Abstract
Pulse oximetry is widely used in all intensive care units and in surgical monitoring and has the advantage of being noninvasive. Here, we report a 1.5 kg male neonate born via lower segment cesarean section at 5:00 pm. At birth, the patient had respiratory distress, mild subcostal retractions, minimal nasal flaring, and grunt audible with a stethoscope (Silverman-Anderson Score: 3) and was kept in the neonatal intensive care unit (NICU) with oxygen by heated humidified high-flow nasal cannula for observation of about 24 hours with a saturation probe connected to the right foot, due to which baby was found to have redness and swelling of the right foot with fluid-filled blebs on the palmar and dorsal surface in the morning at 8:00 am (18 hours of life), suggesting a second-degree burn. Pulse oximetry is a noninvasive and basic test for seeing oxygen saturation but could lead to serious burn injuries, so special care must be taken by nursing staff and doctors to change the pulse oximeter site frequently as suggested in various case reports. Doctors and nursing staff need to be educated and made aware of the risk of pulse oximeter-related burn injuries.