Fuego quirúrgico. Un reto intraoperatorio
Surgical fires: An ongoing intra-operative challenge.
Abdulrasheed I, Lawal AM, Eneye AM.
Arch Int Surg [serial online] 2013 [cited 2013 Aug 28];3:1-5.
Abstract
Background: A surgical fire is a rare but life-threatening event. They are always unexpected and commonly occur in head and neck surgeries resulting in severe burns, disfigurement, and in some cases death. Injuries are not limited to patients alone as they may also involve health-care personnel in the operating theater. There is a resurgence in the awareness of this intra-operative challenge as well as an understanding of the need for a team approach to prevention. Materials and Methods: The surgical fire triangle is a useful paradigm that describes the three elements necessary for initiation of a surgical fire i.e., ignition source, fuel, and an oxidizer. This review will identify operating theatre contents capable of acting as ignition/oxidizer/fuel sources and highlight the management and prevention of surgical fires. Results: Surgical fires can be prevented by education across all professional boundaries in the operating theater. This will entail information on how the elements of the fire triangle interact, recognizing how standard operating room equipment can initiate a fire, and vigilance for the circumstances that increase the likelihood of a surgical fire. Conclusion: Promoting a culture of fire safety in the theater is not optional. Education on the prevention of surgical fires should be included in the curriculum of undergraduate medical students. There is an urgent need to stimulate debate within National burn associations in this context, leading to the formation of proposals to be incorporated into existing National burn prevention plans.
Keywords: Fire triangle, fuel, ignition, oxidizer, prevention, surgical fire
http://www.archintsurg.org/text.asp?2013/3/1/1/117117
Fuegos quirúrgicos. La comunicación perioperatoria es esencial para prevenir esta complicación pero devastadora
Surgical fires: perioperative communication is essential to prevent this rare but devastating complication.
Bruley ME.
Accident and Forensic Investigation, ECRI, 5200 Butler Pike, Plymouth Meeting, PA 19462, USA. mbruley@ecri.org
Qual Saf Health Care. 2004 Dec;13(6):467-71.
Abstract
A fire on or within a surgical patient is a continuing risk in modern surgery. Unfortunately, the sensitivity of surgical and anaesthesia staff to this hazard has waned over the past 25 years with cessation of the use of flammable anaesthetic agents. Prevention of surgical fires requires understanding the risks and effective communication between surgical, anaesthesia, and operating nursing staffs. Preventive measures exist but have yet to diffuse sufficiently across professional boundaries. Based on a review of relevant databases, decades of experience from field investigations, and a review of the medical literature, this paper discusses the incidence of surgical fires, the responsibility for prevention in the perioperative setting, and the procedures for surgical fire prevention and extinguishment.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743921/pdf/v013p00467.pdf
Pensando en tres de: Cambios en las prácticas de seguridad del paciente quirúrgico en el complejo quirófano moderno.
Thinking in three's: changing surgical patient safety practices in the complex modern operating room.
Gibbs VC.
Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, USA. verna.gibbs@va.gov
World J Gastroenterol. 2012 Dec 14;18(46):6712-9. doi: 10.3748/wjg.v18.i46.6712.
Abstract
The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgicalsafety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone have been unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stakeholders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.
KEYWORDS:
Complex adaptive systems, Retained foreign bodies, Retained foreign objects, Retained surgical items, Safety checklist, Surgical fires, Surgical patient safety, Wrong site surgery
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520159/pdf/WJG-18-6712.pdf
Soluciones quirúrgicas a base de alcohol y el riesgo de incendio en la sala de operaciones. Informe de un caso
Alcohol based surgical prep solution and the risk of fire in the operating room: a case report.
Batra S, Gupta R.
Department of Orthopaedic Surgery, Central Institute of Orthopaedics, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi - 110029, India. sumitbatra104@rediffmail.com.
Patient Saf Surg. 2008 Apr 26;2:10. doi: 10.1186/1754-9493-2-10.
Abstract
A few cases of fire in the operating room are reported in the literature. The factors that may initiate these fires are many and include alcohol based surgical prep solutions, electrosurgical equipment, flammable drapes etc. We are reporting a case of fire in the operating room while operating on a patient with burst fracture C6 vertebra with quadriplegia. The cause of the fire was due to incomplete drying of the covering drapes with an alcohol based surgical prep solution. This paper discusses potential preventive measures to minimize the incidence of fire in the operating room.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377238/pdf/1754-9493-2-10.pdf
Atentamente
Dr. Juan Carlos Flores-Carrillo
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
Surgical fires: An ongoing intra-operative challenge.
Abdulrasheed I, Lawal AM, Eneye AM.
Arch Int Surg [serial online] 2013 [cited 2013 Aug 28];3:1-5.
Abstract
Background: A surgical fire is a rare but life-threatening event. They are always unexpected and commonly occur in head and neck surgeries resulting in severe burns, disfigurement, and in some cases death. Injuries are not limited to patients alone as they may also involve health-care personnel in the operating theater. There is a resurgence in the awareness of this intra-operative challenge as well as an understanding of the need for a team approach to prevention. Materials and Methods: The surgical fire triangle is a useful paradigm that describes the three elements necessary for initiation of a surgical fire i.e., ignition source, fuel, and an oxidizer. This review will identify operating theatre contents capable of acting as ignition/oxidizer/fuel sources and highlight the management and prevention of surgical fires. Results: Surgical fires can be prevented by education across all professional boundaries in the operating theater. This will entail information on how the elements of the fire triangle interact, recognizing how standard operating room equipment can initiate a fire, and vigilance for the circumstances that increase the likelihood of a surgical fire. Conclusion: Promoting a culture of fire safety in the theater is not optional. Education on the prevention of surgical fires should be included in the curriculum of undergraduate medical students. There is an urgent need to stimulate debate within National burn associations in this context, leading to the formation of proposals to be incorporated into existing National burn prevention plans.
Keywords: Fire triangle, fuel, ignition, oxidizer, prevention, surgical fire
http://www.archintsurg.org/text.asp?2013/3/1/1/117117
Fuegos quirúrgicos. La comunicación perioperatoria es esencial para prevenir esta complicación pero devastadora
Surgical fires: perioperative communication is essential to prevent this rare but devastating complication.
Bruley ME.
Accident and Forensic Investigation, ECRI, 5200 Butler Pike, Plymouth Meeting, PA 19462, USA. mbruley@ecri.org
Qual Saf Health Care. 2004 Dec;13(6):467-71.
Abstract
A fire on or within a surgical patient is a continuing risk in modern surgery. Unfortunately, the sensitivity of surgical and anaesthesia staff to this hazard has waned over the past 25 years with cessation of the use of flammable anaesthetic agents. Prevention of surgical fires requires understanding the risks and effective communication between surgical, anaesthesia, and operating nursing staffs. Preventive measures exist but have yet to diffuse sufficiently across professional boundaries. Based on a review of relevant databases, decades of experience from field investigations, and a review of the medical literature, this paper discusses the incidence of surgical fires, the responsibility for prevention in the perioperative setting, and the procedures for surgical fire prevention and extinguishment.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743921/pdf/v013p00467.pdf
Pensando en tres de: Cambios en las prácticas de seguridad del paciente quirúrgico en el complejo quirófano moderno.
Thinking in three's: changing surgical patient safety practices in the complex modern operating room.
Gibbs VC.
Department of Surgery, San Francisco Veterans Affairs Medical Center, San Francisco, CA 94121, USA. verna.gibbs@va.gov
World J Gastroenterol. 2012 Dec 14;18(46):6712-9. doi: 10.3748/wjg.v18.i46.6712.
Abstract
The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgicalsafety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone have been unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stakeholders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.
KEYWORDS:
Complex adaptive systems, Retained foreign bodies, Retained foreign objects, Retained surgical items, Safety checklist, Surgical fires, Surgical patient safety, Wrong site surgery
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3520159/pdf/WJG-18-6712.pdf
Soluciones quirúrgicas a base de alcohol y el riesgo de incendio en la sala de operaciones. Informe de un caso
Alcohol based surgical prep solution and the risk of fire in the operating room: a case report.
Batra S, Gupta R.
Department of Orthopaedic Surgery, Central Institute of Orthopaedics, Vardhaman Mahavir Medical College & Safdarjung Hospital, New Delhi - 110029, India. sumitbatra104@rediffmail.com.
Patient Saf Surg. 2008 Apr 26;2:10. doi: 10.1186/1754-9493-2-10.
Abstract
A few cases of fire in the operating room are reported in the literature. The factors that may initiate these fires are many and include alcohol based surgical prep solutions, electrosurgical equipment, flammable drapes etc. We are reporting a case of fire in the operating room while operating on a patient with burst fracture C6 vertebra with quadriplegia. The cause of the fire was due to incomplete drying of the covering drapes with an alcohol based surgical prep solution. This paper discusses potential preventive measures to minimize the incidence of fire in the operating room.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377238/pdf/1754-9493-2-10.pdf
Atentamente
Dr. Juan Carlos Flores-Carrillo
Anestesiología y Medicina del Dolor
www.anestesia-dolor.org
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