A Case Report : Local Perfusion Failure Caused by the Incorrect Attachment of an SpO₂ Probe during General Anesthesia

Abstract

  We report a case in which the SpO₂ value decreased because of a suspected local perfusion failure. A 10-year-old boy underwent left-sided cleft lip and iliac bone grafting of the jaw under general anesthesia. An adhesive tape SpO₂ monitor (OXIMAX N-25 Nellcor^TM Oxisensor^TM Ⅲ, Covidien Japan, Tokyo, Japan) was placed on his left index finger. During general anesthesia induction, no abnormal SpO₂ values were observed. Ninety minutes after the placement of the probe, the SpO₂ value, which was 100% immediately before the procedure, began to drop to 94%-95%. Since no problems were found after checking the tube insertion length, auscultating the lung field, and performing a blood gas analysis, we suspected equipment failure and placed a new probe on the left toe ; the SpO₂ value subsequently returned to 98%-100%. We then suspended the surgery and checked the probe on the left index finger. The skin in proximity to the probe was dark purple, and the probe was immediately removed. Overpressure from the probe was thought to have caused the vessels in the fingertip to constrict, decreasing the blood flow and causing hypoperfusion and, consequently, peripheral circulatory failure, resulting in the decrease in SpO₂. Dental anesthesiologists should pay attention to the appropriate attachment of SpO₂ probes.