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Patient Safety Tip of the Week

May 3, 2022   Iatrogenic Burns Again

 

 

Our first exposure to iatrogenic burns was in a patient who woke up after surgery with a burn on his abdomen that had the shape of a medical instrument. During the surgery a “flash” sterilized instrument was requested. The surgeon noted it was too hot to handle and placed it on the drapes covering the patient. It cooled off enough after several minutes to be used. But, obviously, the duration of exposure to the heated instrument was long enough to cause the burn to the patient.

 

In our June 1, 2010 “Iatrogenic Burns” we noted 3 key conditions that predispose patients to burns. They are either insensitive to pain/temperature, unresponsive, or unable to communicate. There may be some additional predisposing factors, too, like impaired ability for the vasculature to help dissipate heat from the skin. And, of course, you need a heat source. And the duration of exposure is important. Lesser degrees of heat may cause burns when the duration of exposure is longer.

 

A recent report in the Anesthesia Patient Safety Foundation Newsletter described two consecutive patients suffering thermal injuries to the upper extremity and chest after the use of a convective warming system (Janik 2022). The cases were performed sequentially in the same operating room, with the same personnel. Both patients underwent a laparoscopic robotic prostatectomy in the Trendelenberg position with the arms tucked. In both cases, a convective warming system was used in conjunction with an upper body warming blanket. The article shows the configurations used. The hose was then connected to the warming blanket at the blanket port connection near the left shoulder. Notably, in one of the cases the air manifold was inadvertently missing. (The air manifold is an “elbow” shaped plastic tube connected to the end of the warming hose, with several openings on the distal end designed to evenly disperse warm air over the patient.) The warming device was set to a temperature of 44° Celsius (high setting) throughout both cases. Intraoperatively the warming device appeared to function normally, and the patients were normothermic. But, in recovery, both patients were noted to have diffuse erythema on the left upper extremity and chest, in close proximity to the site of the blanket port connection and, on postoperative day one, blistering developed on the shoulder and chest of both patients.

 

The authors note that the pattern of injury suggests a focal area of overheating at the point where the hose connects to the warming blanket. They also suspected there may have been a problem with the “over temperature” alarm. The absence of the air manifold also likely resulted in the concentrated delivery of warmed air onto a small surface area of the patient.

 

Janik et al. note the difficulties and challenges in recognizing a developing thermal injury. They note that clinical signs may not be present until well after the injury has occurred and that the site is often inaccessible or covered by the warming blanket itself or the surgical drapes. They also note that the lighting in an operating room may be dimmed, making detection of subtle erythema challenging.

 

One of the warnings in the instructions for use of the convective warming system is “To prevent thermal injury, do not use the highest temperature setting when treating patients who have decreased sensation, are nonsensate, or have poor perfusion.” Of course, since these patients are under anesthesia, they fit the definition of a patient at-risk. Yet, because of the desire to avoid hypothermia, these devices are frequently used.

 

They also note the importance of several warnings in the operating instructions for the devices. “Always start therapy on the lowest non-ambient temperature setting to prevent thermal injury. Increase the temperature setting, if required, using core body temperature and cutaneous response of skin in contact with the convective warming blanket as indicators.” “…Observe cutaneous response at regular intervals to prevent thermal injury. If erythema or instability in vital signs is evident, decrease the temperature setting or discontinue use of the convective warming therapy.”

 

Following these cases, they issued the following recommendations to anesthesia team members:

·       Always confirm the presence of the air manifold component prior to connecting the hose to the warming blanket.

·       Start with the medium temperature setting (40° Celsius) unless otherwise indicated.

·       Use caution to avoid airflow restriction within the warming blanket.

 

A response from the manufacturer (Cabrera 2022) stressed “The hose nozzle MUST be connected to a … convective warming blanket. Do not treat patients with the hose alone. Thermal injury may occur.” We discussed burns related to warming blankets in detail in our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again”, in which we stressed the importance of avoiding “free hosing”. Cabrera also speculates that the extreme positions often used during robotic prostatectomies might have been a contributing factor and cautions that strict adherence to the operating instructions would be important in such cases.

 

We refer you back to our December 23, 2014 Patient Safety Tip of the Week “Iatrogenic Burns in the News Again” and an editorial accompanying the Janik article (Feldman 2022) for more detailed information on thermal injury related to warming blankets.

 

Ishikawa et al. (Ishikawa 2021) reported a case of a third-degree burn involving 5% of the total body surface area caused by off-label use of an infrared radiant heat lamp for bed-warming in a patient with severe accidental hypothermia. They caution that radiant heat lamps should never be used for rewarming of patients with hypothermia without careful observation. Note that we discussed burns related to fiberoptic light sources and halogen lamps in our March 2015 What's New in the Patient Safety World column “Another Source of Iatrogenic Burns”.

 

Andersen et al. did a review on iatrogenic burn injuries in an academic public hospital over a 15-year period (Andersen 2021). They found 122 patients who suffered iatrogenic burns, with fewer in 2013-2019 (2.9 ± 2.1 per year) compared to 2005-2012 (12.3 ±4.1 per year). Most (41%) of the injuries occurred on the general medical floors, followed by the operating room (33.6%), intensive care unit (17.2%), and long-term care facilities (8.2%). The most common etiology was by scald mechanism by hot liquid (23%), followed by device (21.3%), heat pack (15.6%), and electrocautery (14.8%). The liquids included soup, hot water, and coffee.

 

Device-related burns were associated with high flow nasal cannula, endovascular scope light, bipolar and coblator, drill guard, forced-air patient warming system, ultrasound assisted liposuction system, and endoscopic/laparoscopic light cords. Electrocautery devices alone made up 14.8% of iatrogenic burns.

 

Less common etiologies included food, defibrillator, radiation, curling iron, hot glue gun, cooking equipment, EEG pads, pulse oximetry sensor, and a cooling blanket. The most common location injured was the leg (15.6%), followed by the abdomen (12.3%), back (8.2%), and arm (7.4%). The frequent occurrence on the abdomen and legs was attributed to many spills occurring in sitting patients. Overall, burns were more often attributed to medical personnel rather than patients themselves.

 

While all categories of causes declined over the duration of the study, device-related burns especially declined. The authors felt this may be explained by increased awareness and handling of medical devices in the operating room, including health system implementation of the “time-out” procedure discussing fire risks prior to starting surgical procedures.

 

The authors had several recommendations. Temperature control of soups, hot water, coffee, and other solid foods should be achieved prior to serving or presenting these meals to patients. Care should especially be taken when serving young children, older adults, and people with disabilities who are at higher risk for serious injury from hot food and beverage scalds. They also note that increased communication about fire risk and roles of team members in the event of an operating room fire may help further decrease the incidence of burns sustained by patients within the operating room.

 

The problem of burns related to dietary spills was highlighted in a review by the Pennsylvania Patient Safety Authority (Field 2018) that we discussed in our June 5, 2018 Patient Safety Tip of the Week “Pennsylvania Patient Safety Authority on Iatrogenic Burns”.

 

Another unusual cause for iatrogenic burns was recently reported (Lewis 2020). Hot water immersion (HWI) is a method used for treating marine stings and marine envenomations (Atkinson 2006). Application of hot, but not scalding, water (42-45 °C) for 30-90 minutes or until the pain resolves, seems to be standard advice, though some patients may find such temperatures difficult to tolerate. Atkinson et al. recommend use the highest temperature that can be applied safely and that is tolerable. But there is danger of iatrogenic burns with HWT. Lewis et al. (Lewis 2020) found 9 cases of iatrogenic burns from use of HWT over a 5-year period that were referred to a State Adult Burn Service. All patients continued unsupervised HWI at home and sustained thermal injury to their feet. The authors recommend that, while heat application is an effective treatment for marine stings, further patient education is required following discharge from point of care. They recommend that first-aid treatment guidelines be updated to reflect that patients are not recommended to continue scalding water immersion at home. However, if patients wish to continue HWI, water temperature should be checked manually with a thermometer or with a nonstung limb and limited to 30 minutes immersion, with 30-minute skin recovery time between.

 

We discussed burns related to electrosurgical devices in our Patient Safety Tips of the Week for September 5, 2017 “Another Iatrogenic Burn” and July 28, 2020 “Electrosurgical Safety”. We noted that one of the most serious thermal injuries is that caused by electrocautery devices during abdominal or pelvic surgery, which is often unrecognized during the surgery. The thermal damage often leads to delayed tissue necrosis and subsequent leaks from bowel, ureter or other viscus. So, symptoms and signs often do not appear for several days.

 

Another device implicated in iatrogenic thermal injuries is the dental handpiece. See our October 5, 2010 Patient Safety Tip of the Week “More Iatrogenic Burns” for details.

 

And don’t forget the risk of burns and thermal injury related to metallic or ferromagnetic materials during MRI scanning. Burns can result when any object containing metallic or ferromagnetic material superheats during the scan. While most burns have occurred due to things like superficial EKG electrodes or coils, the risk of thermal injury has also been attributed to some unusual items: transdermal skin patches, tattoos, tags on breast implants, ingested toy magnets, and even metallic eyelashes (see our previous columns for April 2, 2019 “Unexpected Events During MRI” and September 2019 “New MRI Hazard: Magnetic Eyelashes”). But the COVID-19 pandemic led to a new culprit for MRI-related burns – face masks (see our January 2021 What's New in the Patient Safety World column “New MRI Risk: Face Masks”). The FDA issued a warning after receiving a report of a patient suffering facial burns from a face mask during MRI (FDA 2020). Some face masks and respirators contain metal parts or coatings. The FDA notes that metal parts, like nose pieces nose clips or wires, headband staples, nanoparticles (ultrafine particles), or antimicrobial coating that may contain metal (such as silver or copper), may become hot and burn the patient during an MRI. The FDA acknowledges that it may be appropriate for a patient to wear a face mask during an MRI exam, especially during the COVID-19 pandemic. But it is critical to ensure the face mask contains no metal.

 

It's worth repeating recommendations in our September 5, 2017 Patient Safety Tip of the Week “Another Iatrogenic Burn” that your organization should do to minimize the risks of iatrogenic burns:

 

And Cynthia Field’s recommendations from the PPSA review (Field 2018):

 

The PPSA Advisory by Field is an important contribution to the relatively scant literature on iatrogenic burns in healthcare, It especially draws attention to the risks of food and beverages that have largely been ignored in the past. We obviously need to pay more attention not only to the temperature of foods and beverages but also to the likelihood that they might be spilled onto the patient due to patient-related factors or environmental factors.

 

 

Our prior columns on iatrogenic burns:

 

 

References:

 

 

Janik LS, Lewandowski R. Thermal Injury After Use of a Convective Warming System. APSF Newsletter 2022; 37(1): 19-21

https://www.apsf.org/article/thermal-injury-after-use-of-a-convective-warming-system/

 

 

Cabrera JA. Convective Warming Systems – Maintaining Normothermia in the Operating Room. APSF Newsletter 2022; 37(1): 21-22

https://www.apsf.org/article/convective-warming-systems-maintaining-normothermia-in-the-operating-room/

 

 

Feldman J. Convection Warmers and Burn Injury – Still A Clear and Present Danger. APSF Newsletter 2022; 37(1): 23

https://www.apsf.org/article/convection-warmers-and-burn-injury-still-a-clear-and-present-danger/

 

 

Ishikawa K, Maeda T, Hayashi T, et al. Iatrogenic third-degree burn caused by off-label use of an infrared radiant heat lamp in a patient with accidental hypothermia. Burns Open 2021; 5(1): 21-24

https://www.sciencedirect.com/science/article/pii/S2468912220300547

 

 

Andersen ES, Powell LE, Marcaccini RL, Feldman MJ, Drake MD. A 15-Year Review of Iatrogenic Burn Injuries in an Academic Public Hospital. J Burn Care Res 2021; 42(5): 894-899

https://academic.oup.com/jbcr/article-abstract/42/5/894/6290181?redirectedFrom=fulltext&login=false

 

 

Field C. Hot Topic: Nonsurgical, Healthcare-Associated Burn Injuries. Pa Patient Saf Advis 2018; 15(1).

http://patientsafety.pa.gov/ADVISORIES/Pages/201803_BurnInjuries.aspx

 

 

Lewis CJ, Wood F, Goodwin-Walters A. Iatrogenic Thermal Burns Secondary to Marine Sting Treatment. J Burn Care Res. 2020 Jul 3;41(4):878-881

https://academic.oup.com/jbcr/article-abstract/41/4/878/5788260?redirectedFrom=fulltext&login=false

 

 

Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an effective treatment for marine envenomation? Emerg Med J. 2006; 23(7): 503-508

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2579537/

 

 

FDA (US Food and Drug Administration). Wear Face Masks with No Metal During MRI Exams: FDA Safety Communication. FDA 2020; December 7, 2020

https://www.fda.gov/medical-devices/safety-communications/wear-face-masks-no-metal-during-mri-exams-fda-safety-communication

 

 

 

 

 

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