April 24, 2012
Fire Hazard of Skin Preps, Oxygen
The UK National Patient Safety Agency (NPSA) has recently released a “signal” regarding the risk of alcohol-based skin preps in contributing to surgical fires (NPSA 2012). This Signal addresses the risk of a patient being burned when diathermy is used in the presence of alcohol-based skin preparation solutions.
They identified 23 incidents of fire in which the involvement of skin prep was clearly stated and another ten incidents where diathermy was used and the involvement of skin prep was likely but not stated. Four of these incidents were reported as resulting in death or severe harm to the patient.
Key contributing factors found include:
• insufficient time for drying of the skin prep solutions before commencement of surgery
• pooling of the skin preparations
They cite recommendations in the guidance in The Standards and Recommendation for Safe Perioperative Practice (2011) fromwhich state: “Alcoholic skin preparations and other alcohol-based or aerosol products may ignite if they come into contact with sparks from electrosurgery. This can be avoided by not allowing alcoholic prep 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 (MDA 2000). The practitioner should also be aware of the risk that the prep solution will not be able to evaporate if covered with impervious single use drapes.”
A similar surgical fire occurred during a C-section in New Zealand. A report of that fire (Waitemata District Health Board 2002) has a very good discussion on the skin preps and their risk for fire. They pose three key questions:
1) Is it necessary to use alcohol in the skin preps for the specific procedure being performed?
2) If so, what methods/practices could be used to make it safer?
3) What volume of solution is required to make an effective skin preparation and what is the best form of application?
Note also that in our January 2011 What’s New in the Patient Safety World column “Surgical Fires Not Just in High-Risk Cases” pooling of the alcohol-based skin prep under the buttocks of a patient having a C-section in Israel was a key element in producing a surgical fire.
In both the New Zealand case and the Israeli case, the volume of skin prep used was an issue. Common to several of the reports of fires (including an example given in the UK NPSA “signal”), additional skin prep was applied after the initial prep. The volume is important because the amount of run-off is important. It is the run-off that often saturates drapes, etc. and ultimately serves as the fuel for the fire.
The importance of the applicator becomes apparent when we discuss the volume issue. In New Zealand they had, over time, switched from using a forceps to the sponge applicator because the latter allowed for speedier application of the skin prep. But the amount of run-off is considerably higher with the sponge applicator. We’ve seen a similar case occur shortly after a hospital changed from a 10.5 ml sponge applicator to the same prep with a 26 ml applicator.
Allowing sufficient time for the skin prep to dry and any alcohol vapors to disperse is critical. We know of some hospitals that use a timer to ensure that sufficient time is allowed for that drying to occur.
In New Zealand the hospital(s) abandoned the use of alcohol-based skin preps for ob/gyn procedures, moving instead to aqueous-based skin preps, especially in view of lack of a clearcut difference in surgical site infections by skin prep type for such ob/gyn procedures.
The New Zealand report also makes mention that the colorless nature of some of the alcohol-based skin preps may make it difficult to identify run-off. Apparently manufacturers had, over time, removed the coloring from these preps because of allergies. The investigators of the surgical fire noted that having some coloring would likely help staff identify any run-off. Tinted preparations are commonly used in the US.
The debate over which skin prep is the safest and most effective is not yet fully answered. While there is some data suggesting that alcohol-based chlorhexidine preparations may be superior to povidone-iodine in preventing SSI’s (Keller 2011), the fire risk associated with the alcohol-based preps must be considered as well. Particularly if the surgery is one in which the risk of SSI is generally low, it may make more sense to use povidone-iodine. Remember, we are dealing with relatively low risks in either case (but you sure don’t want either an SSI or a surgical fire).
Oxygen is the other key factor in many OR fires. In our December 13, 2011 “Surgical Fires Again” we noted two cases of surgical fires occurring in patients having minor surgical procedures on the head. Though the surgical prep does not appear to have been a contributing factor, the report of the investigation done on one of those surgical fires provides some other insights (Chasteen 2012). In this case, a young woman was having sebaceous cysts removed from the back of her head. The procedure was being done with her in a prone position. Moderate sedation was used with fentanyl, versed and ketamine intravenously. Oxygen was being delivered via a face mask at 10 L/min. The skin was prepped with betadine and apparently no alcohol-based skin prep was used. Upon the third activation of the Bovie a flash fire was noted from under the surgical drape covering the operative site on her head, followed by a “swoosh” and flames between the patient’s oxygen mask and her face. The patient suffered first and second degree burns of the face in the area under the mask and a single spot of a third degree burn on the exterior portion of a nostril. Photos of the charred mask appear in the report.
The investigation included interviews of all parties, collection of multiple items from the OR, review of the literature, and two experiments to try to recreate the circumstances (which did not result in fire). They discuss multiple theoretical scenarios that might have led to this surgical fire but dismiss most of them as improbable.
Probably most important is the discussion of the type of face mask used to administer oxygen. This was a rather loosely-fitting mask that allowed oxygen to escape through holes in the connector and sides and edges of the mask. It was apparently not the oxygen delivery method usually used in this OR and was apparently chosen because they were concerned that nasal prongs might become dislodged with her in the prone position.
Though in their recommendations they suggest against use of such a face mask and recommend use of room air unless necessary to use a higher concentration of oxygen, they don’t go into much detail. But those are the key points in this case. In our November 2009 What’s New in the Patient Safety World column “ECRI: Update to Surgical Fire Prevention” we discussed the 2009 ECRI update of its “New Clinical Guide to Surgical Fire Prevention”. The 2009 key change in clinical practice is discontinuing the open delivery of 100% oxygen during procedures done during sedation and where high concentrations of oxygen are needed the airway should be secured. They discuss ways to minimize the concentration of oxygen being used in a variety of scenarios. The APSF recently highlighted the importance of this in their Winter 2012 newsletter (APSF 2012) and provide an algorithm regarding use of oxygen. Perhaps the most important question to ask is: does the patient need supplemental oxygen? Most probably do not, in which case room air should be used. But if greater than 30% oxygen concentration is needed to maintain oxygenation, the airway should be secured with an endotracheal tube or supraglottic device. In cases where supplemental oxygen at less than 30% is medically necessary they recommend use of a delivery device such as a blender or common gas outlet to maintain concentration below 30%.
However, just as important is timely communication between the surgeon and the anesthesiologist. As the surgeon plans to use the Bovie (or other potential heat source) he/she needs to let the anesthesiologist know and then the oxygen flow may be reduced or stopped temporarily. A period of time for allowing dispersal of oxygen should then pass before the surgeon uses the Bovie.
Please also see our prior columns on surgical fires:
Patient Safety Tips of the Week:
· December 4, 2007 “Surgical Fires”
· April 29, 2008 “ASA Practice Advisory on Operating Room Fires”
· December 13, 2011 “Surgical Fires Again”
What’s New in the Patient Safety World columns:
· 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”
NPSA (UK). Risk of skin-prep related fire in operating theatres | Signal. 28 February 2012
Nishihara Y, Kajiura T, Yokota K, Kobayashi H, Okubo T. A comparative clinical study focusing on the antimicrobial efficacies of chlorhexidine gluconate alcohol for patient skin preparations. J Infus Nurs 2012; 35: 44-50
Keller DM. Preoperative Chlorhexidine Wash Superior to Povidone-Iodine.
Medscape News. September 30, 2011
51st Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC): Abstract K-480. Presented September 18, 2011
Waitemata District Health Board. Report into the Operating Theatre Fire Accident 17 August 2002. Final Report. 29 September 2002
Chasteen CE, Traylor J, Fiedor K, et al. A Report On Potential Causes Of A Fire In An Operating Room At North Okaloosa Medical Center. November 29, 2011
ECRI Institute. New clinical guide to surgical fire prevention. Health Devices.
ECRI Institute. October 2009: 314-332 (www.ecri.org).
Stoelting RK, Feldman JM, Cowles CE, Bruley ME. Surgical Fire Injuries Continue to Occur. Prevention May Require More Cautious Use of Oxygen. Anesthesia Patient Safety Foundation (APSF). APSF Newsletter 2012; 26(3): 41,43 Winter 2012