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市場調查報告書
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1968482

腦氧飽和度監測市場－全球產業規模、佔有率、趨勢、機會、預測：按應用、最終用戶、地區和競爭對手分類，2021-2031年

Cerebral Oximetry Monitoring Market - Global Industry Size, Share, Trends, Opportunity, and Forecast, Segmented By Application, By End User, By Region & Competition, 2021-2031F
出版日期: | 出版商: TechSci Research | 英文 180 Pages | 商品交期: 2-3個工作天內

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簡介目錄

全球腦氧飽和度監測市場預計將從 2025 年的 2.3068 億美元成長到 2031 年的 3.4755 億美元，複合年成長率為 7.07%。

這項非侵入性技術利用近紅外線光光譜技術持續評估額葉皮質的局部氧飽和度，是複雜外科手術中檢測和預防腦缺血的重要工具。市場成長的主要促進因素是全球人口老化和心血管疾病負擔日益加重，這導致高風險心臟和血管手術數量增加，而神經保護在這些手術中至關重要。 2024年胸腔外科協會（STS）的數據證實了這一趨勢，其資料庫中經導管主動脈瓣置換術術（TAVR）的數量在2022年至2018年間激增了66%。這增加了對可靠的術中監測的需求，以最大限度地降低圍手術手術全期神經認知風險。

市場概覽
預測期 2027-2031
市場規模：2025年 2.3068億美元
市場規模：2031年 3.4755億美元
複合年成長率：2026-2031年 7.07%
成長最快的細分市場 心臟外科手術
最大的市場 北美洲

然而，由於高昂的設備購置高成本和一次性感測器的持續使用費用，市場面臨許多障礙。這些經濟因素限制了腦氧飽和度測量技術的應用，尤其是在小規模的醫療機構和新興經濟體。在這種情況下，有限的預算往往迫使決策者優先考慮必要的治療設備而非先進的監測系統，從而阻礙了市場擴張。

市場促進因素

全球心血管和腦血管疾病盛行率的不斷上升是推動全球腦氧飽和度監測市場發展的主要因素。隨著全球心血管和腦血管疾病負擔的加重，醫療系統必須更頻繁地進行高風險手術，例如心臟繞道手術和血管修復，而維持腦氧合是這些手術的關鍵安全指標。根據美國心臟協會 (AHA) 於 2024 年 1 月發布的《2024 年心血管和中風統計更新》，2021 年全球約有 1,991 萬人死於心血管疾病，這意味著大量患者可能需要接受手術治療。因此，醫院越來越重視將腦氧飽和度監測納入手術流程，以確保病患在複雜手術中的預後。

同時，近紅外線光譜技術的進步提高了設備的精度和操作性，加速了市場滲透。製造商們正在推出精密的感測器和非侵入式多參數監測主機，這些設備能夠即時監測腦氧飽和度，從而推動其應用範圍擴展到傳統心血管手術之外。財務報告也印證了這一成長趨勢。 2024年2月，愛德華生命科學公司（Edwards Life Sciences）報告稱，受智慧復健技術普及的推動，其2023年第四季重症監護業務銷售額成長11%，達到2.5億美元。此外，2024年，馬西莫公司（Masimo）宣布其2023年全年醫療保健收入達到12.76億美元，進一步印證了其非侵入式監測解決方案不斷擴大的財務影響力。

市場挑戰

主機設備所需的大量資金投入，加上一次性感測器的持續成本，嚴重限制了腦氧監測系統的應用。對於預算有限的醫療機構而言，為這些設備撥出資金往往十分困難，尤其是在全身麻醉中，因為標準監測參數通常被認為足夠。這種經濟負擔在小規模的區域醫院和發展中地區尤為突出，這些地區的籌資策略優先考慮必要的治療設備，而非專業的輔助監測技術，從而減緩了這些設備在非教學機構中的普及。

目前影響整個醫療產業的金融不穩定進一步加劇了這一經濟障礙。根據美國醫院協會 (AHA) 2024 年的一份報告，飆升的營運和供應成本已導致約 50% 的美國醫院陷入虧損。如此微薄的營運利潤迫使醫院管理者實施嚴格的成本削減措施，導致資本設備採購經常延誤。一次性感測器的持續成本進一步複雜化了預算核准流程，並直接限制了市場擴張，使其僅限於對成本敏感的醫療機構。

市場趨勢

人工智慧 (AI) 和機器學習在預測分析領域的整合正在變革腦氧飽和度測量市場。這使得監測從被動的安全措施轉變為主動的臨床決策工具。先進的演算法現在可以分析血流動力學模式，並在腦氧飽和度下降和低血壓事件發生之前進行預測，使臨床醫生能夠主動穩定患者病情。這項技術變革正在推動顯著的商業性成長，愛德華生命科學公司 2024 年 4 月發布的報告證實了這一點，該報告顯示，2024 年第一季重症監護產品的銷售額成長了 13%，達到 2.51 億美元。這項績效主要歸功於人工智慧驅動的智慧恢復技術的加速應用，這些技術為臨床醫生提供了預測性見解。

此外，監測應用擴展到新生兒和兒童重症監護領域，呈現與傳統成人心臟市場截然不同的顯著成長軌跡。臨床醫生日益認知到腦氧飽和度測量在治療先天性心臟疾病新生兒和早產兒的神經保護價值。維持最佳腦氧合對於預防這些患者出現長期神經發育障礙至關重要。一項發表於2024年1月《胸心血管外科年鑑》（Annals of Thoracic and Cardiovascular Surgery）的題為“最佳化嬰兒心血管手術期間局部腦氧飽和度的效果”的研究支持了這一臨床重點，該研究表明，在嬰兒中實施積極的腦氧飽和度降低治療通訊協定與術後譫妄發生率降低和手術改善顯著發生率相關。

目錄

第1章概述

第2章：調查方法

第3章執行摘要

第4章：客戶心聲

第5章：腦氧飽和度監測的全球市場展望

  • 市場規模及預測
    • 按金額
  • 市佔率及預測
    • 依應用領域（心臟外科、血管外科等）
    • 依最終使用者（醫院/診所、門診手術中心、其他）分類
    • 按地區
    • 按公司（2025 年）
  • 市場地圖

第6章：北美腦氧飽和度監測市場展望

  • 市場規模及預測
  • 市佔率及預測
  • 北美洲：國別分析
    • 美國
    • 加拿大
    • 墨西哥

第7章：歐洲腦氧飽和度監測市場展望

  • 市場規模及預測
  • 市佔率及預測
  • 歐洲：國別分析
    • 德國
    • 法國
    • 英國
    • 義大利
    • 西班牙

第8章：亞太地區腦氧飽和度監測市場展望

  • 市場規模及預測
  • 市佔率及預測
  • 亞太地區：國別分析
    • 中國
    • 印度
    • 日本
    • 韓國
    • 澳洲

第9章：中東和非洲腦氧飽和度監測市場展望

  • 市場規模及預測
  • 市佔率及預測
  • 中東與非洲：國別分析
    • 沙烏地阿拉伯
    • 阿拉伯聯合大公國
    • 南非

第10章：南美洲腦氧飽和度監測市場展望

  • 市場規模及預測
  • 市佔率及預測
  • 南美洲：國別分析
    • 巴西
    • 哥倫比亞
    • 阿根廷

第11章 市場動態

  • 促進因素
  • 任務

第12章 市場趨勢與發展

  • 併購
  • 產品發布
  • 近期趨勢

第13章：全球腦氧飽和度監測市場：SWOT分析

第14章：波特五力分析

  • 產業競爭
  • 新進入者的潛力
  • 供應商的議價能力
  • 顧客權力
  • 替代品的威脅

第15章 競爭格局

  • Masimo Corp.
  • Medtronic Plc
  • Edwards Lifesciences Corporation
  • Nonin Medical Inc.
  • ISS Inc.
  • Hamamatsu Corporation
  • Mespere LifeSciences, Inc.
  • GE HealthCare Technologies, Inc.
  • Terumo Cardiovascular Systems Corporation
  • Koninklijke Philips NV

第16章 策略建議

第17章：關於研究公司及免責聲明

簡介目錄
Product Code: 23871

The Global Cerebral Oximetry Monitoring Market is projected to expand from USD 230.68 Million in 2025 to USD 347.55 Million by 2031, reflecting a compound annual growth rate of 7.07%. This non-invasive technology utilizes near-infrared spectroscopy to continuously assess regional oxygen saturation in the frontal cerebral cortex, serving as a critical tool for detecting and preventing cerebral ischemia during complex surgical interventions. The market's growth is fundamentally driven by the aging global population and the increasing burden of cardiovascular diseases, which necessitate a higher volume of high-risk cardiac and vascular surgeries where neuroprotection is essential. Data from the Society of Thoracic Surgeons in 2024 highlights this trend, revealing that Transcatheter Aortic Valve Replacement procedural volumes in their database surged by 66% in 2022 compared to 2018 levels, thereby amplifying the demand for reliable intraoperative monitoring to minimize perioperative neurocognitive risks.

Market Overview
Forecast Period2027-2031
Market Size 2025USD 230.68 Million
Market Size 2031USD 347.55 Million
CAGR 2026-20317.07%
Fastest Growing SegmentCardiac Surgery
Largest MarketNorth America

However, the market faces a significant obstacle due to the high costs associated with capital equipment and the recurring expense of disposable sensors. These financial requirements can restrict the adoption of cerebral oximetry technology, particularly within smaller healthcare facilities and emerging economies. In such settings, limited budget allocations often force decision-makers to prioritize essential therapeutic devices over advanced monitoring systems, creating a barrier to broader market expansion.

Market Driver

The rising global prevalence of cardiovascular and cerebrovascular diseases acts as a primary catalyst for the Global Cerebral Oximetry Monitoring Market. As the burden of heart and brain disorders escalates worldwide, healthcare systems are compelled to increase the frequency of high-risk interventions, such as cardiac bypasses and vascular repairs, where maintaining cerebral oxygenation is a critical safety parameter. According to the '2024 Heart Disease and Stroke Statistics Update' by the American Heart Association in January 2024, cardiovascular disease accounted for approximately 19.91 million global deaths in 2021, reflecting a massive patient pool requiring potential surgical care. Consequently, hospitals are increasingly prioritizing the integration of cerebral oximetry to safeguard patient outcomes during these complex procedures.

Simultaneously, technological advancements in near-infrared spectroscopy are enhancing market penetration by improving device precision and usability. Manufacturers are introducing refined sensors and non-invasive multi-parameter consoles that offer real-time insights into brain oxygenation, encouraging broader adoption beyond traditional cardiac surgery suites. Financial reports highlight this growth; Edwards Lifesciences reported in February 2024 that sales in their Critical Care segment grew 11% to $250 million in the fourth quarter of 2023, driven by the strong adoption of smart recovery technologies. Furthermore, Masimo reported a full-year 2023 healthcare revenue of $1.276 billion in 2024, underscoring the expanding financial footprint of non-invasive monitoring solutions.

Market Challenge

The substantial capital expenditure required for console units, combined with the recurring costs of disposable sensors, significantly restricts the adoption of cerebral oximetry monitoring systems. Healthcare institutions operating with limited budgets often find it difficult to allocate funds for these devices, particularly when standard monitoring parameters are considered sufficient for general anesthesia. This financial burden is especially pronounced in smaller community hospitals and developing regions, where procurement strategies prioritize essential therapeutic equipment over specialized adjunctive monitoring technologies, thereby slowing the penetration rate of these devices in non-academic settings.

This economic barrier is intensified by the financial instability currently affecting the broader healthcare sector. According to the American Hospital Association in 2024, approximately 50 percent of hospitals in the United States operated at a financial loss due to escalating operational expenses and supply costs. These constrained operating margins compel hospital administrators to implement strict cost-containment measures, frequently leading to the deferral of capital equipment purchases. The ongoing expense of single-use sensors further complicates budget approval processes, directly limiting the expansion of the market into cost-sensitive medical facilities.

Market Trends

The integration of Artificial Intelligence and Machine Learning for predictive analytics is transforming the cerebral oximetry market by evolving monitoring from a passive safety measure into a proactive clinical decision support tool. Advanced algorithms are now capable of analyzing hemodynamic patterns to predict cerebral desaturation and hypotensive events before they manifest, enabling clinicians to preemptively stabilize patients. This technological shift is driving substantial commercial growth, as evidenced by Edwards Lifesciences' report in April 2024, which noted a 13% increase in Critical Care segment sales to $251 million for the first quarter of 2024. This performance was primarily attributed to the accelerating adoption of their AI-enabled Smart Recovery technologies that provide predictive insights for clinicians.

Additionally, the expansion of monitoring applications into neonatal and pediatric intensive care is serving as a critical growth avenue, distinct from the traditional adult cardiac market. Clinicians are increasingly recognizing the neuroprotective value of cerebral oximetry in treating neonates with congenital heart defects and preterm infants, where maintaining optimal cerebral oxygenation is vital for preventing long-term neurodevelopmental deficits. Supporting this clinical focus, a study published in the Annals of Thoracic and Cardiovascular Surgery in January 2024, titled 'Effect of Optimizing Regional Cerebral Oxygen Saturation during Infant Cardiac Surgery', found that the implementation of aggressive cerebral desaturation treatment protocols in infants was significantly correlated with a lower incidence of postoperative delirium and improved surgical recovery.

Key Market Players

  • Masimo Corp.
  • Medtronic Plc
  • Edwards Lifesciences Corporation
  • Nonin Medical Inc.
  • ISS Inc.
  • Hamamatsu Corporation
  • Mespere LifeSciences, Inc.
  • GE HealthCare Technologies, Inc.
  • Terumo Cardiovascular Systems Corporation
  • Koninklijke Philips N.V.

Report Scope

In this report, the Global Cerebral Oximetry Monitoring Market has been segmented into the following categories, in addition to the industry trends which have also been detailed below:

Cerebral Oximetry Monitoring Market, By Application

  • Cardiac Surgery
  • Vascular Surgery
  • Others

Cerebral Oximetry Monitoring Market, By End User

  • Hospitals & Clinics
  • Ambulatory Surgical centers
  • Others

Cerebral Oximetry Monitoring Market, By Region

  • North America
    • United States
    • Canada
    • Mexico
  • Europe
    • France
    • United Kingdom
    • Italy
    • Germany
    • Spain
  • Asia Pacific
    • China
    • India
    • Japan
    • Australia
    • South Korea
  • South America
    • Brazil
    • Argentina
    • Colombia
  • Middle East & Africa
    • South Africa
    • Saudi Arabia
    • UAE

Competitive Landscape

Company Profiles: Detailed analysis of the major companies present in the Global Cerebral Oximetry Monitoring Market.

Available Customizations:

Global Cerebral Oximetry Monitoring Market report with the given market data, TechSci Research offers customizations according to a company's specific needs. The following customization options are available for the report:

Company Information

  • Detailed analysis and profiling of additional market players (up to five).

Table of Contents

1. Product Overview

  • 1.1. Market Definition
  • 1.2. Scope of the Market
    • 1.2.1. Markets Covered
    • 1.2.2. Years Considered for Study
    • 1.2.3. Key Market Segmentations

2. Research Methodology

  • 2.1. Objective of the Study
  • 2.2. Baseline Methodology
  • 2.3. Key Industry Partners
  • 2.4. Major Association and Secondary Sources
  • 2.5. Forecasting Methodology
  • 2.6. Data Triangulation & Validation
  • 2.7. Assumptions and Limitations

3. Executive Summary

  • 3.1. Overview of the Market
  • 3.2. Overview of Key Market Segmentations
  • 3.3. Overview of Key Market Players
  • 3.4. Overview of Key Regions/Countries
  • 3.5. Overview of Market Drivers, Challenges, Trends

4. Voice of Customer

5. Global Cerebral Oximetry Monitoring Market Outlook

  • 5.1. Market Size & Forecast
    • 5.1.1. By Value
  • 5.2. Market Share & Forecast
    • 5.2.1. By Application (Cardiac Surgery, Vascular Surgery, Others)
    • 5.2.2. By End User (Hospitals & Clinics, Ambulatory Surgical centers, Others)
    • 5.2.3. By Region
    • 5.2.4. By Company (2025)
  • 5.3. Market Map

6. North America Cerebral Oximetry Monitoring Market Outlook

  • 6.1. Market Size & Forecast
    • 6.1.1. By Value
  • 6.2. Market Share & Forecast
    • 6.2.1. By Application
    • 6.2.2. By End User
    • 6.2.3. By Country
  • 6.3. North America: Country Analysis
    • 6.3.1. United States Cerebral Oximetry Monitoring Market Outlook
      • 6.3.1.1. Market Size & Forecast
        • 6.3.1.1.1. By Value
      • 6.3.1.2. Market Share & Forecast
        • 6.3.1.2.1. By Application
        • 6.3.1.2.2. By End User
    • 6.3.2. Canada Cerebral Oximetry Monitoring Market Outlook
      • 6.3.2.1. Market Size & Forecast
        • 6.3.2.1.1. By Value
      • 6.3.2.2. Market Share & Forecast
        • 6.3.2.2.1. By Application
        • 6.3.2.2.2. By End User
    • 6.3.3. Mexico Cerebral Oximetry Monitoring Market Outlook
      • 6.3.3.1. Market Size & Forecast
        • 6.3.3.1.1. By Value
      • 6.3.3.2. Market Share & Forecast
        • 6.3.3.2.1. By Application
        • 6.3.3.2.2. By End User

7. Europe Cerebral Oximetry Monitoring Market Outlook

  • 7.1. Market Size & Forecast
    • 7.1.1. By Value
  • 7.2. Market Share & Forecast
    • 7.2.1. By Application
    • 7.2.2. By End User
    • 7.2.3. By Country
  • 7.3. Europe: Country Analysis
    • 7.3.1. Germany Cerebral Oximetry Monitoring Market Outlook
      • 7.3.1.1. Market Size & Forecast
        • 7.3.1.1.1. By Value
      • 7.3.1.2. Market Share & Forecast
        • 7.3.1.2.1. By Application
        • 7.3.1.2.2. By End User
    • 7.3.2. France Cerebral Oximetry Monitoring Market Outlook
      • 7.3.2.1. Market Size & Forecast
        • 7.3.2.1.1. By Value
      • 7.3.2.2. Market Share & Forecast
        • 7.3.2.2.1. By Application
        • 7.3.2.2.2. By End User
    • 7.3.3. United Kingdom Cerebral Oximetry Monitoring Market Outlook
      • 7.3.3.1. Market Size & Forecast
        • 7.3.3.1.1. By Value
      • 7.3.3.2. Market Share & Forecast
        • 7.3.3.2.1. By Application
        • 7.3.3.2.2. By End User
    • 7.3.4. Italy Cerebral Oximetry Monitoring Market Outlook
      • 7.3.4.1. Market Size & Forecast
        • 7.3.4.1.1. By Value
      • 7.3.4.2. Market Share & Forecast
        • 7.3.4.2.1. By Application
        • 7.3.4.2.2. By End User
    • 7.3.5. Spain Cerebral Oximetry Monitoring Market Outlook
      • 7.3.5.1. Market Size & Forecast
        • 7.3.5.1.1. By Value
      • 7.3.5.2. Market Share & Forecast
        • 7.3.5.2.1. By Application
        • 7.3.5.2.2. By End User

8. Asia Pacific Cerebral Oximetry Monitoring Market Outlook

  • 8.1. Market Size & Forecast
    • 8.1.1. By Value
  • 8.2. Market Share & Forecast
    • 8.2.1. By Application
    • 8.2.2. By End User
    • 8.2.3. By Country
  • 8.3. Asia Pacific: Country Analysis
    • 8.3.1. China Cerebral Oximetry Monitoring Market Outlook
      • 8.3.1.1. Market Size & Forecast
        • 8.3.1.1.1. By Value
      • 8.3.1.2. Market Share & Forecast
        • 8.3.1.2.1. By Application
        • 8.3.1.2.2. By End User
    • 8.3.2. India Cerebral Oximetry Monitoring Market Outlook
      • 8.3.2.1. Market Size & Forecast
        • 8.3.2.1.1. By Value
      • 8.3.2.2. Market Share & Forecast
        • 8.3.2.2.1. By Application
        • 8.3.2.2.2. By End User
    • 8.3.3. Japan Cerebral Oximetry Monitoring Market Outlook
      • 8.3.3.1. Market Size & Forecast
        • 8.3.3.1.1. By Value
      • 8.3.3.2. Market Share & Forecast
        • 8.3.3.2.1. By Application
        • 8.3.3.2.2. By End User
    • 8.3.4. South Korea Cerebral Oximetry Monitoring Market Outlook
      • 8.3.4.1. Market Size & Forecast
        • 8.3.4.1.1. By Value
      • 8.3.4.2. Market Share & Forecast
        • 8.3.4.2.1. By Application
        • 8.3.4.2.2. By End User
    • 8.3.5. Australia Cerebral Oximetry Monitoring Market Outlook
      • 8.3.5.1. Market Size & Forecast
        • 8.3.5.1.1. By Value
      • 8.3.5.2. Market Share & Forecast
        • 8.3.5.2.1. By Application
        • 8.3.5.2.2. By End User

9. Middle East & Africa Cerebral Oximetry Monitoring Market Outlook

  • 9.1. Market Size & Forecast
    • 9.1.1. By Value
  • 9.2. Market Share & Forecast
    • 9.2.1. By Application
    • 9.2.2. By End User
    • 9.2.3. By Country
  • 9.3. Middle East & Africa: Country Analysis
    • 9.3.1. Saudi Arabia Cerebral Oximetry Monitoring Market Outlook
      • 9.3.1.1. Market Size & Forecast
        • 9.3.1.1.1. By Value
      • 9.3.1.2. Market Share & Forecast
        • 9.3.1.2.1. By Application
        • 9.3.1.2.2. By End User
    • 9.3.2. UAE Cerebral Oximetry Monitoring Market Outlook
      • 9.3.2.1. Market Size & Forecast
        • 9.3.2.1.1. By Value
      • 9.3.2.2. Market Share & Forecast
        • 9.3.2.2.1. By Application
        • 9.3.2.2.2. By End User
    • 9.3.3. South Africa Cerebral Oximetry Monitoring Market Outlook
      • 9.3.3.1. Market Size & Forecast
        • 9.3.3.1.1. By Value
      • 9.3.3.2. Market Share & Forecast
        • 9.3.3.2.1. By Application
        • 9.3.3.2.2. By End User

10. South America Cerebral Oximetry Monitoring Market Outlook

  • 10.1. Market Size & Forecast
    • 10.1.1. By Value
  • 10.2. Market Share & Forecast
    • 10.2.1. By Application
    • 10.2.2. By End User
    • 10.2.3. By Country
  • 10.3. South America: Country Analysis
    • 10.3.1. Brazil Cerebral Oximetry Monitoring Market Outlook
      • 10.3.1.1. Market Size & Forecast
        • 10.3.1.1.1. By Value
      • 10.3.1.2. Market Share & Forecast
        • 10.3.1.2.1. By Application
        • 10.3.1.2.2. By End User
    • 10.3.2. Colombia Cerebral Oximetry Monitoring Market Outlook
      • 10.3.2.1. Market Size & Forecast
        • 10.3.2.1.1. By Value
      • 10.3.2.2. Market Share & Forecast
        • 10.3.2.2.1. By Application
        • 10.3.2.2.2. By End User
    • 10.3.3. Argentina Cerebral Oximetry Monitoring Market Outlook
      • 10.3.3.1. Market Size & Forecast
        • 10.3.3.1.1. By Value
      • 10.3.3.2. Market Share & Forecast
        • 10.3.3.2.1. By Application
        • 10.3.3.2.2. By End User

11. Market Dynamics

  • 11.1. Drivers
  • 11.2. Challenges

12. Market Trends & Developments

  • 12.1. Merger & Acquisition (If Any)
  • 12.2. Product Launches (If Any)
  • 12.3. Recent Developments

13. Global Cerebral Oximetry Monitoring Market: SWOT Analysis

14. Porter's Five Forces Analysis

  • 14.1. Competition in the Industry
  • 14.2. Potential of New Entrants
  • 14.3. Power of Suppliers
  • 14.4. Power of Customers
  • 14.5. Threat of Substitute Products

15. Competitive Landscape

  • 15.1. Masimo Corp.
    • 15.1.1. Business Overview
    • 15.1.2. Products & Services
    • 15.1.3. Recent Developments
    • 15.1.4. Key Personnel
    • 15.1.5. SWOT Analysis
  • 15.2. Medtronic Plc
  • 15.3. Edwards Lifesciences Corporation
  • 15.4. Nonin Medical Inc.
  • 15.5. ISS Inc.
  • 15.6. Hamamatsu Corporation
  • 15.7. Mespere LifeSciences, Inc.
  • 15.8. GE HealthCare Technologies, Inc.
  • 15.9. Terumo Cardiovascular Systems Corporation
  • 15.10. Koninklijke Philips N.V.

16. Strategic Recommendations

17. About Us & Disclaimer