A&A Case Reports:
Case Reports: Case Report
Brull, Sorin J. MD, FCARCSI (Hon)
Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, SJBrull@me.com
Accepted for publication July 22, 2013.
Pulse oximeter probes, like electrocardiographic surface electrodes, are classified by the Food and Drug Administration (FDA) as class II medical devices (http://www.fda.gov/MedicalDevices). Regulatory control by the FDA increases from class I (low risk) to class III (high risk). In this issue of the journal, 2 case reports highlight the potential harm from misuse of these class II devices.1,2
There are several important “take-home” messages from the forehead oximeter case report1: first, it appears that some users may not be familiar with the manufacturer’s guidelines for use (periodic probe movement and replacement); second, not all nursing protocols contain specific instructions for checking the electrode skin site; third, user work-arounds to prevent inadvertent cable disconnection (e.g., the cable being folded under the probe) may induce injury such as tissue necrosis from prolonged skin pressure. Similarly, the use of the INVOS cerebral oximetry probe was associated with patient injury2: the prolonged use (>24 hours) of the probe in a pediatric patient with low cardiac output (and therefore, with poor ability to dissipate the heat produced by the light-emitting diode [LED] light) and perhaps the probe reuse (that likely stripped the protective gel over the optical windows, decreasing the isolation barrier between LED and skin) are factors that may have led to the skin burn. Together, these case reports underscore that vigilance, scrupulous attention to detail, and following manufacturers’ recommendations are paramount components of safe patient care.
Sorin J. Brull, MD, FCARCSI (Hon)
Department of Anesthesiology
Mayo Clinic, Jacksonville, Florida
1. Lee M, Eisenkraft JB. Forehead pulse oximeter-associated pressure injury. Anesth Analg. 2013
2. Arslantas MK, Arslantas R. Cerebral oximetry probes-associated skin burns in pediatric patients. Anesth Analg. 2013