VCUDEATH AND COMPLICATIONS CONFERENCE

Brian Le M.D.

Introduction:

Complication Intraoperative Fire

Procedure Removal of angioseal and associated

thrombus from right CFA, endarterectomy of CFA, SFA and profunda with patch angioplasty

Primary Diagnosis Acute Right Limb ischemia following IR

procedure

Clinical History

HPI: 62 yo woman hx of smoking 1 ppd for 50 years with a hx of lung cancer, stroke, right CEA who presented on 11/14 with with worsening pain and discoloration of her left toes. Left leg claudicates after walking a block. She did see her PCP 1 month prior with a left 4th toe wound which was attributed to her DM. When her pain and foot got worse, she presented to the ED.

Clinical History

PMHx: DM, HTN, XOL, lung cancer in 2004, stroke in 2004

PSHx: right upper lobe lung resection and right carotid endarterectomy in 2004

FHx: noncontributory SHx: Smoked >50 years of 1ppd, occasional

EtOH Meds: AntiHTN, ASA, Wellbutrin, pepcid, lasix,

insulin, ipratropium, narcotic pain medication, Allg: Advair, Bactrim, ibuprofen, keflex, PCN

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Hospital course

Admitted on 11/14, arterial duplex of her LLE showed monophasic flow at the external iliac artery with ~ 75% stenosis at this region. Studies consistent with severe aortoiliac disease.

Proceeded to IR on 11/16 for angioplasty and stenting of her bilateral common iliac arteries.

Post procedure, pt c/o numbness and pain in RLE. Exam revealed a cold, mottled foot that was

pulseless and nondopplarable at DP, PT and popliteal artery.

Hospital course

Discussion with IR attending reveals that the pt had an angioseal device that was inserted but did not provide hemostasis and manual pressure was applied.

By the time pt examined, sensation and motor function preserved but foot exam was concerning for acute occlusion.

Based on clinical findings, pt was taken to the OR immediately for planned thrombectomy

Analysis of Complication• Was the complication potentially

avoidable?– Yes.

• Would avoiding the complication change the outcome for the patient?– No

• What factors contributed to the complication?• 1. Failure of angioseal device• 2. “immediate” urgency of case• 3. reprepping after timeout

• What else would I have done differently?• Waited for chloroprep to dry• Use of Ioban• Use of betadine• Re-timing out when prep was applied

Intraoperative Fires

• Surgical fires• Procedures at risk for intraop fires• Prepping solutions, electrocautery• Time out verification

Surgical fires are rare but are serious preventable safety risk in hospitals

The National Quality Forum considers operative-fires a “Never Event”; errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility.

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ECRI indicate between 50-100 fires occur each year with 20 serious injuries and 1-2 causing death in the United States.

80-90% do not result in significant injury. When they do occur they have potential to result in serious consequences for the patient and hospital that may result in; death, serious injury requiring long-term medical management, legal implications and negative publicity for the institution.Privileged & Confidential: Subject to Peer Review and Medical

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A study from the UK this past March 2012 reviewing data from a database of patient safety incidents showed 11 out of 13 fires in the UK over a 6 year period was the result of alcohol based surgical preps.

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Types of cases at risk

Head and Neck surgery cases/Cases performed under 100% oxygen via open delivery (nasal canula, mask) If possible, hold supplemental O2 while using bovie use bipolar electrocautery instead of monopolar. Apply water-soluble lubricating jelly to facial and

head hair to decrease flammability; better yet, trim hair.

Place bovie in holster when not in use AVOID draping pt in a mannar to decrease chance

for accumulation of oxygen

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NEVER enter trachea with bovie. Ensure AUDIBLE activation tones

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Laparoscopic surgery and use of fiberoptic light sources/cables. Keep end of scope off drapes Rest instrument shaft on moist towels Place light source on standby mode

Excessively hairy patients Clip hair if possible Avoid alcohol based preps Apply water-soluble lubricating jelly to facial

and head hair to decrease flammabilityPrivileged & Confidential: Subject to Peer Review and Medical

Review Protections, O.C.G.A. 31-7-130 et seq. and 31-7-140 et seq.

Types of prep

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ChloraPrep:

•Active ingredient is chlorhexidine gluconate•70% ispropyl alcohol•Minimum of 3 mins to dry on hairless skin•1 hour in hair•Do not use 26 mL applicator of head and neck preps

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DuraPrep•Active ingredient is Iodine povacrylex•74% ispropyl alcohol•Minimum of 3 mins to dry on hairless skin•1 hour in hair•Do not use 26 mL applicator of head and neck preps

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Chlorhexidine Gluconate•Contains ispropyl alcohol•According to MSDS Chlorhexidine is combustable at high temperatures•Also contains water

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Povidone-Iodine•Does not contain ispropyl alcohol•MSDS indicates that povidone iodine is combustible at high temperatures.

When a fire does occur:

Stop flow of oxidizers (turn off supplemental O2, N2O to patient)

Remove burning materials from the patient and extinguish them

Remove drapes horizontally if possible. Extinguish via aqueous solution (saline, water…) Restore breathing if necessary using room air,

never oxygen and deal with any injuries. Evacuate the OR where the fire occurred if

extreme smoke and fire conditions require evacuationPrivileged & Confidential: Subject to Peer Review and Medical

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Fire extinguishers mounted outside each OR; PASS: pull the pin, aim the nozzle, squeeze

the trigger and sweep out the fire. Most are Co2 or dry powder.

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Lessons learned

It is the responsibility of every perioperative team member to take an aggressive role in preventing surgical fires.

A proactive approach through education, team preparation, participation, and knowledge increases awareness about fire prevention. Surgical fires are 100% preventable, and it is through your vigilance that they will be prevented.

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