Page 19 - Part 2 Anesthesiology Common Risk Issues

SVMIC Anesthesiology: Common Risk Issues

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.

In order to prevent this type of situation, consider these
recommendations:

• Give proper attention to the use of heat and ignition
sources including cauterization units and lasers

• Manage fuels such as skin prepping solutions and
dressings

• Minimize oxygen concentrations

• Prevent tenting of surgical draping

• Consider practice drills with surgical operating room and

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