Forehead pulse oximeter-associated pressure injury
Melissa Lee1, James B Eisenkraft
1From the Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York.
A & a Case Reports
|January 23, 2015
Summary
Forehead pulse oximeter sensors, while generally safe, can cause tissue necrosis if applied too long under a headband. This case highlights the risk of pressure injuries from prolonged use and cable displacement.
Area of Science:
- Medical Devices
- Patient Safety
- Clinical Case Reports
Background:
- Peripherally placed transmittance pulse oximeter sensors are linked to patient injuries like burns and necrosis.
- Existing reports detail burn injuries from forehead reflectance sensors, but not pressure injuries.
Purpose of the Study:
- To report a case of tissue necrosis associated with a specific forehead pulse oximeter sensor.
- To highlight potential risks of prolonged sensor application and cable displacement.
Main Methods:
- Case report detailing the application and outcome of a pulse oximeter sensor.
- Review of existing literature on pulse oximeter sensor-related injuries.
Main Results:
- A patient developed tissue necrosis due to prolonged use of an OxiMax™ MAX-FAST™ forehead sensor under a headband.
- The injury was exacerbated by sensor cable displacement.
Conclusions:
- Prolonged application of forehead pulse oximeter sensors, even with newer designs, can lead to pressure injuries like tissue necrosis.
- Careful monitoring and appropriate application are crucial to prevent device-related patient harm.
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