A patient developed tissue necrosis after prolonged use of a forehead pulse oximeter sensor under a headband. (Image source: Anesthesia & Analgesia)

A patient developed tissue necrosis after prolonged use of a forehead pulse oximeter sensor under a headband. (Image source: Anesthesia & Analgesia)

The patient is cold, the case is about to start, and the finger oximeter does not detect a pulse.  The next step might be to use a reflectance pulse oximeter sensor placed on the forehead.  Drs. Melissa Lee and James B. Eisenkraft, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, New York, describe an 80-year-old man who underwent reexploration of a wound in the lower lumbar region. When the patient came to the OR from the ICU, the OR team noted unfortunately, that the pulse oximeter on the forehead resulted in tissue breakdown.  This case was summarized in the article “Forehead Pulse Oximeter-Associated Pressure Injury” published in the 15 January issue of A&A Case Reports.  The patient’s medical problems included hypertension, coronary artery disease, hyperlipidemia, peripheral vascular disease, and diabetes mellitus.  He had been in the intensive care unit two months before his operation where they used an OxiMax™ MAX-FAST™ forehead pulse oximeter sensor and headband.  When it was removed in the operating room, skin breakdown and tissue necrosis were noted at the site of sensor application.  The forehead pulse oximeter was used intermittently in the ICU when sensor readings from a finger probe were unreliable.

Though this pressure injury occurred in the ICU and not the OR, this lesson is important for either area.  Though blood supply in the forehead derives from the internal carotid artery and is less susceptible to vasoconstriction than peripherally, pressure injury-based ischemia can occur if the applied pressure of the device is greater than manufacturer’s recommendation (up to 20 mm Hg pressure) and if the device is left in place for longer than recommended (2 days).  Certain co-morbidities related to poor perfusion might also increase the risk of injury.

As Dr. Sorin J. Brull, Department of Anesthesiology, Mayo Clinic, Jacksonville, Florida, notes in the accompanying editorial titled “Editorial Comment: Forehead Pulse Oximeter-Associated Pressure Injury and Cerebral Oximetry Probes-Associated Skin Burns in Pediatric Patients,” “these case reports underscore that vigilance, scrupulous attention to detail, and following manufacturers’ recommendations are paramount components of safe patient care.”