NEONATAL

MONITORING
IN-SERVICE
GUIDE
INVOS™ cerebral/somatic oximetry system
Key terms
∙ rSO : regional oxygen saturation
2

∙ INVOS system: In vivo optical spectroscopy

™

∙ Cerebral application: brain area measurement

∙ Somatic application: tissue area of measurement
Regional oximetry versus other oximetry

Regional (capillary) oximetry (rSO2):

∙ Is noninvasive
∙ Provides a capillary (venous and arterial) sample
∙ Measures the balance between O supply and
demand beneath the sensor
2

∙ Alerts to changes in end-organ oxygenation and

perfusion
∙ Requires neither pulsatility nor blood flow
Pulse (arterial) oximetry (SpO2):
∙ Is noninvasive
∙ Uses an arterial sample
∙ Measures O supply in the periphery
2

∙ Measures systemic oxygenation

∙ Requires pulsatility and blood flow
Central (venous) oximetry (SvO2):
∙ Is invasive
∙ Uses a venous sample
∙ Measures O surplus in central circulation
2

∙ Systemic oxygen reserve

∙ Requires blood flow

Distal detector
Proximal detector

LED emitter

The INVOS™ system uses two depths of light

penetration to subtract out surface data, resulting in a
regional oxygenation value for deeper tissues.

Neonatal monitoring in-service guide | 3

 The cerebral-somatic relationship1-3
The INVOS™ system provides perfusion data
from vascular beds that represent opposite
poles of regional circulation and have different
extraction ratios.

Cerebral:
∙ High-flow, high-extraction organ
∙ Compensatory mechanisms
– Autoregulation
– Flow-metabolism coupling
∙ Cerebral desaturations are a late indicator of
shock if cerebral autoregulation is intact
Somatic:
∙ Variable flow, lower O extraction
2

∙ Flow highly influenced by autonomic

(sympathetic) tone
∙ Somatic desaturations as possible early
indicator of shock (i.e., peripheral circulation is
shutting down to preserve the brain)

4 | Neonatal monitoring in-service guide

In neonates, infants, and children, cerebral and
somatic rSO2 values provide noninvasive indications
of oxygen changes in the cerebral and peripheral
circulatory systems. These values may provide an
early indication of oxygen deficits associated with
impending shock states and anaerobiosis.4

rSO2 reflects oxygen balance

rSO2 = regional oxygen saturation:
∙ Increases with rise in delivery or fall in demand
∙ Decreases when delivery falls or if there is an
uncompensated rise in demand
Oxygen delivery/supply influenced by:
∙ Oxygen content
– Hemoglobin concentration
– Hemoglobin saturation
∙ Cardiac output
– Optimize heart rate
– Idealize preload
– Improve contractility
– Manipulate afterload
Oxygen demand/consumption increased by:
∙ Fever, shivering
∙ Malignancy, severe infection
∙ Cold stress
∙ Seizures, status epilepticus
∙ Wounds and burns
∙ Pain

Neonatal monitoring in-service guide | 5

 Oxygen demand/consumption decreased by:
∙ Hypothermia, without shivering
∙ Sedation and paralysis
∙ Shunting or decreased extraction
Interpreting the numbers
rSO2 values reflect a variety of patient-specific
comorbidities as well as other variables. These include:

∙ Circulating blood volume

∙ Cardiac function
∙ Peripheral vascular resistance
∙ Muscular activity
∙ Circulating hormones
∙ Venous pressure
The rSO2 value is expressed both as a real-time
numerical value and a percent change from baseline.
With the patient serving as his/her own control, you
can use either to customize patient assessment,
decision making, and interventions.
The most recognized rSO2 values published on
pediatric patients follow below. These patients are
most often congenital heart neonates undergoing
surgery and recovery in the pediatric ICU. Values for
patients with other diagnoses and comorbidities may
differ from this.

Cerebral — high blood flow, high O2 extraction:

∙ Typical rSO range is 60 to 80, assuming SpO is >90.
2 2

∙ change
Common intervention trigger is rSO <50 or 20%
from rSO baseline.
2
2

∙ rSO
Critical threshold is rSO <45 or 25% change from
baseline.
2
2

6 | Neonatal monitoring in-service guide

Somatic — variable blood flow, lower O2 extraction:
∙ Variances in the cerebral-somatic relationship may
indicate pathology.
∙ Watch for drops of 20% below patient baseline.
The balance of perfusion distribution in premature
neonates depends on gestational age, day of life, and
comorbidities. Simultaneous cerebral/somatic rSO2
monitoring can help you balance cardiac performance
and peripheral perfusion to avoid no- and low-flow
states associated with shock and other complications.

Interventions
You have an opportunity to intervene when rSO2
rises and falls from the patient’s baseline. Follow
your hospital’s intervention protocols for restoring
adequate perfusion. Methods to improve cerebral and
somatic perfusion may include:

Improve cerebral perfusion by:

∙ Increasing cerebral perfusion pressure
∙ Increasing arterial oxygen content
∙ Reducing cerebral metabolic rate
Improve somatic perfusion by:
∙ Increasing total cardiac output
∙ Reducing sympathetic outflow
∙ Increasing hematocrit
∙ Maintaining normal temperature
∙ Considering regional vasodilation in shock

Neonatal monitoring in-service guide | 7

 Setup and baselines
∙ Plug the sensor cable(s) into the preamplifier(s)
connector (Figure 1). When two somatic site sensors
are placed, they must be connected into the same
preamplifier. Secure the sensor cable to a fixed object
to avoid strain on the sensor-to-skin interface using
strain-relief clips. Ensure the cable is properly inserted
into the preamplifier. Sensor cable can be connected
before or after placement. Different INVOS™ system
sensors (adult, pediatric, and infant/neonatal) cannot
be used on the same monitor (Figure 2).
∙ The
Turn on power by selecting the green ON/OFF key.
INVOS system performs a 10-second self-test,
™

stopping at the Start screen.

∙ Press NEW PATIENT. Monitoring begins displaying the
patient’s rSO values in white.
2

∙ When the patient’s rSO values have been displayed

2

for approximately 1 minute, set a baseline. For all

channels, press BASELINE MENU, then press SET
BASELINE.
Status messages on the INVOS™ system display will appear
if monitoring conditions are compromised. Periodically
check skin integrity according to your institution’s patient
care protocol or at least every 24 hours.
For extended monitoring, if adhesive is inadequate to
seal the sensor to the skin, apply a new sensor.
When removing sensors, start at the distal tab and
slowly and carefully peel back while placing fingers on
the exposed skin. Based on your institution’s guidelines,
warm water, petrolatum, or commercial adhesive
removal solutions may be helpful.
For complete instructions, warnings, and
!
precautions, see the operations manual and
instructions for use inside the sensor carton.

8 | Neonatal monitoring in-service guide

 1 2 3 4

1 2 3 4

Figure 1 - INVOS™ 5100C system connections

SomaSensor™ OxyAlert™ NIRSsensor,

disposable sensors infant/neonatal
Adult Pediatric

Figure 2 - INVOS™ system sensors

Patient preparation
For optimum adhesion, clean and dry the patient’s skin
with a gauze pad. Warm the sensor in your hands or an
incubator to ease placement.
Neonatal monitoring in-service guide | 9
 Sensor placement
With the white liner facing up, gently bend the
center of the sensor upward until the ends of the
liner lift away from the sensor’s surface. Peel off
each side, being careful not to touch the adhesive
surface. Apply to the skin. Continue applying the
sensor by smoothing it to the skin from the center
outward. Ensure the edges of the sensor are sealed.

Site selection
To help preserve skin integrity, do not place on
undeveloped skin and do not apply pressure (e.g.,
headbands, wraps, tape) to the sensor.

Cerebral
Select the sensor site on the right or left side of
the forehead. Placing the sensor in other cerebral
locations, or over hair, may cause inaccurate
readings, erratic readings, or no readings at
all. Do not place the sensor over nevi, sinus
cavities, the superior sagittal sinus, subdural or
epidural hematomas or other anomalies such as
arteriovenous malformations, as this may cause
readings that do not reflect brain tissue or no
readings at all.

Somatic
Select the sensor site over the tissue area of
interest (site selection will determine which body
region is monitored). Avoid placing the sensor
over fatty deposits, hair, or bony protuberances.
Do not place the sensor over nevi, hematomas,
or broken skin, as this may cause readings that do
not reflect tissue or no readings at all. Locate the
sensor at your discretion, following the criteria in the

10 | Neonatal monitoring in-service guide

Instructions for Use. Placements may include but are
not limited to:
∙ Posterior flank (T10-L2, ∙ Calf
right or left of midline)
∙ Upper arm
∙ Abdomen ∙ Chest
∙ Forearm ∙ Upper leg
Case graphs
The following case graphs demonstrate the clinical
utility of the INVOS™ system. These sample cases
reflect use of the device as indicated; other patient
populations and applications exist.
Reversal of shock5
100

90
Sedation/intubation
rSO 2: Regional oxygen saturation

80 VSS, but tissue

perfusion low
70

60

50 Blood transfusion

40

30 Inotropes given

20
Cerebral rSO2
Fluids given Perirenal rSO 2
10
3:37 4:37 5:37 6:37 7:37 8:37 9:37 10:37 11:37 12:37 13:37

Time

Alterations in ventilation support in RDS6

CO2 68 on ABG
100 Switched from
HFOV to HFJV due to
90 over- expantion on X-ray
rSO2: Regional oxygen saturation

80

70

60
ETT suctioned

50

40

30

20

Dose two of indomethacin Isolette changed Dopamine started @ 2 mcg/kg/min

10
given for PDA Cerebral rSO2
Somatic / perirenal rSO2
0
0:00 1:01 2:01 3:02 4:02 5:03 6:04 7:04 8:05 9:05 10:07 11:06 12:07 13:07 14:07 15:06 16:05 17:04 18:03 19:02 20:01 21:00 21:59 22:59 23:58
Time

Neonatal monitoring in-service guide | 11

References
1. Clavijo-Alvarez JA, Sims CA, Pinsky MR, Puyana JC. Monitoring skeletal muscle
and subcutaneous tissue acid-base status and oxygenation during hemorrhagic
shock and resuscitation. Shock. 2005;24(3):270-275.
2. Fries M, Weil MH, Sun S, et al. Increases in tissue Pco2 during circulatory
shock reflect selective decreases in capillary blood flow. Crit Care Med.
2006;34(2):446-452.
3. Hoffman GM, Ghanayem NS, Tweddell JS. Noninvasive assessment of cardiac
output. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2005:12-21.
4. FDA 510(k) #K082327
5. Underlying data and case notes on file ISC-10001.
6. Underlying data and case notes on file ISC-10023.

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