Giving new meaning to heartburn
An Australian man’s chest literally caught on fire during emergency heart surgery after a dry surgical pack ignited in a high-oxygen environment.
The 60-year-old patient was undergoing surgery for a tear in the inner wall of the aorta, the main blood vessel leaving the heart, when doctors needed to increase the flow of oxygen in his anaesthetic to 100%.
Soon after, a spark from the electrocautery device — a heated electrode used to stop bleeding — ignited a dry surgical pack. Fortunately the fire was immediately extinguished without any injury to the patient; the rest of the operation proceeded uneventfully and the repair was a success.
Dr Ruth Shaylor and colleagues from Austin Health in Melbourne, where the incident took place, warn that the case highlights the potential dangers of dry surgical packs in the oxygen-enriched environment of the operating theatre where electrocautery devices are used.
“While there are only a few documented cases of chest cavity fires — three involving thoracic surgery and three involving coronary bypass grafting — all have involved the presence of dry surgical packs, electrocautery, increased inspired oxygen concentrations, and patients with COPD or pre-existing lung disease,” explained Dr Shaylor.
“This case highlights the continued need for fire training and prevention strategies and quick intervention to prevent injury whenever electrocautery is used in oxygen-enriched environments. In particular, surgeons and anaesthetists need to be aware that fires can occur in the chest cavity if a lung is damaged or if there is an air leak for any reason, and that patients with COPD are at increased risk.”
The following key learnings were identified:
- Chest cavity fires, though rare, can occur in the presence of high inspired oxygen, electrocautery, and dry surgical packs.
- Patients with underlying lung disease and an airway leak are at increased risk.
- Care should be taken by the anaesthetic team to use the minimum inspired oxygen concentration possible in these cases.
- It is the responsibility of the entire surgical team to be aware of this potential risk and ensure surgical packs are damp prior to placing them in the surgical field.
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