Third-degree burns caused by ignition of chlorhexidine: a case report and systematic review of the literature

Abstract

S urgical fires in the operating room are rare, but can have devastating consequences for the patient and the surgeon. The published literature indicates an incidence of approximately 20 to 200 each year in United States (1). Although the majority of surgical fires cause morbidity, mortality can occur (2). For surgeons, it is a source of litigation and, in a recent review, 100% of incidences have resulted in lawsuits (3); therefore, prevention is important.The surgical fire triangle is a useful paradigm to understand the three elements necessary to initiate a fire ( Figure 1). The three elements are an oxidizer (supplemental oxygen), a fuel and an ignition source. In the operating room, all three are in ample supply (4). The fuel is most often the alcohol-based preparation solution used to disinfect the patient (5). The most common source of ignition is the electrocautery unit, which is used in 85% of surgeries and responsible for initiating 70% of surgical fires. In experimental studies, electrocautery units have been shown to easily ignite all alcohol-based preparation solutions even if the solutions contain as little as 20% alcohol (5).Chlorhexidine provides broad-spectrum bacteriostatic and bacteriocidal activity (6). It has a rapid onset and appears to be more resistant to contamination than many other antiseptic agents, making it the agent of choice for surgical scrub in several studies (7). Although chlorhexidine is less flammable than many other alcohol-based antiseptic agents, surgical fires may still occur. There are very few case reports of burns caused by the ignition of chlorhexidine by an electrocautery unit. We present a case report and a systematic review with best-practice recommendations. CASE PRESENTATIONA 77-year-old man presented to his urologist with worsening obstructive voiding symptoms due to a malfunctioning indwelling artificial urethral sphincter and urethral stricture secondary to radiation. His medical history included type 2 diabetes mellitus, hypertension, hiatus hernia and hyperlipidemia. Previous surgeries included fundoplication, radical prostatectomy for stage T3 prostate cancer and insertion of the artificial sphincter. The urologist elected removal of his artificial sphincter to improve his voiding symptoms.Under general anesthetic, the patient was prepped with chlorhexidine (2% chlorhexidine gluconate in 70% isopropyl alcohol) and draped in the supine position. The bulb, reservoir and pump were removed through a suprapubic incision. The incision was closed and the patient was again prepped with chlorhexidine and draped in the lithotomy position. An incision was made in the perineum overlying the sphincter cuff; however, when the electrocautery unit was activated, the drapes -wet with chlorhexidine -were ignited. It was quickly extinguished with sterile saline. At this point, the procedure was immediately aborted, the incision was closed and plastic surgery was consulted to assess the burns, while the patient was under general anesthetic.Assessment by the plastic surgeon rev...

Preoperative skin antisepsis in hand surgery: a nationwide survey

“…There is strong evidence to show the superiority of alcoholic CHG over any other skin antiseptic (Wade et al, in press), which could reasonably be generalized to hand surgery. However, the evidence concerning the risk of cutaneous reactions, chemical burns (Supradeeptha et al, 2013) and ignition fires (Vo and Bengezi, 2014) is of low-quality. Furthermore, while most show that the risks of adverse events are similar across CHG and povidone-iodine antiseptics, whether alcoholic or aqueous, there appears to be pervasive concern over the use of alcoholic CHG in hand surgery, which we believe are best addressed by a multicentre randomized trial.…”