Forehead pulse oximeter-associated pressure injury.

Peripherally placed transmittance pulse oximeter sensors have been associated with patient injury including burns, gangrene, and necrosis. There are 2 reports of burn injuries associated with the use of forehead reflectance sensors, but there is no report of a pressure injury associated with the use of an OxiMax™ MAX-FAST™ forehead sensor and headband. We report the case of a patient who developed tissue necrosis associated with prolonged application of a forehead pulse oximeter sensor under a headband and displacement of the sensor cable.