A patient who was burned in the operative field: a case report

Chung, Soo‐Ho; Lee, Hae‐Hyeog; Kim, Tae Hee; Kim, Jeong Sig

doi:10.5505/tjtes.2012.49225

Cited by 3 publications

(2 citation statements)

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“…14 Clinically, several case reports and two case series of surgical fires because of alcohol-based skin preparation have been recorded in various surgical fields. [15][16][17][18][19][20] One case series 19 from the United Kingdom between 2004 through 2011 found that 11/13 surgical fires were attributed to alcohol-based skin preparations. The authors concluded that surgical fires continue to occur despite precautions written in the warning labels.…”

Section: Discussionmentioning

confidence: 99%

“…In labs, surgical fires with porcine skin have been noted when using alcohol‐based skin preparation when allowing for 3 min of drying (the standard waiting period) in 10% of cases without pooling and in 25% of cases with pooling 14 . Clinically, several case reports and two case series of surgical fires because of alcohol‐based skin preparation have been recorded in various surgical fields 15–20 . One case series 19 from the United Kingdom between 2004 through 2011 found that 11/13 surgical fires were attributed to alcohol‐based skin preparations.…”

Section: Discussionmentioning

confidence: 99%

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Surgical Fires Involving Alcohol‐Based Preparation Solution, 1991–2020

et al. 2023

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BackgroundAlcohol‐based skin preparations were first approved for surgical use in 1998 and have since become standard in most surgical fields. The purpose of this report is to examine incidence of surgical fires because of alcohol‐based skin preparation and to understand how approval and regulation of alcohol‐based skin preparations impacted trends in fires over time.MethodsWe identified all reported surgical fires resulting in patient or staff harm from 1991 through 2020 reported to the Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. We examined incidence of fires because of these preparations, trends after approval and regulation, and common causes.ResultsWe identified 674 reports of surgical fires resulting in harm to patients and surgical personnel, in which 84 involved an alcohol‐based preparation. The time‐adjusted model shows that from 1996 through 2006, there was a 26.4% increase in fires followed by a 9.7% decrease from 2007 to 2020. The decrease in fires was most rapid for head and neck and upper aerodigestive tract surgeries. Qualitative content analysis revealed improper surgical site preparation as well as close proximity of surgical sites to an oxygen source as the most common causes of fires.ConclusionSince FDA approval, alcohol‐based preparation solutions have been associated with a significant percentage of surgical fires. Warning label updates from 2006 to 2012 coupled with increased awareness efforts of associated risks of alcohol‐based surgical solutions likely contributed to the decrease in fires. Improper surgical site preparation technique and close proximity of surgical sites to oxygen continue to be risk factors for fires.Level of EvidenceIV Laryngoscope, 2023

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Surgical Fires Involving Alcohol‐Based Preparation Solution, 1991–2020

et al. 2023

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Risks and prevention of surgical fires

et al. 2018

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Surgically induced fire is a life-threatening hazard; this topic has received little attention, although only 3 factors, the so-called fire triad, are needed for surgical fires to occur: an oxidizer, fuel and an ignition source. This systematic review aims to determine the impact of each component and to delegate every staff member an area of responsibility, thus ensuring patient health through prevention or protection. The trial was registered in Prospero CRD42018082656. A database search of eligible, preferably evidence-based studies was conducted. The Robins-I tool for assessing the risk of bias revealed a moderate risk of bias. Due to insufficient data, the main findings of these studies could not be summarized through a quantitative synthesis; therefore, a qualitative synthesis is outlined. The results are summarized according to the roles of the fire triad and discussed. (1) Role of the oxidizer: oxygen is the key component of the triad. Safe oxygen delivery is important. An oxygen-enriched environment (ORE) is caused by draping and is preferably prevented by suctioning. Fuel characteristics are affected by varying oxygen concentrations. (2) Role of the ignition source: electrocauterization is the most common ignition source, followed by lasers. Less common ignition sources include fiberoptic cables and preparative solutions, petrol or acetone. (3) Role of the fuel: surgical drapes are one of the most common fuels for surgical fires followed by the patient's hair and skin. Skin preparation solutions are among the less common fuels. Many fire-resistant materials have been tested that do not remain fire resistant in ORE. It was concluded that the main problem is defining the real extent of this hazard. Exact numbers and exact condition protocols are needed; therefore, standardized registration of every fire and future studies with much evidence are needed. Immediate prevention consists of close attention to patient safety to prevent surgical fires from happening.

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