Pulse oximeter-associated toe injuries in a premature neonate: a case report

Pulse oximetry is noninvasive and widely used in the intensive care unit and during surgery. Complications associated with the use of pulse oximetry have been reported, including burns, pressure erosion, skin necrosis and digital sensory loss. The causes of these complications may be due to the incompatibilities between the probes and the monitors used from different companies, pressure duration for too long on a single skin site or overheating induced by a short circuit of the probe cable. We report a 940-g premature infant who had severe pulse oximetry-associated injury to the oximetry site. This may have been due to the infant's susceptibility to injury resulting from his critical condition, including low cardiac output, poor peripheral circulation and poor heat dissemination. Our experience shows that, when pulse oximetry is used, especially in critically ill, premature infants, frequent checking of the sensor and the site where the sensor is applied is required to avoid burn injury or pressure erosion of the skin.