Cause of Device-Related Incident
Device factors; External factors; Support system failures; User errors

Clinical Specialty or Hospital Department
Anesthesia; Clinical/Biomedical Engineering; Emergency Medicine; Obstetrics and Gynecology; OR / Surgery

Device Factors
*Not stated; Design / labeling error; Device failure

Document Type
Hazard Reports

External Factors
*Not stated; Medical gas and vacuum supplies

Mechanism of Injury or Death
Burn (electrical, thermal, chemical); Fire

Support System Failures
*Not stated; Use of inappropriate devices

Tampering and/or Sabotage
*Not stated

User Errors
Failure to read label; Incorrect clinical use

UMDNS
Adhesives [10-034]; Adhesives, Aerosol [10-035]; Burs [10-519]; Cuffs, Blood Pressure [11-073]; Cuffs, Tourniquet [17-231]; Drapes [15-775]; Drills [11-329]; Electrocautery Units [11-418]; Electrocautery Units, Battery-Powered [11-421]; Electrocautery Units, Line-Powered [11-422]; Electrodes, Electrosurgical [15-579]; Electrosurgical Units [11-490]; Handpieces [17-953]; Handpieces, Surgical [17-949]; Lasers [12-296]; Light Sources, Fiberoptic [12-345]; Tracheal Tubes [14-085]

Fires during Surgery of the Head and Neck Area (Update)



Hazard Update [Health Devices Jan 1980;9(3):82]

In the previous report, we discussed the fire hazards associated with enriched oxygen and nitrous oxide concentrations present during surgery of the head and neck area and made recommendations for minimizing these hazards. In our continuing studies, we have found that a water-soluble sterile surgical lubricating jelly may be used to minimize fire hazards posed by the presence of hair near the operative site.

We performed flammability tests on facial and scalp hair impregnated with surgical sterile lubricating jelly. Ignition was attempted in enriched atmospheres of 70% and 100% oxygen using both electrosurgical current and incandescent sparks as ignition sources (see the previous hazard report for more information on these and other ignition sources). In all tests, the jelly prevented the test hair from igniting. Exposed sections of hair not coated by the jelly would ignite but would self-extinguish when the flame reached the jelly. The jelly could be easily washed off following the procedure.

Recommendations

  1. If oxygen or nitrous oxide is being administered during oral or ophthalmic surgery, make hair near the operative site (e.g., eyebrows, mustaches, and beards) nonflammable by coating it thoroughly with a water-soluble surgical lubricating jelly. This practice should minimize the chance that the hair will either be the primary point of ignition or add fuel to a fire originating elsewhere. Furthermore, use of the jelly will also eliminate the need to shave facial hair before surgery to minimize the risk of fire.
  2. The extent to which the hair around the mouth should be coated with jelly may be dictated by the procedure and the draping technique. We recommend that the jelly cover the patient's mustache and beard for at least 5 cm from the edge of the mouth.
  3. The need for coating the eyebrows also depends on the procedure and draping techniques. In many cases of ophthalmic surgery, the eyebrows are covered by a drape, and the application of jelly would have minimal benefit. However, it may be prudent to apply the jelly to the eyebrows if they are within the operative area and oxygen or nitrous oxide is being administered.

UMDNS Terms

  • Adhesives [10-034]
  • Adhesives, Aerosol [10-035]
  • Burs [10-519]
  • Cuffs, Blood Pressure [11-073]
  • Cuffs, Tourniquet [17-231]
  • Drapes [15-775]
  • Drills [11-329]
  • Electrocautery Units [11-418]
  • Electrocautery Units, Battery-Powered [11-421]
  • Electrocautery Units, Line-Powered [11-422]
  • Electrodes, Electrosurgical [15-579]
  • Electrosurgical Units [11-490]
  • Handpieces [17-953]
  • Handpieces, Surgical [17-949]
  • Lasers [12-296]
  • Light Sources, Fiberoptic [12-345]
  • Tracheal Tubes [14-085]

Cause of Device-Related Incident

Device factors: Design/labeling error; Device failure

User errors: Failure to read label; Incorrect clinical use

External factors: Medical gas and vacuum supplies

Support system failure: Use of inappropriate devices

Mechanism of Injury or Death

Burn (thermal); Fire


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