Infant was placed on a nasal cpap.Approximately five minutes later, the infant was found to be crying.The mask was removed and the skin in and around the mask was noted to be red and swollen.The cpap machine appeared to have a faulty heat display and did not shut off when overheating.The infant developed a second degree burn.The initial temp was noted to be 30.9 0c and was found to be 54.8 oc when the cpap was removed.Manufacturer response for cpap humidity heater, h900 (per site reporter).The company has indicated they can interrogate a memory card to investigate the issue.We have not seen a final report to date.
|