a laboratory value of pCO2(a) it tracks the arterial changes with errors of less than 1 mmHg.

Applications

Transcutaneous technology is used in many ways, some of which are discussed in accompanying papers:

Neonatology

Guidance of O2 therapy remains the most common use of transcutaneous monitoring [43-45]. The suspected etiologic role of hyperoxia (tcpO2 > 80 mmHg) in retinitis of premature infants has been confirmed in a cohort study [46]. tcpO2 can be measured above and below the ductus to demonstrate closure [47]. 

In low birth weight infants tcpO2 (at 40 °C!) is the best available monitor of ventilation [48]. (Fig. 1).

cur sta trans bg baby fig 1

FIG 1. Alexander Boalth, born 13 weeks prematurely. Photo taken two hours after birth on July 23, 1994. Alexander is a healthy and strong boy today. (photo by N. Boalth).

Fetal monitoring

Using specially designed electrodes attached to the fetal scalp, intrapartum monitoring revealed some important new patho-physiologic understanding [49-52]. As hoped, changes in tcpO2 rapidly reflected changing maternal and fetal conditions [53]. tcpO2 fell and tcpCO2 rose with contractions during the second stages of labor [54]. tcpCO2 closely followed fetal pCO2(a) [55]. 

When there were signs of fetal distress, fetal scalp tcpO2 was lower than 15 mmHg [56]. Surprisingly, O2 administration to mothers with fetal distress did not alter fetal pCO2 or raise pO2 [57]. During maternal hypocapnia, fetal tcpO2 fell due to the Bohr effect, whereas it rose during hypercapnia [58]. 

Fetal tcpO2 was said to be considerably influenced by local scalp blood flow [59]. Repeated episodes of asphyxia were reported to express catecholamines which reduced blood flow to the fetal skin, and caused an misleading reduction in tcpO2 [60,61]. Fetal tcpCO2 may have failed to disclose severe acidosis or circulatory impairment [62].

Sleep studies

Combined tcpO2-pCO2 electrodes are used in sleep studies in combination with pulse oximetry, because nostril sampling of end-tidal pCO2 is somewhat annoying and more prone to become plugged or dislodged [63-70]. 

The combined tcpO2-pCO2 electrode made it possible to show that the ventilatory response to induced mild hypoxia in sleeping infants changes with age from acute depression at 1-5 days, to stimulation at 4-8 weeks and mild or no stimulation at 10-14 weeks [71]. 

A method was designed for estimating the ventilatory response to CO2 during sleep using only pCO2(ET) and tcpCO2 [66].

Peripheral circulation

tcpO2 electrodes are extensively used in evaluating arterial disease in the peripheral circulation [72-75]. A test of adequacy of peripheral circulation, “initial slope index” or ISI, was suggested by Lemke and Lübbers [76]. 

Blood flow is stopped by an arm cuff above the electrode and restarted when tcpO2 = 0. The initial rate of rise should be a slope per min of at least 75 % of the preocclusion tcpO2.

Skin circulation

Monitoring the viability of skin after injury, transplant, or flap movement [77,78].

Ventilatory control

In intensive care transcutaneous electrodes greatly increased the safety and simplicity of PEEP optimization and respiratory management of adults with ARDS [79]. They are widely used simply to reduce arterial blood sampling.

Hyperbaric oxygen (HBO)

Monitoring and guiding hyperbaric oxygen therapy, primarily for infections and wound healing [80,81]. tcpO2 tracked pO2(a) up to 4 atm hyperbaric pressure in normal subjects [82]. 

Surprisingly, no one has reported using tcpO2 in hyperbaric treatment of CO poisoning despite the demonstration by Barker and Tremper in experimental CO administration that transcutaneous pO2 falls linearly as COHb increases, and reaches about one-fifth of its initial value at the highest COHb levels despite the maintenance of constant arterial pO2 [83]. It is thus unknown whether HBO can normalize tissue pO2 in the presence of high levels of COHb.

Clinical physiology

Transcutaneous monitoring has found use in exercise tolerance studies [84,85]. End-tidal CO2 is not exactly equal to pCO2(a) and the difference between them varies with posture and inspired oxygen concentration. When testing hypoxic ventilatory responses by monitoring pCO2(ET), we have found it helpful to use tcpCO2 to correct these small errors [86].

Pharmacologic research

Transcutaneous monitoring may be the simplest monitor of the depressant effects of opiates, sedatives and anesthetics especially in awake children [87].

Animal studies

Intestinal or other animal tissue experimental ischemia has been found to be better detected by the rise of the organ or tissue surface pCO2 using tcpCO2 electrodes at body temperature, than by gastric tonometry [88]. Both tcpO2 and tcpCO2 have been widely used in small and large animal studies [89], and to assess effect of CPR [90].

Accuracy

With the widespread use of tcpO2 and tcpCO2 came concern about its accuracy and the possible sources and effects of errors, especially with severe hypotension [15,91]. Peabody et al [10] identified two groups of infants in whom tcpO2 was lower than pO2(a). 

These were infants receiving an intravascular infusion of tolazoline and infants with mean arterial blood pressures more than 2.5 SD below the predicted average value. 

Vasoconstrictors also lower tcpO2 [92]. Both of these situations represent extreme alterations in peripheral blood flow. Mild hypotension, hypothermia, anemia, radiant warmers, and bilirubin lights did not adversely affect transcutaneous accuracy [93].

Defining a tcpO2 index as tcpO2/pO2(a), Tremper and Shoemaker [94] studied the effect of shock. For 934 data sets taken on 92 patients not in shock, there was a correlation coefficient (r) of 0.89 and a tcpO2 index 0.79 ± 0.12 (SD). 

In five patients with moderate shock, the r was 0.78 and the tcpO2 index was 0.48 ± 0.07. In 9 patients with severe shock, there was no correlation between tcpO2 and pO2(a) and the tcpO2 index was 0.12 ± 0.12.

A 12-institution study of accuracy collected 756 samples from 251 patients, 116 neonates. For values of pO2(a) less than 80 mmHg, the tcpO2 index was 1.05 ± 0.16 in neonates and 0.93 ± 0.21 in those older than 1 month. 

When pO2(a) was between 80 and 220 mmHg, in neonates this index was 0.88 ± 0.18, giving a mean bias ± SD of -16 ± 25. In older subjects, the ratio was 0.74 ± 0.21, with a mean bias ± SD of tcpO2 of -43 ± 40 mmHg. [95]. 

In the same study, tcpCO2/pCO2(a) was 1.01 ± 0.11 at low pCO2(a) and 1.04 ± 0.08 at pCO2(a) above 40 mmHg; the regression slope was 1.052, R2 = 0.929, bias and SD = 1.3 ± 4.0 mmHg (n = 756).

Limitations

Skin burns may occur after an electrode has been in one place over several hours at 45 °C, and sometimes even at 43 °C. Long term monitoring requires site changes, or a dual electrode alternating system [96]. 

There may be problems with drift of calibration, membrane failure, partial loss of skin contact giving errors in both O2 and CO2 readings. Maintenance of these electrodes requires training and some technical proficiency.

Impact of pulse oximetry

Pulse oximetry came into widespread use in 1985-87, and quickly replaced transcutaneous blood gas analysis in many situations. 

However, after an initial switch to oximetry, neonatologists found that oximetry failed to detect hyperoxia adequately [97] and now mostly use both technologies [98-102]. 

In neonatology, a significant problem is that the inherent errors of pulse oximetry are about 3 %, which could fail to warn of pO2(a) > 80 mmHg unless a set point of about 90 % is chosen for sO2(p) [103]. 

Some have arbitrarily dismissed transcutaneous monitoring as “...plagued by technical problems,... Its use in efforts to prevent retinopathy of prematurity, an eye disease of preterm newborns often leading to blindness, proved disappointing” [104]. 

To them, the transcutaneous field served as a model of problems in medical innovation, new technology and personnel training.

I do not agree with this pessimism. Most technical problems have been solved, and the occurrence of blindness in very premature infants is now believed to be multi-factorial and not just due to hyperoxia. So when it occurs it is not appropriate to attribute it to failed transcutaneous methodology.

Conclusions

The enthusiasm for transcutaneous blood gas analysis of the period 1976-1986 was followed by a decrease due to the advent of pulse oximetry.

The number of papers per year listing medline keywords “transcutaneous blood gas” reached an early peak of 75 in 1979, when the first international symposium in Marburg was devoted to this field, and rose to 200 in 1987. 

However, after 1986 many papers used the key words “transcutaneous blood gas” when writers meant to refer to pulse oximetry.

Inherently transcutaneous technology is somewhat complicated. Users must change membranes and calibrate, change skin sites periodically, beware of drift or error due to poor circulation or poor skin attachment, and take account of the slower response than given by oximetry. 

Nonetheless, transcutaneous blood gas measurement continues to be used because of its unique ability to meet many special situations needing its characteristics of noninvasiveness and continuous determination of the partial pressures of O2 and CO2. Several professional organizations have published guidelines for using these monitors [105,106].

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  76. Lemke R, Klaus D, Lübbers DW, Oevermann G. Noninvasive PtCO2 initial slope index and invasive PtCO2 arterial index as diagnostic criterion of the state of peripheral circulation. Crit Care Med 1988; 16: 353-57.
  77. Keller HP, Klaue P, Hockerts T, Lübbers DW. Transcutaneous pO2 measurement on skin transplants. Birth Defects Orig Artic Ser 1979; 15: 511-16.
  78. Lübbers DW. Transcutaneous measurements of skin O2 supply and blood gases. Adv Exp Med Biol 1992; 316: 49-60.
  79. Tremper KK, Waxman K, Shoemaker WC. Use of transcutaneous oxygen sensors to titrate PEEP. Ann Surg 1981; 193: 206-09.
  80. Dooley J, Schirmer J, Slade B, Folden B. Use of transcutaneous pressure of oxygen in the evaluation of edematous wounds. Undersea Hyperb Med 1996; 23: 167-74.
  81. Wattel F, Pellerin P, Mathieu D, et al. [Hyperbaric oxygen therapy in the treatment of wounds, in plastic and reconstructive surgery]. Ann Chir Plast Esthet 1990; 35: 141-46.
  82. Huch A, Huch R, Hollmann G, et al. Transcutaneous pO2 of volunteers during hyperbaric oxygenation. Biotelemetry 1977; 4: 88-100.
  83. Barker SJ, Tremper KK. The effect of carbon monoxide inhalation on pulse oximetry and transcutaneous pO2 [see comments]. Anesthesiology 1987; 66: 677-79.
  84. Sridhar MK, Carter R, Moran F, Banham SW. Use of a combined oxygen and carbon dioxide transcutaneous electrode in the estimation of gas exchange during exercise. Thorax 1993; 48: 643-47.
  85. Breuer HW, Skyschally A, Alf DF, Schulz R, Heusch G. Transcutaneous pCO2-monitoring for the evaluation of the anaerobic threshold. Comparison to lactate and ventilatory thresholds [see comments]. Int J Sports Med 1993; 14: 417-21.
  86. Sato M, Severinghaus JW, Powell FL, Xu FD, Spellman MJJ. Augmented hypoxic ventilatory response in men at altitude. J Appl Physiol 1992; 73: 101-07.
  87. Alswang M, Friesen RH, Bangert P. Effect of preanesthetic medication on carbon dioxide tension in children with congenital heart disease. J Cardiothorac Vasc Anesth 1994; 8: 415-19.
  88. Rozenfeld RA, Dishart MK, Tønnessen TI, Schlichtig R. Methods for detecting intestinal ischemic anaerobic metabolic acidosis by local pCO2. J Appl Physiol 1996; 81: 1834-42.
  89. Keller HP, Klaue P, Lübbers DW. Transcutaneous pO2 measurements on rats and rabbits. Birth Defects Orig Artic Ser 1979; 15: 621-23.
  90. Tremper KK, Shoemaker WC. Continuous CPR monitoring with transcutaneous oxygen and carbon dioxide sensors. Crit Care Med 1981; 9: 417-18.
  91. Versmold HT, Linderkamp O, Holzmann M, Strohhacker I, Riegel K. Transcutaneous monitoring of pO2 in newborn infants: where are the limits? Influence of blood pressure, blood volume, blood flow, viscosity, and acid base state. Birth Defects Orig Artic Ser 1979; 15: 285-94.
  92. Wendling P, Fussinger R, Schmidt HD, Stosseck K. [Validity of the transcutaneous pO2-measurement during pharmacologically induced changes of skin perfusion (author’s transl)]. Anaesthesist 1982; 31: 135-38.
  93. Ewald U, Huch A, Huch R, Rooth G. Skin reactive hyperemia recorded by a combined tcpO2 and laser Doppler sensor. Adv Exp Med Biol 1987; 220: 231-34.
  94. Tremper KK, Shoemaker WC. Transcutaneous oxygen monitoring of critically ill adults, with and without low flow shock. Crit Care Med 1981; 9: 706-09.
  95. Palmisano BW, Severinghaus JW. Transcutaneous pCO2 and pO2: a multicenter study of accuracy. J Clin Monit 1990; 6: 189-95.
  96. Fallenstein F, Ringer P, Huch R, Huch A. A new system for tcpO2 long-term monitoring using a two-electrode sensor with alternating heating. Adv Exp Med Biol 1987; 220: 285-89.
  97. Paky F, Koeck CM. Pulse oximetry in ventilated preterm newborns: reliability of detection of hyperoxaemia and hypoxaemia, and feasibility of alarm settings. Acta Paediatr 1995; 84: 613-16.
  98. Baeckert P, Bucher HU, Fallenstein F, et al. Is pulse oximetry reliable in detecting hyperoxemia in the neonate? Adv Exp Med Biol 1987; 220: 165-69.
  99. Braghiroli A, Sacco C, Carone M, Donner CF. Pulse oximeter and transcutaneous O2 monitoring: criteria for a choice. Eur Respir J 1990; Suppl 11: 515-17.
  100. Fallenstein F, Baeckert P, Huch R. Comparison of in-vivo response times between pulse oximetry and transcutaneous pO2 monitoring. Adv Exp Med Biol 1987; 220: 191-94.
  101. Wimberley PD, Helledie NR, Friis-Hansen B, Fogh-Andersen N, Olesen H. Pulse oximetry versus transcutaneous pO2 in sick newborn infants. Scand J Clin Lab Invest 1987; 47, Suppl 188: 19-25.
  102. Wimberley PD. Oxygen monitoring in the newborn. Scand J Clin Lab Invest 1993; 53, Suppl 214: 127-30.
  103. Poets CF, Southall DP. Noninvasive monitoring of oxygenation in infants and children: practical considerations and areas of concern [see comments]. Pediatrics 1994; 93: 737-46.
  104. Mike V, Krauss AN, Ross GS. Doctors and the health industry: a case study of transcutaneous oxygen monitoring in neonatal intensive care. Soc Sci Med 1996; 42: 1247-58.
  105. Anon A. American Academy of Pediatrics Committee on Drugs: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992; 89: 1110-15.
  106. Wimberley PD, Burnett RW, Covington AK, et al. Guidelines for transcutaneous pO2 and pCO2 measurement. IFCC document. Ann Biol Clin 1990; 48: 39-43.
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References
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  3. Clark LC, Clark EW. Personalized history of the clark oxygen electrode. Internat Anesthesiol Clinics 1987; 25: 1-30.
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  31. Severinghaus JW, Bradley AF, Stafford MJ. Transcutaneous pCO2 electrode design with internal silver heat path. Birth Defects Orig Artic Ser 1979; 15: 265-70.
  32. Parker D, Delpy D, Reynolds EOR. Single electrochemical sensor for transcutaneous measurement of pO2 and pCO2. Birth Defects: Original Article Series 1979; 15: 109-116.
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  38. Jacobsen E, Gothgen I. Relationship between arterial and heated skin surface carbon dioxide tension in adults. Acta Anaesthesiol Scand 1985; 29: 198-202.
  39. Hazinski TA, Severinghaus JW. Transcutaneous analysis of arterial pCO2. Med Instrum 1982; 16: 150-53.
  40. Wimberley PD, Pedersen KG, Thode J, et al. Transcutaneous and capillary pCO2 and pO2 measurements in healthy adults. Clin Chem 1983; 29: 1471-73.
  41. Tremper KK, Mentelos RA, Shoemaker WC. Effect of hypercarbia and shock on transcutaneous carbon dioxide at different electrode temperatures. Crit Care Med 1980; 8: 608-12.
  42. Phan CQ, Tremper KK, Lee SE, Barker SJ. Noninvasive monitoring of carbon dioxide: a comparison of the partial pressure of transcutaneous and end-tidal carbon dioxide with the partial pressure of arterial carbon dioxide. J Clin Monit 1987; 3: 149-54.
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  47. Schmidt S, Kakatschikaschwili T, Langner K, Dudenhausen JW, Saling E. [Circulatory adaptation of the newborn infant immediately post partum by bilocal measurement of transcutaneous pCO2]. Z Geburtshilfe Perinatol 1984; 188: 21-23.
  48. Binder N, Atherton H, Thorkelsson T, Hoath SB. Measurement of transcutaneous carbon dioxide in low birthweight infants during the first two weeks of life. Am J Perinatol 1994; 11: 237-41.
  49. Huch A, Huch R, Schneider H. Fetal transcutaneous pO2-current knowledge. Birth Defects Orig Artic Ser 1979; 15: 185-91.
  50. Huch R, Huch A. Fetal and maternal PtCO2 monitoring. Crit Care Med 1981; 9: 694-97.
  51. Lofgren O. Continuous transcutaneous carbon dioxide monitoring in the fetus during labor. Crit Care Med 1981; 9: 750-51.
  52. Okane M, Shigemitsu S, Inaba J, et al. Non-invasive continuous fetal transcutaneous pO2 and pCO2 monitoring during labor. J Perinat Med 1989; 17: 399-410.
  53. Antoine C, Young BK, Silverman F. Simultaneous measurement of fetal tissue pH and transcutaneous pO2 during labor. Eur J Obstet Gynecol Reprod Biol 1984; 17: 69-76.
  54. Schmidt S, Langner K, Dudenhausen JW, Saling E. Reliability of transcutaneous measurement of oxygen and carbon dioxide partial pressure with a combinedpO2-pCO2 electrochemical sensor in the fetus during labor. J Perinat Med 1985; 13: 127-33.
  55. Bergmans MG, van Geijn HP, Weber T, et al. Fetal transcutaneous pCO2 measurements during labour. Eur J Obstet Gynecol Reprod Biol 1993; 51: 1-7.
  56. Kaneoka T, Kobayashi H, Uchida K, Shirakawa K. [Continuous fetal biochemical monitoring and cardiotocography]. Nippon Sanka Fujinka Gakkai Zasshi 1988; 40: 721-28.
  57. Bartnicki J, Langner K, Harnack H, Meyenburg M. The influence of oxygen administration to the mother during labor on the fetal transcutaneously measured carbon-dioxide partial pressure. J Perinat Med 1990; 18: 397-402.
  58. Aarnoudse JG, Oeseburg B, Kwant G, et al. Influence of variations in pH and pCO2 on scalp tissue oxygen tension and carotid arterial oxygen tension in the fetal lamb. Biol Neonate 1981; 40: 252-63.
  59. Smits TM, Aarnoudse JG, Zijlstra WG. Fetal scalp blood flow as recorded by laser Doppler flowmetry and transcutaneous pO2 during labour. Early Hum Dev 1989; 20: 109-24.
  60. Jensen A, Kunzel W, Kastendieck E. Fetal sympathetic activity, transcutaneous pO2, and skin blood flow during repeated asphyxia in sheep. J Dev Physiol 1987; 9: 337-46.
  61. Paulick R, Kastendieck E, Wernze H. Catecholamines in arterial and venous umbilical blood: placental extraction, correlation with fetal hypoxia, and transcutaneous partial oxygen tension. J Perinat Med 1985; 13: 31-42.
  62. Braems G, Kunzel W, Lang U. Transcutaneous pCO2 during labor-a comparison with fetal blood gas analysis and transcutaneous pO2. Eur J Obstet Gynecol Reprod Biol 1993; 52: 81-88.
  63. Fukui M, Ohi M, Chin K, Kuno K. The effects of nasal CPAP on transcutaneous pCO2 during non-REM sleep and REM sleep in patients with obstructive sleep apnea syndrome. Sleep 1993; 16: S144-45.
  64. Manning DJ, Stothers JK. Sleep state, hypoxia and periodic breathing in the neonate. Acta Paediatr Scand 1991; 80: 763-69.
  65. Morielli A, Desjardins D, Brouillette RT. Transcutaneous and end-tidal carbon dioxide pressures should be measured during pediatric polysomnography. Am Rev Respir Dis 1993; 148: 1599-604.
  66. Naifeh KH, Severinghaus JW. Validation of a maskless CO2-response test for sleep and infant studies. J Appl Physiol 1988; 64: 391-96.
  67. Naughton M, Benard D, Tam A, Rutherford R, Bradley TD. Role of hyperventilation in the pathogenesis of central sleep apneas in patients with congestive heart failure [see comments]. Am Rev Respir Dis 1993; 148: 330-38.
  68. Naughton MT, Benard DC, Rutherford R, Bradley TD. Effect of continuous positive airway pressure on central sleep apnea and nocturnal pCO2 in heart failure. Am J Respir Crit Care Med 1994; 150: 1598-604.
  69. Schafer T, Schafer D, Schlafke ME. Breathing, transcutaneous blood gases, and CO2 response in SIDS siblings and control infants during sleep. J Appl Physiol 1993; 74: 88-102.
  70. Schlaefke ME, Schaefer T, Kronberg H, Ullrich GJ, Hopmeier J. Transcutaneous monitoring as trigger for therapy of hypoxemia during sleep. Adv Exp Med Biol 1987; 220: 95-100.
  71. Milerad J, Hertzberg T, Lagercrantz H. Ventilatory and metabolic responses to acute hypoxia in infants assessed by transcutaneous gas monitoring. J Dev Physiol 1987; 9: 57-67.
  72. White RA, Nolan L, Harley D, et al. Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension. Am J Surgery 1982; 144: 68-75.
  73. Kram HB, Shoemaker WC. Diagnosis of major peripheral arterial trauma by transcutaneous oxygen monitoring. Am J Surg 1984; 147: 776-80.
  74. Padberg FT, Back TL, Thompson PN, Hobson RWn. Transcutaneous oxygen (tcpO2) estimates probability of healing in the ischemic extremity. J Surg Res 1996; 60: 365-69.
  75. Wutschert R, Bounameaux H. Determination of amputation level in ischemic limbs. Reappraisal of the measurement of tcpO2. Diabetes Care 1997; 20: 1315-18.
  76. Lemke R, Klaus D, Lübbers DW, Oevermann G. Noninvasive PtCO2 initial slope index and invasive PtCO2 arterial index as diagnostic criterion of the state of peripheral circulation. Crit Care Med 1988; 16: 353-57.
  77. Keller HP, Klaue P, Hockerts T, Lübbers DW. Transcutaneous pO2 measurement on skin transplants. Birth Defects Orig Artic Ser 1979; 15: 511-16.
  78. Lübbers DW. Transcutaneous measurements of skin O2 supply and blood gases. Adv Exp Med Biol 1992; 316: 49-60.
  79. Tremper KK, Waxman K, Shoemaker WC. Use of transcutaneous oxygen sensors to titrate PEEP. Ann Surg 1981; 193: 206-09.
  80. Dooley J, Schirmer J, Slade B, Folden B. Use of transcutaneous pressure of oxygen in the evaluation of edematous wounds. Undersea Hyperb Med 1996; 23: 167-74.
  81. Wattel F, Pellerin P, Mathieu D, et al. [Hyperbaric oxygen therapy in the treatment of wounds, in plastic and reconstructive surgery]. Ann Chir Plast Esthet 1990; 35: 141-46.
  82. Huch A, Huch R, Hollmann G, et al. Transcutaneous pO2 of volunteers during hyperbaric oxygenation. Biotelemetry 1977; 4: 88-100.
  83. Barker SJ, Tremper KK. The effect of carbon monoxide inhalation on pulse oximetry and transcutaneous pO2 [see comments]. Anesthesiology 1987; 66: 677-79.
  84. Sridhar MK, Carter R, Moran F, Banham SW. Use of a combined oxygen and carbon dioxide transcutaneous electrode in the estimation of gas exchange during exercise. Thorax 1993; 48: 643-47.
  85. Breuer HW, Skyschally A, Alf DF, Schulz R, Heusch G. Transcutaneous pCO2-monitoring for the evaluation of the anaerobic threshold. Comparison to lactate and ventilatory thresholds [see comments]. Int J Sports Med 1993; 14: 417-21.
  86. Sato M, Severinghaus JW, Powell FL, Xu FD, Spellman MJJ. Augmented hypoxic ventilatory response in men at altitude. J Appl Physiol 1992; 73: 101-07.
  87. Alswang M, Friesen RH, Bangert P. Effect of preanesthetic medication on carbon dioxide tension in children with congenital heart disease. J Cardiothorac Vasc Anesth 1994; 8: 415-19.
  88. Rozenfeld RA, Dishart MK, Tønnessen TI, Schlichtig R. Methods for detecting intestinal ischemic anaerobic metabolic acidosis by local pCO2. J Appl Physiol 1996; 81: 1834-42.
  89. Keller HP, Klaue P, Lübbers DW. Transcutaneous pO2 measurements on rats and rabbits. Birth Defects Orig Artic Ser 1979; 15: 621-23.
  90. Tremper KK, Shoemaker WC. Continuous CPR monitoring with transcutaneous oxygen and carbon dioxide sensors. Crit Care Med 1981; 9: 417-18.
  91. Versmold HT, Linderkamp O, Holzmann M, Strohhacker I, Riegel K. Transcutaneous monitoring of pO2 in newborn infants: where are the limits? Influence of blood pressure, blood volume, blood flow, viscosity, and acid base state. Birth Defects Orig Artic Ser 1979; 15: 285-94.
  92. Wendling P, Fussinger R, Schmidt HD, Stosseck K. [Validity of the transcutaneous pO2-measurement during pharmacologically induced changes of skin perfusion (author’s transl)]. Anaesthesist 1982; 31: 135-38.
  93. Ewald U, Huch A, Huch R, Rooth G. Skin reactive hyperemia recorded by a combined tcpO2 and laser Doppler sensor. Adv Exp Med Biol 1987; 220: 231-34.
  94. Tremper KK, Shoemaker WC. Transcutaneous oxygen monitoring of critically ill adults, with and without low flow shock. Crit Care Med 1981; 9: 706-09.
  95. Palmisano BW, Severinghaus JW. Transcutaneous pCO2 and pO2: a multicenter study of accuracy. J Clin Monit 1990; 6: 189-95.
  96. Fallenstein F, Ringer P, Huch R, Huch A. A new system for tcpO2 long-term monitoring using a two-electrode sensor with alternating heating. Adv Exp Med Biol 1987; 220: 285-89.
  97. Paky F, Koeck CM. Pulse oximetry in ventilated preterm newborns: reliability of detection of hyperoxaemia and hypoxaemia, and feasibility of alarm settings. Acta Paediatr 1995; 84: 613-16.
  98. Baeckert P, Bucher HU, Fallenstein F, et al. Is pulse oximetry reliable in detecting hyperoxemia in the neonate? Adv Exp Med Biol 1987; 220: 165-69.
  99. Braghiroli A, Sacco C, Carone M, Donner CF. Pulse oximeter and transcutaneous O2 monitoring: criteria for a choice. Eur Respir J 1990; Suppl 11: 515-17.
  100. Fallenstein F, Baeckert P, Huch R. Comparison of in-vivo response times between pulse oximetry and transcutaneous pO2 monitoring. Adv Exp Med Biol 1987; 220: 191-94.
  101. Wimberley PD, Helledie NR, Friis-Hansen B, Fogh-Andersen N, Olesen H. Pulse oximetry versus transcutaneous pO2 in sick newborn infants. Scand J Clin Lab Invest 1987; 47, Suppl 188: 19-25.
  102. Wimberley PD. Oxygen monitoring in the newborn. Scand J Clin Lab Invest 1993; 53, Suppl 214: 127-30.
  103. Poets CF, Southall DP. Noninvasive monitoring of oxygenation in infants and children: practical considerations and areas of concern [see comments]. Pediatrics 1994; 93: 737-46.
  104. Mike V, Krauss AN, Ross GS. Doctors and the health industry: a case study of transcutaneous oxygen monitoring in neonatal intensive care. Soc Sci Med 1996; 42: 1247-58.
  105. Anon A. American Academy of Pediatrics Committee on Drugs: Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics 1992; 89: 1110-15.
  106. Wimberley PD, Burnett RW, Covington AK, et al. Guidelines for transcutaneous pO2 and pCO2 measurement. IFCC document. Ann Biol Clin 1990; 48: 39-43.
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John W. Severinghaus John W. Severinghaus

 

UCSF 
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