An Australian man’s chest has caught fire during emergency heart surgery after a dry surgical pack ignited in a high oxygen environment, researchers report.
The 60 year old man with a history of COPD was undergoing surgery for a tear in the inner wall of the aorta when doctors had to suddenly increase the flow of oxygen in his anaesthetic to 100%.
Soon after, a spark from the electrocautery device ignited a dry surgical pack. The fire was immediately extinguished without any injury to the patient. The rest of the operation proceeded uneventfully and the repair was a success.
Dr Ruth Shaylor and colleagues from Melbourne’s Austin Health, where the incident took place, warn that the case highlights the potential dangers of dry surgical packs in the oxygen-enrich environment of the operating theatre where electrocautery devices are used.
“While there are only a few documented cases of chest cavity fires-three involving thoracic surgery and three involving coronary bypass grafting-all have involved the presence of dry surgical packs, electrocautery, increased inspired oxygen concentrations, and patients with COPD or pre-existing lung disease”, explains Dr Shaylor.
“This case highlights the continued need for fire training and prevention strategies and quick intervention to prevent injury whenever electrocautery is used in oxygen-enriched environments. In particular surgeons and anaesthetists need to be aware that fires can occur in the chest cavity if a lung is damaged or there is an air leak for any reason, and that patients with COPD are at increased risk.”
The researchers were presenting their case at the Euroanaesthesia conference in Vienna.