Diathermy and alcohol skin preparations - a potential disastrous mix

Review, analysis, and education of antiseptic related ocular injury in the surgical settings

Preoperative skin antiseptic preparation is the gold standard for prevention of surgical infection. However, improper use of antiseptics may lead to severe ocular damage. Currently, the most common surgical antiseptics can be divided into aqueous-based and alcohol-based disinfectants, with chlorhexidine and iodine/iodophors being the two major components. Chlorhexidine has a persistent antimicrobial effect and is resistant to neutralization by blood or organic products in surgical wounds. Nevertheless, due to its toxicity to the ears, meninges, and eyes, application of chlorhexidine should be prohibited in these surgical fields. Iodine/iodophor is better tolerated by the ocular surface and is the recommended antiseptic for ophthalmic or head and neck surgeries close to the periocular area. Alcohol is less pricey and has a rapid antiseptic effect, though its desiccating effect and flammability restrict the use in mucosal or laser surgeries. The single or combined use of these antiseptics may inadvertently induce severe ocular damage, especially during time-consuming head and neck surgeries with prone, hyperextension, or lateral tilt positions, or surgeries under general anesthesia. Apart from the choice of antiseptics, appropriate selection and attachment of bio-occlusive dressings are key to avoiding antiseptic-related ocular injuries. In this review, we provided a comprehensive summary of the characteristics of antiseptics used in surgical settings and the possible mechanisms and outcomes of antiseptic-related ocular injuries. The prevention, diagnosis, and acute management of these complications were also discussed.

Intraoperative Fire Risk: Evaluating the 3-Minute Wait After Chlorhexidine-Alcohol Antiseptic Scrub

OBJECTIVE

We sought to determine the flammability of the skin at different time intervals after chlorhexidine-alcohol antiseptic scrub application, to provide evidence for hospital protocols recommending a 3-minute drying time.

METHODS

Swine feet, which contain the skin, subcutaneous tissue, muscle, and bone, were used for an experimental cohort. The skin was prepped with chlorhexidine-alcohol solution. Attempted ignition with an open flame was then performed in the presence of visible pooling, as well as at time points 0, 30, 60, and 90 seconds after application, in addition to when the skin appeared visibly dry. Six samples were used for each time point tested.

RESULTS

At time 0 seconds and with gross pooling, ignition was achieved with all samples tested. However, at 30 seconds, only 2 of 6 samples were ignited (which appeared wet). No samples after 60 or 90 seconds were flammable. Samples appeared dry after an average of 40.5 seconds and were not able to ignite.

CONCLUSIONS

Although our findings do support that a chlorhexidine-alcohol antiseptic scrub is a potentially flammable surgical prep solution, we found little support for a 3-minute time cutoff. More importantly, the presence of pooling and persistently wet appearing prep is a more important fire risk than the time elapsed after prep application. Caution should be used when working with any flammable solution, and efforts to minimize chemical burns and combustion should be sought based on evidence.

Efficacy of application of an alcohol-based antiseptic hand rub or a 2% chlorhexidine gluconate scrub for immediate reduction of the bacterial population on the skin of dogs

OBJECTIVE To compare the efficacy of application of an alcohol-based antiseptic (80% ethyl alcohol) hand rub (ABAHR) with that of a 2% chlorhexidine gluconate scrub (CGS2) for immediate reduction of the bacterial population on the skin of dogs. ANIMALS 50 client-owned dogs with no evidence of skin disease. PROCEDURES On each dog, 2 areas of hair on the ventral aspect of the abdomen were clipped with a No. 40 blade and cleared of debris. A direct contact plate holding tryptic soy agar with polysorbate 80 and lecithin was gently pressed (for 2 seconds) on each skin site (preapplication sample). The CGS2 and ABAHR were each aseptically applied to 1 skin site on each dog. A direct contact plate was subsequently applied to each site in a similar manner (postapplication sample). All plates were cultured, and bacterial isolates were identified and quantified by the number of CFUs per plate. RESULTS Application of the CGS2 and ABAHR significantly decreased skin bacterial colony counts, compared with findings for preapplication samples. The number of CFUs per plate or postapplication percentage reduction in CFUs per plate did not differ between treatments. There were no adverse skin reactions associated with either application. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that applications of ABAHR and CGS2 were equally effective at immediately reducing the bacterial population on the skin of dogs, and there was no significant difference in percentage reduction in colony counts between the 2 applications.

Operating room fires in periocular surgery

AIM

A survey of ophthalmic plastic and reconstructive surgeons as well as seven-year data regarding claims made to the Ophthalmic Mutual Insurance Company (OMIC) is used to discuss operating room fires in periocular surgery.

METHODS

A retrospective review of all closed claim operating room fires submitted to OMIC was performed. A survey soliciting personal experiences with operating room fires was distributed to all American Society of Oculoplastic and Reconstructive Surgeons.

RESULTS

Over the last 2 decades, OMIC managed 7 lawsuits resulting from an operating room fire during periocular surgery. The mean settlement per lawsuit was $145,285 (range $10,000-474,994). All six patients suffered burns to the face, and three required admission to a burn unit. One hundred and sixty-eight surgeons participated in the online survey. Approximately 44% of survey respondents have experienced at least one operating room fire. Supplemental oxygen was administered in 88% of these cases. Most surgical fires reported occurred in a hospital-based operating room (59%) under monitored anesthesia care (79%). Monopolar cautery (41%) and thermal, high-temperature cautery (41%) were most commonly reported as the inciting agents. Almost half of the patients involved in a surgical fire experienced a complication from the fire (48%). Sixty-nine percent of hospital operating rooms and 66% of ambulatory surgery centers maintain an operating room fire prevention policy.

CONCLUSIONS

An intraoperative fire can be costly for both the patient and the surgeon. Ophthalmic surgeons operate in an oxygen rich and therefore flammable environment. Proactive measures can be undertaken to reduce the incidence of surgical fires periocular surgery; however, a fire can occur at any time and the entire operating room team must be constantly vigilant to prevent and manage operating room fires.

Surgical fire caused by electrocautery in ambient air

Introduction:

The fire triangle comprises the ignition source, fuel and oxidizer which is necessary for the initiation of fire. Most surgical fires occur in an oxygen-enriched environment. We report a case of surgical fire in ambient air where an alcohol-based antiseptic was involved.

Case report:

A 20-year-old male diagnosed with left pleural empyema and respiratory failure, requiring emergent intubation and respiratory support, was brought into the operating theatre for decortication of the left lung. Shortly after induction, the patient desaturated despite 100% oxygen and lung recruitment manoeuvres. The surgical team decided to insert a chest tube emergently to drain the empyema to improve respiratory function. A non-functioning drainage catheter that was in situ was removed and placed on the operating table beside the patient. Skin was prepared using chlorhexidine gluconate 0.5% w/v in methylated spirit solution and iodine. Soon after, cotton drapes were used to cover the patient. After the initial incision for chest tube insertion, electrocautery was introduced. Smoke and a smell of something burning was immediately noted by the surgical team. The drapes were removed and the drainage catheter with a burnt tip was discovered beside the patient. The patient suffered second degree burns to his chest wall.

Conclusion:

Although it is more common for surgical fires to occur in an oxygen-enriched environment, this case highlights that without adequate precautions they can also occur in ambient air. Recognition that standard anaesthetic and surgical equipment can act as sources of fuel and vigilance for the circumstances that complete the fire triangle are key to the prevention of surgical fires.

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

Ignition of chlorhexidine by an electrocautery unit is rare but can have devastating consequences for the patient and the surgeon. A case involving a 77-year-old man who underwent removal of an indwelling artificial urethral sphincter is presented. The chlorhexidine was ignited when the urologist activated the electrocautery unit, causing third-degree burns to the patient. A plastic surgeon treated the burns with surgical debridement and split-thickness skin grafting. A systematic review of the literature was performed with best practice recommendations. To the authors' knowledge, the present case is the ninth such case reported.

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

Ignition of chlorhexidine by an electrocautery unit is rare but can have devastating consequences for the patient and the surgeon. A case involving a 77-year-old man who underwent removal of an indwelling artificial urethral sphincter is presented. The chlorhexidine was ignited when the urologist activated the electrocautery unit, causing third-degree burns to the patient. A plastic surgeon treated the burns with surgical debridement and split-thickness skin grafting. A systematic review of the literature was performed with best practice recommendations. To the authors' knowledge, the present case is the ninth such case reported.

Flaming alcoholic drinks: flirting with danger

Alcohol-related burn injuries carry significant mortality and morbidity rates. Flaming alcoholic beverages served in trendy bars and clubs are becoming increasingly popular. The dangers associated with an ignited alcoholic drink are often underestimated by party goers whose risk assessment ability is already impaired by heavy alcohol consumption. The authors present two cases demonstrating the varied severity of burn injuries associated with flaming alcoholic drinks, and their clinical management. Consumption of flaming alcoholic drinks poses potential risks for burn injuries. Further support is required to enable national and local agencies to implement effective interventions in drinking environments.

Risco do uso do eletrocautério em pacientes portadores de adornos metálicos

INTRODUÇÃO: A eletrocirurgia é tecnologia conhecida há longo tempo que, atualmente, tem adquirido cada vez mais destaque. Apesar disso, ainda apresenta vários riscos quanto à sua utilização. Várias lesões podem ser causadas por eletrocautérios, sendo as queimaduras a complicação mais frequente. Nem sempre existe a cooperção do paciente frente a medidas preventivas. MÉTODO: Revisão da literatura pertinente em função de questionamento jurídico de paciente que se negou a retirar seus ornamentos no início de procedimento cirúrgico, já estando ela na sala de operações. CONCLUSÃO: É essencial o conhecimento dos fundamentos da eletrocirurgia, seu uso correto, equipamento seguro, monitoramento constante e investigação imediata diante de quaisquer suspeitas, para minimizar o risco de acidentes em paciente com adornos metálicos, e a cooperação do paciente na obediência das medidas preventivas de acidentes deve ser obrigatória.

Crisis in the operating room: fires, explosions and electrical accidents

Fires, explosions and electrical accidents in the operating theater are rare events, but are devastating in terms of structural damage to the equipment in theaters and to human lives. While various circumstances lead to these troubles, we can avoid and manage them by learning from the instructive cases accumulated so far. We describe operating room crises such as fires, explosions and electrical breakdowns, and discuss causes and countermeasures.

Chlorhexidine - Pharmacology and Clinical Applications

chlorhexidine is a widely used skin antisepsis preparation and is an ingredient in toothpaste and mouthwash. It is an especially effective antiseptic when combined with alcohol. Its antimicrobial effects persist because it is binds strongly to proteins in the skin and mucosa, making it an effective antiseptic ingredient for handwashing, skin preparation for surgery and the placement of intravascular access. Catheters impregnated with chlorhexidine and antimicrobial agents can reduce the incidence of catheter-related bloodstream infections. Contact dermatitis related to chlorhexidine is not common in health care workers. The incidence of contact dermatitis to chlorhexidine in atopic patients is approximately 2.5 to 5.4%. Acute hypersensitivity reactions to chlorhexidine are often not recognised and therefore may be underreported. This review discusses the pharmacology, microbiology, clinical applications and adverse effects of chlorhexidine.

Surgical fires and alcohol‐based skin preparations

Alcohol-based skin preparations are known to be flammable. Their use continues despite a significant level of risk. Two cases of fires resulting from ignition of pooled alcohol-based skin preparations are reported. Both cases were associated with use of electrocautery for haemostasis. The literature is reviewed and recommendations are made to reduce the risk of further similar occurrences.