by Elizabeth Douglas
Las Vegas–The cause of malpractice claims for burn injuries in the operating room has changed, compared with 10 years ago. In the last decade, the major cause of burn claims in the American Society of Anesthesiologists (ASA) Closed Claims Project database has been fires and burns that resulted from the use of electrocautery, Karen B. Domino, MD, MPH, reported at the 2004 annual meeting of the American Society of Anesthesiologists. “The cause of burns has shifted from primarily the inappropriate use of I.V. bags to warm a patient to burns that are induced by electrocautery,” she told Anesthesiology News.
Indeed, in response to the growing threat of patient injury from fires, the ASA Committee on Practice Parameters is currently formulating a “Practice Alert for Perioperative Management of Operating Room Fires.”
In a 1994 analysis of the Closed Claims database (Anesthesiology 1994;80:806-810), 64% of burns were from I.V. bags or bottles that were used to warm the patient externally. A decade later, only 12% of burns were associated with I.V. bags or bottles, while 56% were due to cautery burns and fires.
The largest single cause of burn claims since 1994 was cautery fires, at 44%. The majority of these occurred during plastic surgery cases under monitored anesthesia care and involved burns on the face or in the airway.
For an electrocautery or laser fire to occur, all three components of the “fire triad” must be present, said Dr. Domino. Steven J. Barker, MD, PhD, and colleagues defined this triad as consisting of an ignition source (e.g., electrocautery), fuel (e.g., an alcohol-based prep solution) and an oxidizer (e.g., supplemental oxygen) (Anesth Analg. 2001;93:960-965). When all three elements are in one place, they “end up causing fire,” Dr. Domino said in an interview. Dr. Barker is Department Head, Anesthesiology, University of Arizona Health Science Center, Tucson.
Burns from cautery fires should be preventable, noted Frederick W. Cheney, MD. The use of supplemental oxygen during surgery of the head and neck in awake patients can be reduced or eliminated, he advised. If oxygen is required, “systemic oxygenation can be monitored with pulse oximetry and supplemental oxygen administered only if necessary and in the lowest concentrations needed. Another factor is an alcohol-based prep solution which could easily be replaced,” Dr. Cheney told Anesthesiology News.
Drapes around the face may trap oxygen so the area becomes oxygen-rich. If supplemental oxygen is used, Dr. Domino recommended arranging the drapes so that oxygen does not build up at the operative site. Also, supplemental oxygen may be discontinued a few minutes before the surgeon uses the electrocautery or laser.
Finally, Dr. Domino recommended avoiding prep solutions containing alcohol. If they are used, she advised waiting until the solution is “totally” vaporized before using a cautery. She cautioned that a new prep solution that has become popular, Duraprep (3M Healthcare), contains alcohol.
Dr. Barker concluded that the use of a flammable prep solution (i.e., one containing alcohol) for surgery in the head-neck region in patients who are not intubated is particularly dangerous. These patients are generally given supplemental oxygen by face mask underneath the surgical drapes, resulting in a combination of flammable vapors from the prep solution in a high-oxygen environment. A spark from the electrocautery completes the triad, and the result can be disastrous, he said in an interview with Anesthesiology News. To avoid this scenario, some hospitals have banned the use of alcohol-based prep solutions for surgery in the head-neck region.
Burn Claims Analysis
The study conclusions are drawn from the ongoing ASA Closed Claims Project database. The database is a collection of case summaries prepared from the closed claims files of 35 professional liability insurance companies in the United States. These companies insure about half of all practicing U.S. anesthesiologists.
The investigators analyzed 145 burn injury claims among 6,449 total claims in the database. Burns represented 2.2% of total claims, compared to 1.8% in the 1994 analysis. Fifty-four burn claims occurred before 1994, and 91 after. Injury data were compared using the chi square test or Fisher’s exact test, with Bonferroni corrections as needed. Payments were compared using the Kolmogorov-Smirnov test. P less than 0.01 was considered significant.
Anesthesiologists should not externally apply warmed I.V. bags or bottles to the patient to maintain normothermia, said Dr. Domino. “They are not effective and may cause a burn,” she said. The best way to avoid burns from regulated warming devices is to follow manufacturers’ recommendations. “Don’t improvise,” she advised. Warming devices should not be applied to the lower extremities in patients who have compromised circulation, such as those with vascular disease, or those undergoing major vascular surgery.
Severity and Payment
Payment occurred more frequently for burn claims than for claims overall (72% vs. 52%), but dollar amounts were lower (median $48,260 vs. $175,800, 1999 dollars) (Table, page 6).
Smaller payments for burn injuries reflected their lower severity, the investigators suggested; 93% of burn injuries were temporary or nondisabling compared to 50% in the database overall.
Burns from laser airway fires were rare (n=3; 2% of burn claims), but they were the most severe and resulted in the highest payments (median $167,500). Payment was made for 100% of airway fires compared to 82% for warming device claims and 80% for claims involving I.V. bags or bottles. Median payment for cautery burns was $80,375, while the median for cautery fires was $71,375.
There was only one death in the database, which occurred subsequent to an airway fire during laser vaporization of tracheal stenosis in which 100% oxygen was used.
There were nine additional cases that involved permanent or disabling injuries. Two occurred in children. One involved an airway fire during a tonsillectomy. The second child sustained an abdominal burn from a warming blanket and subsequently had a cardiac arrest.
In addition, there were two airway fires that caused permanent disabling injuries; both fires involved prolonged intubation in the intensive care unit and resulted in lifelong disability. There were four permanent, disabling burns attributed to warming blankets. Three occurred during vascular surgery.
Co-workers with Drs. Domino and Cheney were Kimberly A. Kressin, MD, Karen L. Posner, PhD, and Lorri A. Lee, MD.
Based on a poster presentation (Abstract 1282) at the 2004 annual meeting of the American Society of Anesthesiologists, articles in Anesthesiology (1994; 80:806-810) and Anesthesia & Analgesia (2001; 93:960-965), and interviews with Karen B. Domino, MD, MPH, Frederick W. Cheney, MD, and Steven J. Barker, MD, PhD.