TY - JOUR
AU - PhD, Norbert Pallua, MD,
AB - Abstract The purpose of this report is to increase awareness of intraoperative burns during standard procedures, to discuss their possible causes and warning signs and to provide recommendations for prevention and procedures to follow after their occurrence. A total of 19 patients associated with intraoperative burn accidents were treated surgically and analyzed after a mean follow-up of 5 ± 3.5 months. Review included retrospective patient chart analysis, clinical examination, and technical device and equipment testing. A total of 15 patients recently underwent cardiac surgery, and 4 pediatric patients recovered after standard surgical procedures. A total of 15 patients had superficial and 4 presented with deep dermal or full-thickness burns. The average injured TBSA was 2.1 ± 1% (range, 0.5–4%). Delay between primary surgery and consultation of plastic surgeons was 4.5 ± 3.4 days. A total of 44% required surgery, including débridment, skin grafting or musculocutaneous gluteus maximus flaps, and the remaining patients were treated conservatively. Successful durable soft-tissue coverage of the burn region was achieved in 18 patients, and 1 patient died after a course of pneumonia. Technical analysis demonstrated one malfunctioning electrosurgical device, one incorrect positioned neutral electrode, three incidents occurred after moisture under the negative electrode, eight burns occurred during surgery while fluid or blood created alternate current pathways, five accidents were chemical burns after skin preparation with Betadine solution, and in one case, the cause was not clear. The surgical team should pay more attention to the probability of burns during surgery. Early patient examination and immediate involvement of plastic and burn surgeons may prevent further complications or ease handling after the occurrence. Accidental burn injury during surgery may occur as a result of electrical current, thermal injury, chemical irritation, and mechanical stress during surgery with permanent nerve, muscle, or skin damage occurring to the patient.1,2 These types of injuries tend to be ignored or treated with delay when seeking the involvement of specialized colleagues such as burn and plastic surgeons. Although incident rates are low, individual accidents tend to be fairly catastrophic and traumatic to both the patient and the team of surgeons. These unexpected accidents result not only in psychological trauma to the patient but also in the prolongation of hospitalization and in possible disruption of the doctor-patient relationship.3 The literature has proven to be sparse in terms of reference; here, we report 19 severe cases of intraoperative burns during surgery, including 4 pediatric patients, all of whom were treated and reviewed in our burn center. The purpose of this report is to increase awareness of the possibility to burns during surgery and to discuss the causes, warning signs, and methods that may reduce their occurrence. Finally, recommendations for prevention and procedures to follow if a burn incident occurs will be described. PATIENTS AND METHODS During a period between May 2002 and March 2005, 19 patients (10 female, 9 male) with burn accidents during surgery were treated in our burn center at the University-Hospital Aachen. The mean age in the adult group (n = 15) was 68.5 ± 15.4 years (range, 21–75 years). Four pediatric patients averaged 4.7 ± 5.4 years (range, 5 days–12 years). Permission to review the patient charts and describe the incidents and clinical cases and clinical patient follow-up was obtained under the condition of anonymity (in respect to patient identity, primary involved institution and surgical team, and internal or external referral to our burn unit) from colleagues who considered it important to share incidents from their experience to help others to avoid future accidents. Fifteen patients recently underwent cardiac surgery, including seven patients following valve replacement surgery (mitral valve, three patients, and aortic valve, four patients) and eight patients who underwent coronary artery bypass grafting. Extracorporeal circulation was used in 12 patients during cardiac surgery. There were no emergency situations, extensive hypothermic conditions, or extensive blood loss during any reported cardiac surgery procedures. Two patients suffered from type I diabetes, and one patient suffered from type II diabetes. One patient was diagnosed with arterial occlusive disease of the abdominal aorta. Four pediatric patients were treated after standard surgical procedures (such as duodenal stenosis, ostium primum defect, inguinal hernia), including one patient treated under ambulatory conditions (otoplasty) who was referred secondarily on the second postoperative day. A total of 17 patients suffered from intraoperative burns in the typical “butterfly” distributions on their gluteal regions; the 12 month-old patient presented with superficial burn on the left lower abdominal region. Patient records and preoperative clinical examination ruled out any preexisting pressure sores or other dermal lesions contributing to or mimicking the observed burn injury following surgery. Clinical examination and follow-up evaluation took place in our institution after a mean follow-up period of 5 ± 3.5 months (range, 2–13 months) in all patients. RESULTS The average injured TBSA was 2.1% ± 1 (range, 0.5–4%). Fifteen patients (79%) had superficial burns, whereas 4 patients (21%) presented with deep dermal or full-thickness burns. The average delay between primary surgery and initial consultation of plastic surgeons was 4.5 ± 3.4 days (range, 1–13 days; Table 1; Figure 1). None of the primary care surgeons had noticed irregularities during surgery indicating the possibility of electrode burns. Table 1. Burn injury and surgical management View Large Table 1. Burn injury and surgical management View Large Figure 1. View largeDownload slide A. Typical “butterfly pattern” of superficial and partially deep dermal burn (4% TBSA) in the gluteal region of a 74-year-old woman 3 days after coronary bypass surgery. B. A 75-year-old woman with deep dermal burn (2% TBSA) in the sacral region on the second day after aortic valve-replacement surgery. Figure 1. View largeDownload slide A. Typical “butterfly pattern” of superficial and partially deep dermal burn (4% TBSA) in the gluteal region of a 74-year-old woman 3 days after coronary bypass surgery. B. A 75-year-old woman with deep dermal burn (2% TBSA) in the sacral region on the second day after aortic valve-replacement surgery. Nine patients (50%) had reported pain or numbness across the burned region while lying or during first mobilization, that is, 7 ± 3.1 hours (range, 2–20 hours) post surgery. Four patients (22%) required controlled ventilation or underwent prolonged recovery periods after surgery with supplemental analgesia and sedatives for 49 ± 10.4 hours (range, 34–68 hours) until first symptoms, such as discomfort, pain, or numbness, were reported. Eight patients (42%) required surgery, including débridment (5 patients, 26%), split-thickness skin grafting after tangential burn eschar excision (1 patient, 5%) or local musculocutaneous gluteus maximus rotational or advancement flaps after epifascial burn eschar excision (2 patients, 11%; Figure 2). The remaining 11 patients (58%) could be treated conservatively with topical silver-sulfadiazine wound dressing on a daily basis (Figure 3; Table 1). Retrospective technical and clinical data analysis demonstrated that one (5%) bipolar electrosurgical device was malfunctioning below current technical safety standards and that one (5%) neutral electrode was not properly positioned during preoperative preparations. A number of 3 (16%) incidents occurred after moisture accumulated on or beneath tissue under the negative electrode. Eight (42%) burns occurred during surgery while flushing fluid or blood created alternate current pathways. Five cardiac patients (26%) received skin preparations after receiving polyvinylpyrrolidone iodine (PI), which was most likely trapped and pooled under the body of the patient during surgery. The patients had partial-thickness chemical burns. In one accident (5%), the cause was not clear (Table 2). Figure 2. View largeDownload slide Left panel, day 5 after coronary bypass surgery, a 69-year-old man, initial presentation of deep dermal third-degree burn in the gluteal region (1% TBSA); right image, 5 weeks after intraoperative burn, sufficient defect coverage with local gluteus maximus rotational flap plasty after epifascial burn eschar excision. Figure 2. View largeDownload slide Left panel, day 5 after coronary bypass surgery, a 69-year-old man, initial presentation of deep dermal third-degree burn in the gluteal region (1% TBSA); right image, 5 weeks after intraoperative burn, sufficient defect coverage with local gluteus maximus rotational flap plasty after epifascial burn eschar excision. Figure 3. View largeDownload slide A. A 12 year-old boy with superficial and partially deep dermal intraoperative burns during otoplasty procedure. B. After the initial débridment procedure, conservative treatment with silver-sulfadiazine achieved successful wound healing. Figure 3. View largeDownload slide A. A 12 year-old boy with superficial and partially deep dermal intraoperative burns during otoplasty procedure. B. After the initial débridment procedure, conservative treatment with silver-sulfadiazine achieved successful wound healing. Table 2. Most likely injury mechanism View Large Table 2. Most likely injury mechanism View Large During follow-up, successful stable and durable soft-tissue defect coverage of the gluteal region was achieved in 18 patients (95%). One patient (5%) died of postoperative pneumonia 3 days after undergoing coronary bypass surgery. A total of 13 patients (79%) underwent successful rehabilitation after cardiac surgery without any further problems; the remaining two patients were discharged home. The four pediatric patients recovered without further complications or disabilities. DISCUSSION Under established jurisdiction, burn damage to the skin during surgery is not regarded as unavoidable. On the contrary, a breach of duty by the surgeon will be assumed. Surgeons are responsible for acquainting themselves with the techniques and risks of high-frequency surgical devices and chemical solutions with which they are working. They have to prevent injuries on the basis of controllable risks. The evaluation of judicial decisions, the literature, presented clinical reports, and expert opinions confirm that most injuries could have been avoided by compliance with the recommended precautions.1,2,4,–6 A study of 49 court decisions related to intraoperative burns in Germany demonstrated that a large number of these incidents were related to human mistakes (10%) and errors rather than technical problems (2%). However, 88% of these incidents demonstrated technical insufficiencies during equipment examination and repair.7 Electrical Burns There are two general categories of electrical burns that occur during surgery: excessive radiofrequency current density originating from an electrosurgical unit (ESU) and direct current originating from the malfunctioning battery or device.1 A lack of knowledge concerning these devices or situations warrants concerns because ESUs have been associated with severe burns or patient deaths.2,4,8,–15 The ESU often confused is with electrocautery; the latter does not use high-frequency current and does not perform cauterization by passing current through tissue. A heated probe or blade is used instead which, when applied to tissue, cauterizes blood vessels.10 The ESU, in comparison, can be used for coagulation, cutting, and tissue ablation purposes and to produce hemostasis of blood vessels. There is no difference in the ESU circuit between the monopolar and bipolar mode, except the volume of tissue through which the current passes is greatly reduced while using the ESU in the bipolar mode.2 It is critical to emphasize that current is passing through the patient's body in the monopolar mode, ranging from the probe tip to the grounding pad thereby incorporating the patient in the ESU circuit. In comparison, during bipolar mode operation, the ESU passes current between the active and dispersive prong generating a high current density and heat between the prongs.10 With the exception of equipment failure and human error, improper functioning of the ESU or improper placement of the grounding pad are the most frequent causes of electrical burns during surgery regardless of whether monitoring electrode are involved.16,–18 We observed this scenario in only 10% of our cases. It is evident that proper placement of the grounding neutral pad during monopolar electrosurgery is of eminent importance. Short circuiting caused by overwetting the sheet or heating blankets or the remains of blood after preoperative shaving before electrode or electrocardiogram lead application may be responsible for these avoidable accidents. Spilled saline, other flushing fluid, or blood on the OR table during surgery may create alternate current pathways.10,18 According to our retrospective data analysis, this was the case in the majority of our patients (58%). Numerous factors are involved in ensuring a proper pathway to ground the patient during monopolar electrosurgery, including the number of pads used, pad orientation, distance between electrode and pad, type of grounding pads, and poorly applied pads.10,17,19 The use of faulty or dried out beyond-expiration date pads is an additional factor.16,18 Additional problems during operation of the ESU in monopolar mode include breaks or cracks in the cable, causing burns directly from the capacitive-induced current.8,20 The second general category of burns occurs when the patient is exposed to DC current originating from a battery or equipment malfunction over a period of time. When seemingly harmless low-voltage DC current is applied to tissue, it may cause electrolysis of moisture on or beneath tissue, creating a strongly alkaline medium under the electrode sufficient enough to produce full-thickness epidermal burns as the result of reduced skin resistance.21,–25 Chemical Burns The pathogenesis of chemical burns resulting from skin preparation agents is a combination of concentration and lipid solubility of the chemical, inherent toxicity of the compound, duration of skin contact, manner of skin contact (eg, under occlusive garment), and prior condition of the skin (eg, maceration, irritation, friction). The burn is distributed in typical locations in the skin, that is, over bony prominences, points of pressure, or underneath constricted areas with tourniquet dressings or bandages. Patients are asleep when the preparation is in progress, they cannot sense whether a solution is irritating or if the skin is abraded.3 Introducted in 1965, PI is a widely used antiseptic.26 The wate-soluable compound results from the combination of molecular iodine and polyvinylpyrrolidone commercially available as solutions, scrub ointment, and foam.3 Chemical burns caused by PI are relatively under-recognized and potentially preventable problems that may be more frequent than believed and often are misdiagnosed as electrical burns.3 The extent of chemical burns often is underestimated. They often result in greater morbidity than thermal burns. In our series, all chemical burns were partial thickness but resulted in an average of 2% TBSA. A number of case reports have described burn incidents while using Betadine solutions during surgical skin preparations.27,–31 Even if patients were usually patch tested with different Betadine solutions with negative results,3 after closed and prolonged exposure to PI, skin damage may occur nonimmunologically. In addition, the epidermal lipid barrier may be decreased by another washing step using alcohol, which deesterifies the skin and may cause hypersensitivity.32,33 Systemic toxicity has not been a problem so far. Warning Signs and Prevention Guidelines Because of their greater surface area, paste-on surface electrodes are safer than either needles or collodion surface electrodes. Only equipment that has been approved by an appropriate regulatory panel should be used. Make sure that the equipment is examined at regular intervals. Basic device controls before each surgical procedure is recommended. The best defense against ESU burns is the quality of equipment and careful grounding. The use of large-surface grounding pads is helpful. Place the grounding pad or electrode where the heat dispersion is greatest as the result of sufficient blood circulation. While shaving hair-bearing regions, avoid alcoholic substances for disinfection and be aware of small skin bleeders increasing the electrical current flow by the factor of 6.1 On the contrary, 42% of intraoperative burns in cardiac patients occurred while trapped fluid created alternate current pathways. This distribution may be explained by the fact that, in six patients, larger-than-usual grounding pads were placed below the gluteal region. The common practice of placing this electrode under the buttock does not seem advisable, as demonstrated in our series of burns. The use of the lateral thigh or lower-extremity region, for instance, seems to be advisable. During preoperative patient preparation and draping, avoid and control any additional contact of patient parts and extremities with surrounding instruments and metal-supporting devices. The majority of the reported accidents were based on the fact that moisture was trapped under the patient's torso. Intraoperative control and sheet changes after wet disinfection or after large volumes of flushing fluids is recommended. Significant blood loss during surgery may cause wet sheets, which could be redraped while using double or triple sterile sheeting initially. Awareness is the key to preventing chemical burns such as incidents that occurred while Betadine was used. The skin must not be abraded excessively before the final skin preparation solution is applied. The agent should not be allowed to pool and become trapped under the tourniquet or the patient torso. The agent should be allowed to dry before the patient is draped.3 One of the warning signs that an electrical burn may occur is when electrosurgical equipment does not appear to be functioning normally, such as when the ESU appears to not be working at its normal level, prompting the surgeon to request an increase in intensity.34 One possible reason of this occurrence is a poorly attached ground pad or neutral electrode. Surgical procedures with excessive wear on cables as they enter or exit trocars during laparoscopic monopolar electrosurgery may result in intraoperative burns by capitative coupling or insulation failures.20,35 After surgery careful patient examination with special focus on regions after electrode application and underneath the patient torso where fluids may have been pooled is recommended. Finally, it may be considered to include the possibility of intra-operative burns into the list of material risks of the procedure in the informed consent paperwork form, even if incidence rates are very low.7 Procedures to Follow After Suspected Burn Occurrence A burn or plastic surgeon should be consulted immediately if a burn or lesion of unusual origin is suspected. All available information should be recorded, including patient data, pre- and intraoperative risks and occurrences, color photographs at the time of injury should be taken, and surgical setting and draping, skin preparation protocol, equipment packaging with manuals and connecting devices should be available for work-up. Patient questionnaires and a complete manual of procedures to investigate potential burns are available.36 It is important to determine the source of the burn to reduce the probability of the occurrence of another in the future. It is critical, necessary, and without a doubt ethical to clearly explain the burn accident and the most likely theory of mechanism to the patient, even if responsibilities need to be taken and mistakes confessed. This confession may regain his or her trust, preventing disappointed reactions with the loss of countenance and perhaps liability issues at court. Although injuries may have the appearance of full- or partial-thickness burns, electrical or chemical sources are not always involved. Other potential sources of injury that may resemble a burn, such as mechanical pressure, pharmacologic, or physiologic explanations, also should be suspected. The incidence of dermal lesion has become a rare problem in the experience of most surgical units, despite the fact that patients referred to surgery are older and have more complex diseases. Still, we suggest that medical staff and responsible surgeons should pay more attention to the probability of an incident. 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TI - Accidental Burns During Surgery
JF - Journal of Burn Care & Research
DO - 10.1097/01.BCR.0000245650.67130.5C
DA - 2006-11-01
UR - https://www.deepdyve.com/lp/oxford-university-press/accidental-burns-during-surgery-RMbVeYUE0k
SP - 895
EP - 900
VL - 27
IS - 6
DP - DeepDyve
ER -