SCARRED Jeanne Holden, 86, was disfigured after flames erupted in an Oregon surgery center.
That's a difficult image to look at, isn't it? It's the charred face of 86-year-old Jeanne Holden, who went to the Oregon Outpatient Surgery Center in Tigard, Ore., on Sept. 16, 2016, for a left temporal artery biopsy, but left burned and blistered inside her mouth, down her throat, up her nose, in her ear, neck and down part of her back. A $1 million lawsuit filed on Ms. Holden's behalf last month says she was breathing supplemental oxygen through a mask during cauterization of the incision when a low blue flame ignited on her face. Ms. Holden's nose and left eye are so badly disfigured that she can no longer wear her eyeglasses, says her daughter.
The lawsuit seems to implicate her alcohol-based skin prep as the cause of the fire, but that's far from certain. The language in the complaint is confusing, in several instances seemingly mistaking "antiseptic" for "anesthetic" when describing the cause of the flash burns. "A local liquid anesthetic was applied to plaintiff's left face and as [the surgeon] attempted to use an electrocautery unit, plaintiff's face, head and neck caught fire," reads the suit.
Regardless of the cause of Ms. Holden's fire, you must still exercise care when applying flammable prepping agents. Here are a few questions to test your prepping knowledge.
APPLIED BEHAVIOR Let prepping agents dry completely — including time for the vapors to dissipate — before draping and using a potential ignition source.
Alcohol-based skin preps cause only 4% of all OR fires. Was the prep likely to blame in Ms. Holden's case?
a. yes
b. no
c. maybe
Show Answer
Answer: c
It's possible, but not likely, that an alcohol-based prep was the fuel that ignited the fire. The physical evidence suggests this was a classic case of an oxygen-enriched fire (oxygen-enriched atmospheres are reportedly involved in about 75% of surgical fires). Check out the incision site above Ms. Holden's left eye. The burn marks don't extend to that area, indicating the prep did not ignite. Also notice that Ms. Holden's hair and ear were not burned, which could have happened if the prep had ignited — or if the surgical team let excess prepping solution drip off her face. The suit says Ms. Holden received supplemental oxygen through a mask rather than a nasal cannula during the procedure. That suggests the surgeon's electrocautery device ignited the oxygen that escaped the mask and the resulting flames, fueled by vellus hair ("peach fuzz") on Ms. Holden's face, burned off her eyelashes and most of her left eyebrow. Also consider that if the surgeon cauterized the surgical incision at the end of the procedure, as Ms. Holden's husband and daughter claim, the prep would have likely dried by then.
A key aspect of proper surgical prepping involves deciding if supplemental oxygen will be needed during the case. If it's clinically indicated, there are steps you can take to minimize the risk of igniting an oxygen-enriched fire, including the use of open-air delivery if the patient can maintain a safe blood oxygen saturation, delivering the minimum oxygen concentration necessary for adequate oxygenation, and stopping supplemental oxygen at least 1 minute before and during use of electrosurgery, electrocautery or laser (ecri.org/surgical_fires).
Greg Kafoury, Ms. Holden's lawyer, says "there's a level of uncertainty" as to what sparked the fire. The lawsuit states that the "anesthetic" fueled the flames, but given that the anesthetic traditionally used for left temporal artery biopsy is a local injection, that seems unlikely.
What precautions should you take when applying an alcohol-based prep?
a. let it dry for 3 minutes on hairless skin
b. avoid use of an ignition source until the solution is completely dry
c. avoid applying solution into hairy areas
d. do not let the solution pool
e. all of the above
Show Answer
Answer: e
Let preps that contain isopropyl alcohol (IPA) and give off flammable vapors — ChloraPrep (70% IPA), DuraPrep (74% IPA) and Prevail-FX (72.5% IPA) — dry for at least 3 minutes on hairless skin before draping the patient or activating an ignition source such as an electrocautery device, say the prep manufacturers. Should the prep seep into the patient's hair, let it dry for 1 hour before surgery begins (wet hair is flammable). Don't let the prep pool during application; if excess solution drips off the patient, remove soaked materials such as drapes, gowns and towels before activating electrosurgery devices. When prepping the neck, place towels on either side to catch runoff and remove the towels from the surgical field before surgery begins.
Should you use an alcohol-based prep for head and neck surgery?
a. yes
b. no
c. sometimes
Show Answer
Answer: c
Some alcohol-based preps should not be used around the eyes, ears and mouth because they can cause significant injury if they enter those sensitive areas. At least one manufacturer says it's safe to use a smaller-sized applicator that applies prep in a concentrated area.
A diluted povidone-iodine solution is a good choice for surgery performed on the face, says Molly Wright, RN, the clinical care coordinator of the surgical department at Tri-State Memorial Hospital in Clarkston, Wash. When applying the prep, be sure to tape the patient's eyes shut and ensure the solution does not pool underneath the tape, says Ms. Wright. She says ophthalmic ointment helps protect the eyes during prepping.
A 50-year-old vaginal hysterectomy patient has an allergy to povidone-iodine. Which prep solution is an appropriate alternative?
a. baby shampoo
b. soap-saline mix
c. 4% chlorhexidine
d. all of the above
Show Answer
Answer: d
Many surgical teams are faced with this scenario quite often and there is no FDA-approved alternative product to povidone-iodine for vaginal prepping, says Lori Benton, RN, an infection preventionist at Tri-State Memorial. Research has shown that sterile saline and baby shampoo are as effective as povidone-iodine in prepping hysterectomy patients. Ms. Benton says staff at Tri-State Memorial use a mild soap combined with saline solution.
Although CHG labels warn specifically against using the products in the genital area, the American College of Obstetricians and Gynecologists published a position statement in 2013 that notes 4% CHG with 4% IPA is well tolerated and may be used off-label to prepare the vaginal area for surgery (osmag.net/8npquf). The statement also mentions that 4% CHG with 70% IPA should not be used for this purpose in order to avoid skin irritation.
Ms. Benton says your care team and infection preventionists must ultimately confer to decide which prepping alternative is best for these patients, based on a literature review and manufacturers' instructions for use and contraindications.
CLOSE CUT Whenever possible, hair should be removed with single-use surgical clippers in the pre-op area.
A 40-year-old male hernia patient with a very hairy chest and abdomen sits in pre-op. The day's schedule is packed and you're under significant pressure to move the patient to the OR. What should you do?
a. clip the hair around the surgical site in the OR
b. clip the hair around the surgical site in pre-op
c. shave the hair around the surgical site in the OR
d. hair removal is not needed in this case
Show Answer
Answer: b
In this case, you make the judgment call that the patient's body hair will interfere with the surgeon's access during surgery or the proper marking of the surgical site and should be removed. Hair that's determined to not be an impediment should be left untouched, because hair removal of any kind can cause minute skin abrasions that increase the risk of infection. Whenever possible, remove hair in the pre-op holding area with single-use surgical clippers or depilatory cream. In this case, a time crunch is no excuse to resort to removing the patient's hair in the OR. Don't shave because razor blades cause microscopic nicks that increase the risk of a surgical site infection. Instruct patients not to remove hair at home before surgery.
Only remove hair in the OR if a patient's modesty or privacy is jeopardized when the surgical site is on or near sensitive areas of anatomy, says Ms. Wright. In those instances, she suggests you clip the hair once the patient is anesthetized and do your best to remove the clippings from the surgical field with sticky-fingered gloves or tape.
A patient who's scheduled to undergo a knee arthroscopy should wash the surgical site with CHG the night before.
a. true
b. false
Show Answer
Answer: a
It certainly can't hurt to have patients wash the skin around the incision site with soap or antiseptic solution before they arrive for surgery, but pre-op bathing has not been definitively proven to reduce the risk of surgical site infections. At-home pre-op cleansing was among the World Health Organization's 29 recently released evidence-based guidelines for preventing SSIs (osmag.net/shr7zo). The recommendation says it's "good practice" for patients to bathe or shower before surgery with plain or antimicrobial soap or CHG-impregnated cloths, but did not tout the use of one over the other and noted that there is limited to low-quality evidence that shows any of the options reduce SSIs. Ms. Benton says getting patients to follow the directives to wash and to use proper application techniques at home is a challenge, but clearly written directives, automated text message reminders and voicemails left by staff can help improve compliance. OSM
.svg?sfvrsn=be606e78_3)
.svg?sfvrsn=56b2f850_5)