598459 research-article2015
PSH0010.1177/2010105815598459Proceedings of Singapore HealthcareTan and Thong
PROCEEDINGS
Short Communication
OF SINGAPORE HEALTHCARE
Surgical fire caused by electrocautery in ambient air
Proceedings of Singapore Healthcare 2015, Vol. 24(3) 195–197 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2010105815598459 psh.sagepub.com
Zihui Tan and Sze Ying Thong
Abstract Introduction: The fire triangle comprises the ignition source, fuel and oxidizer which is necessary for the initiation of fire. Most surgical fires occur in an oxygen-enriched environment. We report a case of surgical fire in ambient air where an alcohol-based antiseptic was involved. Case report: A 20-year-old male diagnosed with left pleural empyema and respiratory failure, requiring emergent intubation and respiratory support, was brought into the operating theatre for decortication of the left lung. Shortly after induction, the patient desaturated despite 100% oxygen and lung recruitment manoeuvres. The surgical team decided to insert a chest tube emergently to drain the empyema to improve respiratory function. A non-functioning drainage catheter that was in situ was removed and placed on the operating table beside the patient. Skin was prepared using chlorhexidine gluconate 0.5% w/v in methylated spirit solution and iodine. Soon after, cotton drapes were used to cover the patient. After the initial incision for chest tube insertion, electrocautery was introduced. Smoke and a smell of something burning was immediately noted by the surgical team. The drapes were removed and the drainage catheter with a burnt tip was discovered beside the patient. The patient suffered second degree burns to his chest wall. Conclusion: Although it is more common for surgical fires to occur in an oxygen-enriched environment, this case highlights that without adequate precautions they can also occur in ambient air. Recognition that standard anaesthetic and surgical equipment can act as sources of fuel and vigilance for the circumstances that complete the fire triangle are key to the prevention of surgical fires.
Keywords Surgical fire, electrocautery, alcohol-based skin antiseptics
Introduction Surgical fires are rare but can have serious consequences. Most surgical fires reported in the literature occurred in an oxygen-enriched environment. We report a case of surgical fire in ambient air where an alcohol-based antiseptic has been used. We will also discuss and suggest some measures which are important in the prevention of surgical fires.
Case report A 20-year-old male with Down syndrome presented with lethargy and respiratory tract infection symptoms. He was diagnosed as having community-acquired pneumonia, a leftsided pleural empyema and respiratory failure, and was intubated emergently in the Emergency department. He was admitted to the intensive care unit and his two-week stay was complicated by septic shock requiring inotropic support. During his admission, a 10F drainage catheter (Navarre drain,
C.R. Bard Inc) was inserted on the left side in an attempt to drain the empyema. Although his pneumonia and sepsis improved with antibiotics, the empyema required surgical drainage after the initial drainage catheter became blocked with pus and ceased to drain. He was listed for left lung decortication in the operating theatre. The patient was kept intubated and transferred from the intensive care unit into the operating theatre. He was then placed in supine position on the operating table and general anaesthesia was induced. Shortly after induction, the patient desaturated despite 100% oxygen and lung recruitment
Department of Anaesthesiology, Singapore General Hospital, Singapore Corresponding author: Zihui Tan, Department of Anaesthesiology, Singapore General Hospital, Level 5, Academia, 20 College Road, 169856, Singapore Email:
[email protected]
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196 manoeuvres. After multiple attempts to improve his oxygenation failed, the surgeon decided to insert a chest tube emergently in an attempt to improve respiratory function by draining the empyema. In preparation for the chest tube insertion, the nonfunctioning 10F drainage catheter (Navarre drain, C.R. Bard Inc) that was in situ was removed and placed on the operating table beside the patient’s left chest wall. The skin was prepared using chlorhexidine gluconate 0.5% w/v in methylated spirit solution (chlorhexidine gluconate and methylated spirit 70%, Beacons Pharmaceuticals Pte Ltd) and Prodine (Povidone-Iodine Solution BP, ICM Pharma Pte Ltd). Soon after, a layer of cotton drapes was used to square off the surgical site as well as cover the rest of the patient. After the initial skin incision for the chest tube was made with a scalpel, monopolar electrocautery in the cutting mode was used. The chief surgeon first noted that the operation site and his gloved hands were hot and the procedure was stopped immediately. Smoke and a smell of something burning then followed and the rest of the team was alerted. The drapes were quickly removed and the drainage catheter with a burnt tip (Figure 1) was discovered beside the patient. The cotton sheet underneath the patient was noted to be soaked with alcohol-based solution. After ensuring that there was no more fire, the surgeon then proceeded to insert the chest tube. The patient was then repositioned to a right lateral position and cleaned and draped again for the surgery. Upon turning, second degree burn injury was noted on patient’s left lateral chest wall. Planned surgery proceeded in view of its urgent nature. Postoperatively, the plastics team reviewed the patient and noted a 2% deep dermal burn on the patient’s left lateral chest wall (Figure 2).
Discussion As the use of flammable anaesthetics largely ceased in 1970s, the risk of a surgical fire has been played down and hence surgical and anaesthesia staff today are less vigilant about this hazard.1 Surgical fires are uncommon but can have devastating consequences when they occur. Most cases of fire reported in the literature resulted in minor morbidity with no permanent damage, but there have also been case reports of mortality as a result of surgical fires.2 Surgical fires can be prevented if we are aware of the hazards around the operating room and take on an active role in preventing them. According to the Emergency Care Research Institute (ECRI), approximately 200–240 surgical fires occur in the United States each year.3 Most surgical fires occur within the airway (34%) and head and face (28%).4 This is mainly due to the fact that oxygen-enriched environments are usually found within or near the airway.5 In order to start a fire, three components must be present: fuel, oxidizer and ignition source, commonly known as the fire triangle.2,6 There are many sources of fuel within the surgical field. The patient’s hair, for example, can be a potential fuel for fire. Other examples include the various antiseptics available for cleaning, our personal protective equipment, and linens and dressings
Proceedings of Singapore Healthcare 24(3)
Figure 1.
Figure 2.
used on patients. Anaesthetic equipment such as the breathing circuits, airway adjuncts and monitoring equipment have also been identified,4 and external devices such as stents have been implicated. Lee et al. reported a case of airway fire involving a silicon stent used for dilatation of tracheal stenosis.7 According to ECRI, an oxygen-enriched environment is a contributing factor in 74% of surgical fires.4 Barker and Polson demonstrated that while a plastic face mask melts when exposed to an open flame, it will ignite into flames when as little as 3 l/min of oxygen is flowing through it.2 Other gases, such as nitrous oxide, are also flammable. An oxygen-enriched environment can also be found within the patient. Friedrich et al. reported a case of intrathoracic fire during coronary artery bypass grafting, when a gauze sponge caught fire when electrocautery was introduced.8 Obvious ignition sources like electrosurgical equipment is involved 68% of the time.4 The cutting mode of electrocautery in particular is more hazardous than coagulation mode. Other sources which are less common but are reported in the literature include lasers, fibre-optic bronchoscope, defibrillators, sparks from high-speed drills and burrs as well as glowing embers of charred tissue.9 In our case, the alcohol-based solution and the initial drainage catheter was the fuel, and the ignition source was the electrocautery. The oxidizer was ambient air.
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Tan and Thong The area of burns corresponded with the area of cotton sheet soaked with alcohol. Hence, the injuries were only noted upon turning the patient on his side and away from the cotton sheet he was lying on. A combination of factors allowed the completion of the fire triangle resulting in this incident. First of all, the team did not allow sufficient time for the alcohol to dry before using the electrocautery, as it was an emergency procedure. In addition, the cotton sheet underneath the patient which was soaked with excess alcohol was not removed after cleaning. The drapes which were used subsequently were not adherent to the patient’s body, allowing the accumulated alcohol fumes collected underneath to come into contact with the ignition source. Lastly, the drainage catheter which was removed prior to cleaning was also left beside the patient, instead of being taken out of the surgical field. Although most case reports of surgical fires have involved supplemental oxygen around the surgical field, our case report highlights the fact that these fires can occur just as readily in ambient air. Equal importance needs to be placed on ensuring the oxygen content in the surgical field is minimal, and attention to detail should be paid when an alcohol-based skin solution is used.
Recommendations to prevent surgical fires Awareness remains the key to prevention. The American Society of Anaesthesiologists Task Force on Operating Room Fires recommends that all anaesthetists should be educated on fire safety, especially operating room fires. Anaesthetists should also be updated on operating room fire drills and participate in them regularly. Every surgery should be assessed for risk of fire, and equipment necessary for managing an operating room fire should be available in a high-risk situation.10 Prevention also includes managing the components of the fire triad safely. Drapes should only be applied when the alcohol-based solution has been given sufficient time to dry (manufacturer’s recommendation 2–3 min, and if possible 5 min). The prolongation of drying time is necessary as some solution will pool during cleaning. In order to avoid that, only the minimum amount necessary should be used. Skin must be dry before the use of any electrosurgical unit.10–13 Temporary absorptive sheets should not be used around the surgical site while cleaning the patient. If used, they should be removed before the start of surgery and replaced with sterile ones.14 In this case report, an oxygen-enriched environment was not present. However, as a general precaution, drapes should be arranged appropriately to minimize oxygen build-up underneath, especially if an auxiliary oxygen source is present. An adherent drape should be used to isolate the incision site from the possible oxygen-enriched environment.10 If, unfortunately, a surgical fire occurs, extinguish the fire in the shortest possible time to limit the extent of injury. All unnecessary oxygen and nitrous oxide supply must be switched off immediately. Drapes and any burning material
must be removed. After the fire is extinguished, reassess the patient’s status, especially for risk of inhalational injury if the patient was not intubated.10,15
Conclusion Surgical fires can lead to serious morbidity and mortality to our patients. If we take the necessary precautions for every patient, we can eliminate surgical fires. Understanding the three components of the fire triangle is essential to that process. Declaration of conflicting interest None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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