Page 66 - 2022 Risk Basics - Anesthesiology

SVMIC Risk Basics: Anesthesiology

CASE STUDY

Regarding inoperative burns, a case involved a 45-year-
old who was having a lesion removed from her cheek
using monitored anesthesia care with a mask. During the

procedure, oxygen flared and caused second degree burns
about the face, neck, and shoulders. Apparently, the

patient’s head was not in a stable position and while the

CRNA was reaching under the drapes to adjust the head,
the mask may have allowed more oxygen to accumulate

under the drapes and ignite. Tented drapes may also have
contributed to the fire. The circulating nurse had

completed a fire risk assessment prior to surgery. This
patient’s risk was high and the entire room should have

been alerted to this fact. It is unknown whether the nurse

or CRNA alerted the team.

The Anesthesia Patient Safety Foundation also offers a very

powerful video on fire prevention and management in the OR,
which many anesthesia practices mandate as required

viewing. Periodic emergency simulations as referred to in the
26
previous section should include OR fires.

Anesthesia Awareness

Patient awareness under general anesthesia is a rare condition
(estimated to affect 1/1000 patients) that occurs when surgical

patients can recall their surroundings, an event, and even

26 https://www.apsf.org/videos/or-fire-safety-video/

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