Patient catches fire during organ surgery

A recent example of a surgical fire reported by Mary A. Herman, MD, PhD, assistant professor of anesthesiology at the University of Florida College of Medicine in Gainesville, illustrates how such an incident can occur in routine circumstances.

Herman reports that the case involved a 19-year-old man who suffered severe head trauma and multiple injuries in a motor vehicle accident.1 After he was declared brain dead at Shands Hospital at the University of Florida, clinicians began an organ procurement procedure. The donor was ventilated with a 32% oxygen/air mixture, and the donor's oxygen saturation (SpO2) was 100%. A transplant surgeon cleaned the thorax and abdomen with alcohol, and a purulent discharge around the tracheostomy site was also removed with alcohol. The surgeon then wrapped a soaked, gauze sponge around the tracheostomy tube and left it in place. The donor was then aseptically prepared from sternal notch to pelvis with iodine povacrylex and isopropyl alcohol, which dried before the body was draped with cloth towels and paper drapes.

About 15 minutes after incision using an electrocautery device, the surgeon exclaimed that the donor was on fire. The anesthesiologist immediately disconnected the breathing circuit from the anesthesia machine and turned off all gases. The surgeon used a towel in an attempt to smother the flames, but the fire spread quickly to the drapes. The circulating nurse left the room to find water or a fire extinguisher, and the scrub technician threw pieces of ice toward the fire from across the room. The anesthesiologist disconnected a bag of intravenous fluid from the donor and used it to extinguish the fire.

The fire left a 10-by-5 inch area of sooting and singed skin on the right neck and shoulder where the breathing circuit had been. The donor's chin and face were reddened, and eyebrows, eyelashes and facial hair were singed. The patient was prepped again and the organ procurement was completed successfully.

Later, the surgeon speculated that had he started the fire by placing the electrocautery device next to the alcohol-soaked sponge wrapped around the tracheostomy.

Reference

1. Herman MA, Laudanski K, Berger J. Surgical fire during organ procurement. The Internet Journal of Anesthesiology 2009; 19: No. 1.

Sources

For more information on this case, contact:

• Mary A. Herman, MD, PhD, Department of Anesthesiology, University of Florida College of Medicine, Gainesville. Telephone: (352) 265-8012. E-mail: mherman@anest.ufl.edu.