Case report
Surgical burn secondary to the use of alcoholic chlorhexidine
Quemadura por clorhexidina alcohólica. Exposición de caso clínico
SENSAR
Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR), Spain
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Exposición de caso clínico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1203 "Ancho" => 1250 "Tamanyo" => 169449 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Burn on the shoulder. (B) Burn on the cheek. (<span class="elsevierStyleSmallCaps">C</span>) Burn on the neck.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Intraoperative fires may seem rare because few reports have been published in the literature. Nevertheless, their incidence is increasing, and this complication can have serious consequences. The main causes of mortality are airway burns, and most fires are avoidable. All operating room personnel must be qualified to detect risk situations and to act correctly if a fire should occur.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 51-year-old man who underwent elective cardiac surgery due to severe mitral regurgitation. The patient had no history of interest and arrived at the operating room both clinically and haemodynamically stable. Following the usual protocol, a 16G catheter was placed in a peripheral vein and the right radial artery was cannulated. Anaesthetic induction and intubation were uneventful and a triple lumen catheter and a Swan Ganz introducer were placed in the right internal jugular vein. The surgical site was swabbed with alcoholic 2% chlorhexidine. After waiting a few seconds for the antiseptic to dry, the patient was draped. After performing the longitudinal sternal incision using a cold scalpel, we continued the procedure with an electric scalpel to perform haemostasis. This was immediately followed by strong smell of burning with smoke rising from the patient's head. We immediately removed the surgical drape and saw flames advancing through the patient's hair from the nape of the neck to the ear.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Once the fire had been controlled, we observed significant damage in the endotracheal tube, the central line and the Swan Ganz introducer, with an air leak in the endotracheal tube and a copious bleeding from the Swan Ganz introducer (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In order of priority, the Swan Ganz introducer was clamped to avoid blood loss and the endotracheal tube was replaced using an exchanger. Once mechanical ventilation had been restored, and after checking that neither ventilation nor oxygenation was impaired, the central line and the Swan Ganz introducer were replaced. An external examination showed serious burns to the patient's cheek, neck and right shoulder (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Given the superficial nature of these injuries, and in view of the patient's cardiac pathology, it was decided to continue with the intervention, which concluded without further incident. After surgery, and having transferred the patient to the cardiac critical care unit, we contacted the hospital's patient safety unit to report the incident and a plastic surgeon was called to assess the injuries. The initial diagnosis was superficial burns on the face and second degree burns on the neck and shoulder. These were treated conservatively with linitul and betadine gel during the first few postoperative days, but after 1 week required 3 separate surgical treatments and debridement.</p><p id="par0025" class="elsevierStylePara elsevierViewall">An analysis of the incident suggested that a large amount of alcoholic 2% chlorhexidine had probably pooled in the sternal hollow and under the surgical drape. The source of heat probably came from the electric scalpel.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patient was discharged home, asymptomatic, 23 days after surgery.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Alcoholic chlorhexidine is one of the most widely used pre-surgery skin antiseptics. Chlorhexidine solutions are bactericidal and fungicidal, and have a residual effect that can last up to 6<span class="elsevierStyleHsp" style=""></span>h. Ethyl alcohol, meanwhile, is a fast-acting bactericidal, fungicidal and virucidal agent with intermediate potency. The synergic effect of chlorhexidine and alcohol improves the individual effectiveness each antiseptic, since it combines the speed of action of alcohol with the residual action of chlorhexidine. In addition, alcohol appears to facilitate penetration of chlorhexidine to the stratum corneum of the skin and thus prolong the effect.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> The use of this preparation is not free from adverse effects, one of them being fire, due to the flammable nature of the solution.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Intraoperative fires may seem rare, but 600 cases are reported each year in the USA.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> These events have serious consequences, such as second or third degree superficial burns, and are fatal in 5% of cases, usually due to airway burns.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Three factors must combine for fire to occur: an ignition source, such as the electric scalpel; a source of combustion, such as the use of alcohol-based antiseptics on the skin or the surgical drapes; and an oxidant, such as oxygen or nitric oxide. Surgical procedures involving the face, neck and upper chest are most susceptible to these events.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Operating room personnel should be able to identify patients who may be at risk of this adverse event<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> and implement measures to minimise the risk. These measures include minimising oxygen delivery, particularly when using nasal cannulas in face surgery; avoiding the formation of oxygen-rich closed spaces when placing the surgical drapes; and limiting the use of the electric scalpel. Regarding alcohol-based antiseptic solutions, some basic rules must be learnt: wait at least 3<span class="elsevierStyleHsp" style=""></span>min after application of the solution before placing the surgical drape; use applicators to minimise the amount of antiseptic applied; check that the antiseptic has not pooled in skin folds, and if so, remove it with a sterile swab; and make sure the solution has not impregnated the surgical drape.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Alcoholic chlorhexidine is more effective than povidone iodine in preparing the patient's skin for surgery. Nevertheless, it is a flammable substance that can lead to major complications, such as intraoperative fire. Although this is an uncommon adverse event, the resulting complications can be serious and even fatal. The surgical team must be able to identify patients with the highest risk of presenting this complication and take the necessary measures to minimise this as much as possible.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interest</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to report.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1008355" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec968028" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1008356" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec968029" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-01-26" "fechaAceptado" => "2017-10-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec968028" "palabras" => array:3 [ 0 => "Alcoholic clorhexidine" 1 => "Skin burn" 2 => "Electrocautery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec968029" "palabras" => array:3 [ 0 => "Clorehexidina alcohólica" 1 => "Quemadura cutánea" 2 => "Bisturí eléctrico" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Surgical wound infection is one of the main sources of postoperative morbidity/mortality. Skin preparation with an antiseptic agent such as chlorhexidine alcohol solution is an effective method to reduce the incidence of surgical wound infections. Nevertheless, the use of alcohol solutions is associated with some risk as they are inflammable products. We report a case of a 51-year-old male who suffered an extensive burn associated with concurrent use of electrocautery and clorhexidine alcohol solution.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las infecciones del campo quirúrgico constituyen unas de las principales causas de morbimortalidad en los pacientes quirúrgicos. La utilización de clorhexidina alcohólica para la preparación del campo quirúrgico ha demostrado ser eficaz en su prevención. Es necesario saber que se trata de un producto inflamable, por lo que hay que tomar una serie de precauciones para evitar complicaciones importantes. Exponemos el caso de un varón de 51 años que sufrió quemaduras graves al asociar la utilización de clorhexidina alcohólica con el uso del bisturí eléctrico.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Sistema Español de Notificación en Seguridad en Anestesia y Reanimación (SENSAR). Quemadura por clorhexidina alcohólica. Exposición de caso clínico. Rev Esp Anestesiol Reanim. 2018;65:e1–e3.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1532 "Ancho" => 1250 "Tamanyo" => 232413 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Central line removed from the patient. (B) Swan Ganz introducer removed from the patient.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1203 "Ancho" => 1250 "Tamanyo" => 169449 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Burn on the shoulder. (B) Burn on the cheek. (<span class="elsevierStyleSmallCaps">C</span>) Burn on the neck.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of residual antimicrobial activity of chlorhexidine-containing antispetics: an express report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J. Sogawa" 1 => "H. Kobayashi" 2 => "T. Kajiura" 3 => "Y. 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