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Burns to patients in the operating room (O.R.) can
occur from dramatic events such as fire or relatively
benign activities such as maintenance of normothermia.
Burn injury in the O.R. is a significant source
of morbidity for patients and a source of liability
for anesthesiologists. The ASA Closed Claims Project
database was analyzed to identify recurrent patterns
of burn injury associated with anesthesia. The Closed
Claims Project database consists of standardized
summary data on anesthesia malpractice claims collected
from 35 professional liability carriers that insure
about half of the practicing anesthesiologists in
the United States. Claims for dental damage are
excluded from the database. There are currently
145 claims (2.2 percent) for burn injury among the
6,449 total claims in the ASA Closed Claims Project
database.
Mechanism of Injury
The most common devices causing burns in the O.R.
were intravenous (I.V.) bags or bottles (35 percent,
n = 51) [Figure 1]. Another 23 percent of burns
(n = 33) were associated with warming devices such
as heating pads (n = 11), heating blankets (n =
16), warming lights (n = 4) and hot compresses (n
= 4). Cautery fires (n = 27) made up 19 percent
of the burn claims. Cautery burns (12 percent, n
= 18) included direct burning from the cautery or
burns secondary to a faulty grounding pad. Other
devices causing burns included lasers in the patient
airway (n = 3), magnetic resonance imaging (MRI)
(n = 3), retractors (n = 2), defibrillator paddles
(n = 2) and electrocardiogram leads (n = 1). The
MRI burns all occurred at the site of pulse oximeter
probes.
Figure 1: Device Causing
Burn
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| Most burns
(58 percent) were from devices used to warm
the patient, including intravenous bags (n=51)
and warming devices (n=33). Cautery devices
caused burns either from grounding pads (n=18)
or by causing a fire (n=27). Miscellaneous devices
associated with burns included magnetic resonance
imaging, retractors, defibrillator paddles and
electrocardiogram leads. |
General Location of Burn
The most common location of burns was the trunk
or axilla (28 percent) [Figure 2], commonly caused
by I.V. bags (80 percent from this device). Burns
to the buttocks/thighs/legs/feet (21 percent) were
most often caused by warming devices (61 percent).
There also was a trend of vascular cases in this
category, although this trend was not significant
statistically. Burns on the face (21 percent) were
caused most frequently by cautery fires (64 percent).
Figure 2: Location of
Burn (n=145)
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| The most common
area of burn was the trunk (including the axilla).
Most lower-extremity burns were caused by warming
devices. Burns to the face were most frequently
caused by cautery fires. |
Severity of Injury
Burn injuries were less severe than other injuries
in the database [Table 1, page 11]. Most (93 percent)
burn injuries were temporary or nondisabling. Only
6 percent of the burn injuries were permanent or disabling,
and there was only one death. The death occurred in
the case of an airway fire during laser vaporization
of tracheal stenosis (100 percent oxygen was being
used). The nine cases that involved permanent or disabling
injuries included two burns in children. One involved
an airway fire during a tonsillectomy; the second
was a child who sustained an abdominal burn from a
warming blanket and subsequently had a cardiac arrest.
There were two airway fires causing permanent disabling
injuries, both involving prolonged intubation in the
intensive care unit and lifelong disability. There
were four permanent, disabling burns attributed to
warming blankets. The location of these burns included
the abdomen, buttocks, legs and feet. Three of these
severe warming blanket burns occurred during vascular
surgeries.
Payment
Payment was more often made in the burn claims (72
percent) than in other claims in the database [Table
1]. The size of payments in burn claims was smaller
than other claims in the database, reflecting the
lower severity of injury in most burn claims [Table
1]. Payments varied by the device that caused the
burn. Payment was made for 100 percent of the airway
fires, and this group had the highest median payment.
A payment was made in 82 percent of warming device
claims and 80 percent of claims involving I.V. bags
or bottles. Payments were least often made for cautery
burns and other nonwarming devices. The largest payments
(adjusted to 1999 dollar amounts) were for airway
fires (median $167,500) followed by cautery burns
($80,375) and cautery fires ($71,375).
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Discussion
Burns continue to have significance in current anesthesia
practices. As this database shows, although they
tend to occur infrequently, they still can result
in significant morbidity for the patient and result
in financial liability on the part of the anesthesiologist.
A previous analysis of burns in the Closed Claims
Project database by Cheney et al.1
found 54 of 3,000 total claims (1.8 percent) attributed
to burn injury. In that analysis, 64 percent of
the burns from devices used to warm patients were
due to I.V. bags or bottles. The current database
has now accumulated 6,449 claims with the majority
of burns that were sustained from I.V. bags occurring
before 1994. Since 1994 only 12 percent of burn
claims in the database were associated with I.V.
bags or bottles. In contrast the proportion of burn
claims from cautery fires has increased since 1994:
44 percent of burn claims since 1994 were associated
with cautery fires compared to 11 percent of earlier
claims [Figure 3]. The majority of cautery fires
occurred during plastic surgery cases under monitored
anesthesia care. Most cautery fire burns occurred
on the face or in the airway (85 percent), and the
use of supplemental oxygen was most often listed
as an inciting event. In some cases, the use of
an alcohol-based preparation solution also was thought
to contribute to the fire. The “fire triad”
has three components that must come together to
ignite a fire: 1) heat or an ignition source, 2)
fuel and 3) an oxidizer.2,3
Selective use of supplemental oxygen and open-face
draping has therefore been recommended.4,
Figure 3: Trends in Burn
Claims Over Time
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| Burns from
intravenous bags or bottles used as warming
devices were more common prior to the 1994 publication
warning of their risks and were less common
among recent claims. Cautery fires and burns
from warming devices were more common since
1995. |
Laser airway fire is another area that has had
a small but important presence in the Closed Claims
Project files. The claims may involve severe injury
and high payments, and in the database, these cases
received payment 100 percent of the time. The components
of the fire triad also apply to these cases.2,5,6
Conclusion
Burn injuries in the Closed Claims Project database
continue to occur primarily from cautery, warming
devices and airway fires. Burns from I.V. bags have
declined since 1994 after publication of hazards
associated with their use as warming devices.2
Burns from cautery fires, especially to the face,
have increased in the 1990s. Regulated warming devices
continued to cause burns, primarily of the lower
extremities.
References:
1. Cheney FW, Posner KL, Caplan RA, Gild WM. Burns
from warming devices in anesthesia: A closed claims
analysis. Anesthesiology. 1994; 80:806-810..
2. Barker SJ, Polson JS. Fire in the operating room:
A case report and laboratory study. Anesth Analg.
2001; 93:960-965.
3. Ehrenwerth J, Seifert HA. Fire safety in
the operating room. ASA Refresher Courses
in Anesthesiology. American Society of Anesthesiologists.
2003; 31:25-33.
4. Greco RJ, Gonzalez R, Johnson P. Potential dangers
of oxygen supplementation during facial surgery.
Plast Reconstr Surg. 1995; 95:978-984.
5. Reyes RJ, Smith AA, Mascaro JR, Windle BH. Supplemental
oxygen: Ensuring its safe delivery during facial
surgery. Plast Reconstr Surg. 1995; 95:924-928.
6. Bowdle TA, Glenn M, Colston H, Eisele D. Fire
following use of electrocautery during emergency
percutaneous transtracheal ventilation. Anesthesiology.
1987; 66:697-698.
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Kimberly A. Kressin, M.D., is a CA-4 resident
at the University of Washington, Seattle, Washington. |
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