Background
Approximated 500-600 operating room fires every year in the U.S. with ~10% of these producing serious injuries to the patient.
Burn injuries represent 20% of MAC related malpractice claims, 95% of which involved head/neck surgery.
Intra-abdominal fires are much rarer events, with the first documented case occurring in 1933.
We report an unprecedented case of an intra-abdominal fire upon surgical attempt at retrieving retained rectal paint spray can.
Case Description
A 64 year old male presented to the ED with abdominal pain, found to have retained a high pressure spray paint container and a plastic bottle in his rectum for over a month.
Taken to the OR for trans-anal retrieval of these objects under GETA
Use of ring forceps and Kocher clamp during this procedure resulted in can puncture.
Jet of paint and pressurized gas exited the can through the rectum. The abdomen then became insufflated and tense.
Converted to exploratory laparotomy using scalpel and scissors via a para-median approach. After opening the abdomen, the surgeons manually decompressed the peritoneal cavity to evacuate any retained volatile gas.
Two areas of perforation noted over the sigmoid and descending colon.
Once the peritoneal cavity was decompressed, electro-cautery was utilized at which point a flash explosion emerged from the abdomen rising to a level above to surgeons’ head.
Intra-abdominal cavity was immediately irrigated with a liter of saline. Examination of the abdomen did not show any visceral thermal injury, nor were any persons in the operating room harmed. Surgeon’s gloves were damaged.
Abdomen was left open and packed after retrieving the foreign bodies. The patient was transferred to the ICU. Partial colectomy with a diverting ileostomy was done the following day.
The patient recovered after ten days in the ICU and was discharged in stable conditions.
Discussion
OR fires are infrequent but catastrophic--disfiguring, psychologically traumatic, and a major cause of medical malpractice litigation, and death.
Anticipate the situation where these three elements are present in high concentration and close proximity.
Change practice and processes in order to prevent these largely avoidable events:
Use oxygen blender to reduce Fi02 to 30% which will lessen the risk of combustion.
If more than 30% oxygen is required to maintain saturations then place LMA or intubate.
~70% the time ignition source is electrosurgical unit, which is used in 85% of surgeries. Fiberoptic light sources: Connect cables before activating. Place on standby/off before disconnecting. Avoid proximity to surgical drapes while on.
Flammable skin prepping solutions should be dry before draping. Attention to pooling.
The drying time for skin preparations might need to be longer than the manufacturer's recommendation (usually 2−3 min), 5 min might be preferable where possible
Laser Surgery: use laser resistant ETT, fill cuff with water instead of air.
Surgical drapes should be configured to minimize the accumulation of oxidizers (oxygen and nitrous oxide) under the drapes.
Gauze and sponges should be moistened when used in proximity to an ignition source.
•Where is the fire extinguisher is in your O.R.?
