Letter: A case of pressure ulcer development on a patient's ear as a result of pulse oximetry probe

Dear Sirs

Patients in intensive care unit (ICU) are haemodynamically unstable. All of them are monitored with advanced monitoring systems. Oxygenation in critically ill patients is very important. This parameter in this group of patients is monitored with pulse oximetry apparatus. Pulse oximetry probe is usually attached to the hand and foot fingers. In some patients, especially critically ill patients who are agitated, this probe may be attached to the other site of body. Ears are the least choice for this purpose. New studies on Iran intensive care units have reported an incidence of pressure ulcer between 5.3 and 11.8 among this group of patients 1, 2. A 51‐year‐old man with subarachnoid haemorrhage and diffuse axonal injury admitted to ICU was selected for this case study. In occiput, the patient had a 10‐cm wound that was sutured, and its dressing was changed three times a day. Patient's position was supine, and head of bed was elevated by 30°. Patient's hands were restricted to bed rail by restrict band. Patient was in ICU for 23 days. Patient's vital signs in the time that ulcer found were as follows: BP, 160/100; P, 118; Spo2, 98; and T, 36/7 (axillary). Drugs that patient received during night were morphine, midazolam, nitroglycerin, ranitidine, phenytoin and enoxaparin (clexan). Pulse oximetry probe was attached to the patient's left ear in the night before the day when the ulcer was found. During morning, nurse who initiated to care for this patient reported that in the upper part of left ear a pressure ulcer was seen. The researcher assessed the patient's ear and ensured that the ulcer caused by pressure was related to pulse oximetry probe. Ulcer was in stage II, and its length was 1 cm.

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Patients in ICU are at high risk of developing pressure ulcers (3). Previous studies have reported that pressure ulcers usually develop in bony part of body. Researches report that sacrum, occiput, buttock, heel and toe are more common sites of pressure ulcer development in critically ill patients 1, 4, 5, 6. Critical care nurses usually assess patients' skin in these parts. The case that is reported in the present study developed pressure ulcer in his left ear. It seems that probe was attached to patient's ear at midnight, because ulcer was deep. Patient's oxygenation and circulation were good. So the only cause for pressure ulcer in that part was pressure caused by pulse oximetry probe that was attached on the patient's left ear. Nurse who cared for the patient in the night shift said that she/he did not know that pulse oximetry probe can cause pressure ulcer development. This patient was in ICU for 23 days and had no pressure ulcer in any part of body. This indicates that patient received appropriate nursing skin care, and nurses were knowledgeable about prevention of pressure ulcer. So the development of such an ulcer could be related to the fact that nurses were not aware that pulse oximetry also can cause pressure ulcer development. This case showed that deep pressure ulcer can also develop in parts of body that are not usually assessed by nurses for signs of pressure ulcer and less considered by them. So nurses are suggested to check continuously all instruments attached to the patients' skin for any signs of pressure ulcer. Nurses should be aware of the ways that prevent pressure ulcer development and facilitate its improvement.

Respectfully submitted, Sedigheh Iranmanesh ¹ , PhD, Hossein Rafiei ² , MSc, Mohammad Esmaeili Abdar ³ , MSc,