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Patient Safety Tip of the Week
April 25, 2023
Joint
Commission: Beware Light Source Burns
In our many columns
on iatrogenic burns and surgical fires, we have only briefly mentioned fiber
optic cables as a heat source. Now Joint Commission has published a Quick
Safety issue on the dangers of fiber optic cables in producing burns in laparoscopic
or arthroscopic surgery (TJC
2023). Fiber optic cables
are used in the light sources for the scopes used in these procedures. More
than half of the fires/burns sentinel events reported to The Joint Commission
since 2019 were associated with surgical or invasive procedures, and nearly 15%
of those peri-procedural incidents were related to light sources.
The Joint Commission emphasizes that burns from these types
of light sources can go unnoticed by the surgical team because they typically
do not produce smoke or charring, even of surgical drapes.
Either of the two major components to the illumination
system, the light source and the light cable, are capable of producing heat.
The light sources themselves has safety mechanisms to minimize the heat
generated (heat filters and light source fans). Laparoscopic light cables
are available as fiberoptic or gel-filled. Gel-filled cables are capable of
transmitting 30% more light, but also more heat, and therefore they can be
potentially more hazardous.
Excess heat can occur if any of the heat minimizing devices
fail within the light source or if the light source or light cable is
defective. Also, use of different connectors or components may result in excess
heat.
Detached light cables resting against surgical drapes may
also lead to burns. This can happen without knowledge by the surgical team
because of the lack of smoke or fire. The patient, who is under anesthesia,
cannot feel pain so the exposure to the heat source may continue for some time
(remember: thermal injuries are a function of both temperature and duration of
exposure). Weve seen similar injuries when a flash sterilized retractor that
was too hot for the surgeon to handle was placed on the drapes over a patient.
In such cases there may be no evidence of burn on the drapes but burn of the patients
skin (and even deeper levels) may be extensive. In one case report (Chitnavis
2020), a full-thickness 1-cm burn occurred on a patients thigh related
to the fiber optic cables that had been rested on a paper drape overlying the
patients thigh. Examination of the drape revealed only a pinhole-sized
perforation with localized brown staining on the part that had covered the thigh.
The risk of thermal injury rises with the brightness of the
lamp used. But, as above, the duration of exposure is equally important.
In our September 5,
2017 Patient Safety Tip of the Week Another
Iatrogenic Burn we noted that
delayed complications may arise from thermal injuries related to
electrocautery devices during surgery. Such are well known to structures such
as bowel and ureters. Such injuries are often not recognized and result in
tissue necrosis and delayed manifestations of symptoms. It is certainly
conceivable that a thermal injury from light sources or cables could be capable
of the same.
Joint Commission recommends organizations
take the following actions to help prevent burns related to the use of these
scopes:
·
Educate all surgeons, including
physicians-in-training, who perform laparoscopic or arthroscopic procedures on
the importance of handling the scope safely.
·
Implement system changes to minimize the risk of
patient burns associated with laparoscopy and arthroscopy.
·
Label light sources with the following:
"Warning: High-intensity light sources and cables can ignite drapes and
other materials. Complete all cable connections before activating the light
source."
·
Do not turn on the light source before the cable
is connected to the scope; the end of the cable becomes hot and could ignite
dry combustibles.
·
If the cable is disconnected from the scope
during surgery, hold the cable end away from the drapes or place it on a moist
towel.
·
Keep illuminated light cords away from drapes,
patient's skin, personnel's skin, and any flammable material.
·
Connect the correct size light source to the
correct scope.
·
Inspect all instruments and equipment before use
to ensure the equipment is in good working order.
Many of those recommendations come from an article on a
thermal injury related to the distal tip of the laparoscope had been placed on
drapes over a patients thigh (Ball
2004).
Perhaps the other lesson here is that we probably should not
be using the drapes overlying a patient for temporary placement of any items.
If we are in the habit of placing instruments there, it is not surprising that
we might place a potential heat source there as well. It probably makes more
sense to hand such items to the scrub nurse or surgical tech to place on the
instrument tray.
Other light sources linked to iatrogenic burns have included
ultraviolet light therapy, the operating microscope, and even overhead halogen
lamps in the OR.
Dont forget light sources as potential ignition sources in
surgical fires. The 2008 ASA Practice Advisory for the Prevention and
Management of Operating Room Fires (ASA
2008) also mentions fiberoptic light cables as potential heat
sources in surgical fires.
Our prior columns on
iatrogenic burns:
·
March 2009 Risk
of Burns during MRI Scans from Transdermal Drug Patches
·
June 1, 2010 Iatrogenic
Burns
·
October 5, 2010 More
Iatrogenic Burns
· December 23, 2014 Iatrogenic Burns in the News Again
· March 2015 Another Source of Iatrogenic Burns
· September 5, 2017 Another
Iatrogenic Burn
· June 5, 2018 Pennsylvania
Patient Safety Authority on Iatrogenic Burns
· July 28, 2020 Electrosurgical Safety
· January 2021 New MRI Risk: Face Masks
· May 3, 2022 Iatrogenic Burns Again
· December 6, 2022 Rare Risk Defibrillator
Fires
Our prior columns on
surgical fires:
·
December 4, 2007 Surgical
Fires
·
April 29, 2008 ASA
Practice Advisory on Operating Room Fires
·
November 2009 ECRI:
Update to Surgical Fire Prevention
· January 2011 Surgical Fires Not Just in High-Risk Cases
· March 2011 APSF Fire Safety Video
· November 2011 FDA Initiative on Preventing Surgical Fires
·
December 13, 2011 Surgical
Fires Again
· April 24, 2012 Fire Hazard of Skin Preps Oxygen
· April 2013
Reminder: Hand Sanitizers Are Flammable
· June 25, 2013 Update on Surgical Fires
· October 1, 2013 Fuels and Oxygen in OR Fires
· August 12, 2014 Surgical Fires Back in the News
· December 16, 2014 More on Each Element of the Surgical Fire
Triad
· December 2015 Unique Ignition Sources in Surgical/OR Fires
· January 10, 2017 The
26-ml Applicator Strikes Again!
· January 9, 2018 More
on Fire Risk from Surgical Preps
· June 2018 ISMP
on Fire Risk from Skin Preps
· July 2018 FDA
on Surgical Fires
· September 11, 2018 Lessons
from a Surgical Fire
· May 7, 2019 Simulation Training for OR
Fires
· July 2019 Surgical Fire A New Risk
Factor
· July 28, 2020 Electrosurgical Safety
· July 2021 Unique Way to Rapidly
Identify Oxygen Flow
· November 30, 2021 Fire in the OR
· December 6, 2022 Rare Risk Defibrillator
Fires
References:
The Joint Commission. Quick Safety Issue 69: Preventing
light source-related burns from laparoscopy and arthroscopy. The Joint
Commission 2023; April 10, 2023
Ball K. Lap Burn. Agency for Healthcare Research and
Quality, PS Net. Oct. 1, 2004.
https://psnet.ahrq.gov/web-mm/lap-burn
Chitnavis J. Silent burn: The
hidden danger and effects of bright light from fibre-optic
cables in arthroscopic knee surgery. Journal of Surgical Case Reports 2020; 2020(4)
https://academic.oup.com/jscr/article/2020/4/rjaa068/5816682
ASA (American Society of Anesthesiologists). American
Society of Anesthesiologists Task Force on Operating Room Fires. Practice
advisory for the prevention and management of operating room fires. Anesthesiology
2008; (108): 786-801
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