|Year : 2013 | Volume
| Issue : 1 | Page : 40-43
Surgical site fire during cesarean section
Leena Goel, Greeshma Murdeshwar, Sidhesh Bharne
Department of Anesthesia, Goa Medical College, Bambolim, Goa, India
|Date of Web Publication||1-Jul-2013|
1501/3, Shiv-Kuteer, Rego-Bagh, P.O. Bambolim Complex, Goa - 403 202
Source of Support: None, Conflict of Interest: None
Electrocautery has become an indispensable tool in the operating room mainly, to achieve a bloodless surgical field. At the same time, the use of alcohol-based antiseptics, like spirit, is commonly used these days for skin preparation before surgery. However, it does carry several risks including fire burns, with the use of electrocautery in a field smeared with spirit. Here, we report a case of pregnant patient undergoing elective cesarean-section under spinal anesthesia who suffered 17% second degree-superficial partial thickness burns due to electrocautery where spirit was used for skin preparation resulting in circulatory shock managed by inducing general anesthesia. Perioperative management was uncomplicated and both mother and newborn were discharged without any untoward problem. This report highlights general safety issues relating to the risk of fire in all surgical patients and the preventive measures for such injury.
Keywords: Cesarean section, electrocautery fire, operation theatre, spirit
|How to cite this article:|
Goel L, Murdeshwar G, Bharne S. Surgical site fire during cesarean section. J Obstet Anaesth Crit Care 2013;3:40-3
| Introduction|| |
Fires in the operating suites, although considered rare events, are certainly one of the most frightening incidents and potentially result in significant morbidity and mortality.  In a recent analysis of the surgical fire cases, Emergency Care Research Institute's (ECRI), a federal Patient Safety Organisation by U.S. Department of Health and Human Services, reports that the most common ignition sources include electrosurgical equipment (68%) and laser equipment (13%); with the most common fire location being the airway (34%), head or face (28%), and elsewhere on or inside the patient (38%). An oxygen enriched atmosphere was a contributing factor in 74% of all cases.  The fuel for the fire may be the surgical drapes, prepping agents, or even human tissue itself. ,, We present an interesting case of surgical site fire in a patient undergoing elective cesarean section with ligation under spinal anesthesia and its subsequent management. This brief report is meant to create awareness among the surgeons and theatre staff regarding potential risk of iatrogenic burn injury due to electrocautery. It also briefly discusses the possible mechanisms and preventive measures for such injury.
| Case Report|| |
A 33-year-old, 60 kg, multigravida with 37 weeks of amenorrhea, was planned for elective cesarean section with ligation in view of grade 2 posterior placenta previa and two previous cesarean sections. She was a known case of bronchial asthma and was on treatment with formoterol rotahaler. Preoperative routine investigations were normal. Fifty mg of intravenous (IV) ranitidine and 10 mg of metoclopromide was given 30 minutes prior to induction for aspiration prophylaxis. Antibiotic prophylaxis was obtained with 1 gm of intravenous ceftriaxone. Monitoring of pulse rate, electrocardiography, oxygen saturation, respiratory rate, urine output, and non-invasive blood pressure began and continued throughout surgery. Patient was preloaded with 500 ml of Ringer's lactate solution. Spinal anesthesia was given in the sitting position with 1.8 cc of 0.5% heavy bupivacaine and 60 mcg of buprenorphine under strict asepsis after ensuring free flow of clear cerebrospinal fluid (CSF) with 25G spinal needle. The patient was kept supine with 15° left lateral tilt with the help of a wedge. Oxygen via polymask 3 L/min. was started. The abdomen was cleaned twice with povidone iodine followed by spirit as per hospital routine, sterile drapes were applied; pfannensteil incision was taken with scalpel and then rectus sheath incised. Thereafter, a monopolar blend cautery was used to secure hemostasis. As soon as the cautery was used, a loud noise was heard and flames were observed on both sides of the abdominal wall and thigh. The electrocautery was switched off, oxygen was immediately turned off and the drapes were removed. The fire was extinguished using a cotton towel and sterile saline. The fire lasted for 10-15 seconds and resulted in superficial burns on both sides of the abdominal wall and thigh. A call was immediately sent to the surgeons. The electrocautery was checked and found to be intact and properly functioning. On careful examination, it was observed that the prepped abdominal wall skin was still wet with the last coating of spirit which had not dried up completely. The residual spirit film on the skin had caught fire from the sparks of the cautery leading to the burns. Monitoring continued. The pulse rate was 120-130/min, blood pressure (BP) 80/60 mmHg and oxygen saturation (SpO 2 ) was 100%. Due to burns, the patient developed circulatory shock which was managed with ephedrine and fluid resuscitation was done with Ringer Lactate solution (by Parkland Formula). As a safety measure, the patient was wheeled into an adjacent operating room and surgery was resumed after swiftly painting and draping the surgical site again. A baby boy weighing 2.65 kg was delivered and cried at birth, with an Apgar score 8 and a score of 10 at 5 minutes. Twenty units of oxytocin were given in infusion. The patient was sedated with 2 mg of IV midazolam. After 5-6 minutes, it was realized that the placenta was adherent to the uterus and an obstetric hysterectomy was decided upon. In view of ongoing hemorrhage and hypotension pulse with 150-160/min, BP 60 mmHg systolic, it was decided to give general anesthesia. Rapid sequence induction was carried. The patient was preoxygenated with 100% oxygen for 5 minutes; anesthesia was induced with 100 mg of IV Ketamine and
75 mg of IV Succinylcholine. Trachea was intubated with No 7.5 oral Cuffed endotracheal tube. Lungs were ventilated with 50% O 2 and 50% N 2 O and 0.6-0.8% sevoflurane; 0.08 mg/kg of vecuronium and 100 mcg of IV fentanyl. End-tidal carbon dioxide (EtCO 2 ) was maintained around 36-40 mmHg. The patient had tachycardia of around 140-150/minute following induction, BP was maintained with systolic over 100/60 mmHg. The tachycardia settled to around 110/minute over the next 15 minutes. IV Hydrocortisone 100 mg, IV Deriphyllin was given. Arterial blood gases (ABG) was done towards the end of surgery showed metabolic acidosis of P H 7.20, P CO2 of 37mm of Hg, P O 2 of 223 mmHg, and 14 mEq/L HCO 3,
BE-12.6 mEq/L, SpO 2 99%. Bicarbonate correction was given. Intraoperating urine output was 500 ml. Blood loss was around 1.4 litres. She received a total of 2.5L of crystalloids, 500ml of hydroxyethyl starch (HES), and 2 units of whole blood. The patient was hemodynamically stable with a pulse rate of 105-110/minute, BP 110/70 mmHg, and SpO 2 98% at the end of surgery. The surgery lasted for 90 minutes. Patient was reversed with neostigmine (3 mg) and glycopyrrolate (0.6 mg).
On examination by surgeons, the patient was found to have sustained around 17% of second degree-superficial partial thickness burns (Right anterior thigh-2%, anterior abdominal wall-4%, left thigh-(3 + 4)%, and back-4%) as shown in [Figure 1]. Biofilm dressing (Collagen layering) was given for the burns. Patient was shifted to Intensive Care Unit for observation.
|Figure 1: Representation of burns sustained by patient, A: anterior view, B: Posterior view|
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| Discussion|| |
Consequences of a surgical fire can be fatal. Flammable inhalation of an anesthetic agent was responsible for many incidents in the past, but these are no longer available in many countries. Other causes of fire still exist in the operating rooms and reports of serious surgical fires and occasional fatal fires continue to be documented in literature. There are very few reported cases of fires caused by a leaking oxygen connection in operating room. , In other cases, surgical fires resulted next to airways. , For the rapid exothermic reaction known as fire, to occur, three ingredients are required namely fuel, oxidizer, and an ignition source.  These three elements can be modeled into a fire triangle and are normally prevalent in operating room settings. Understanding this fire triangle and how to properly manage its components can greatly reduce the risk of fire [Figure 2].
The common oxidizer in operating room are the gases such as oxygen and nitrous oxide which can support combustion.  During surgical procedures, anesthesia often requires delivering oxygen-enriched mixture above the 21% oxygen of room air to ensure proper oxygenation of the patient. An oxygen enriched atmosphere exists, whenever the oxygen concentration is above 21%. With increased oxygen, it is easy to ignite fire, which will burn faster, hotter, and will be more difficult to extinguish. 
Electrocautery has been in use since the late 1920's for control of bleeding  and is the most common ignition source in surgical fires. Electrocautery acts as the heat source, which can result in fire in the presence of highly inflammable fuels in oxygen-enriched atmosphere. The use of electrocautery is also accompanied with certain other hazards like burn injury, electrocution, operating room fire, inhalation of diathermy smoke, and gene mutation not only to the patient, but also to the operating surgeon and theatre staff. , Lasers and fiber optic light sources are the other most common sources of ignition.
The various possible fuel sources are in or on a person (hair, tissue, and gastrointestinal tract gases), prepping agents (alcohol, detergents, and tincture), dressings (Gauge, Sponge, and petroleum-based ointments), linen (surgical drapes, gowns, and equipments covers), equipment used (endotracheal tubes, masks, gloves, and Blood pressure cuffs). Therefore, continuous awareness about presence and removal of these potential fuels is the most reasonable and efficacious approach. 
In critical situations, oxygen-rich ventilation is often needed. The use of 100% oxygen during episodes of hypoxemia is a corner stone of anesthetic management. Additionally, in cases of open airways (e.g. tracheal, carinal, and bronchial resections), a continuous positive airway pressure is often applied with preferred air-mixture of 100% oxygen to improve oxygenation.  We must realize that a high oxygen concentration in closed spaces may increase a risk of fire. ,, Electrocautory or laser may have led increased the temperature near or above ignition temperature. , Aly et al.,  reported a fire caused by electrocautery when it entered in to trachea, probably due to high pressure stream of oxygen passing over the hot electrocautery tip and hot charred tissue. Casey et al.,  reported an intratracheal fire ignited by neodymium-doped yttrium aluminum garnet (Nd-YAG) laser during treatment of tracheal stenosis.
In the present case, which was started under spinal anesthesia, burns occurred before birth of the baby as soon electrocautery was brought in surgical field for hemostasis. The electrocautery acted as the heat source, inflammable material was residual spirit solution left after cleaning and draping which was not dried completely, ignited due to sparks generated from the monopolar cautery, resulting in a fire. Further, the skin prepping solution used might have dribbled from the abdominal wall (surgical site) and got pooled at the sides of patient's thighs resulting in burn injuries (17% of second degree-superficial partial thickness). Due to this, she had circulatory shock. Further, the placenta was adherent to the uterus and continuing hemorrhage worsened circulatory shock. Therefore, general anesthesia was planned to stabilize the vitals.
One should be cautious while using alcohol-based solutions, which can be ignited with sparks from the electrocautery. This can be avoided by not allowing the solutions to pool around the site of surgery while prepping and allowing them to dry or be dried with a surgical swab prior to the start of any surgical procedure. Care should be taken not to drape the wet prepped part which may result in soakage of drapes. Other strategies recommended are not to use alcohol-based skin antiseptics in operating rooms, using fire retardant surgical drapes, installing over-current protection devices, proper electrical equipment, and minimizing inflammable conditions by avoiding nitrous-oxide and using the lowest required concentration of inspired oxygen.  Other general safety measures recommended to prevent occurrence of operation room fire includes to keep the electric cautery tip in a holster when it is not being used, use of Bipolar not monopolar electrocautery for coagulation, use water soluble substances such as K-Y Jelly instead of petroleum-based ointments, and to know the location of all fire extinguishers and alarms, pull stations, and fire exists. 
Therefore, it can be concluded that awareness and vigilance are of vital importance in minimizing and preventing catastrophic events such as a surgical fire as highlighted in this particular case and further to avoid possible medico legal complication.
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[Figure 1], [Figure 2]