Alcoholic skin preparation: fire risks

The concept of cauterising using heat goes back hundreds of years, and it has become an invaluable tool within theatres. Electrocautery has been used since the late 1920s, helping to control bleeding during operations. It is also now being extended to initial skin incision – thanks to the key benefits of speed, less pain, haemostasis and minimal scarring. However, the use of electrocautery is accompanied by risk to the patient, surgeon and theatre staff – with potential hazards including burns, electrocution, theatre fire and smoke inhalation. Of all of these, it is the risk that a patient can be set on fire which has recently hit the headlines. Such cases are statistically rare, but incidents of fire involving the use of alcoholic skin preparations are devastating when they occur, and inevitably raise questions about patient safety. The National Reporting and Learning System (NRLS) identified 23 such incidents from 2003 to 2011. A further ten incidents involving diathermy indicate the incorrect use of skin preparations may have been a significant factor. Four of these incidents resulted in death or severe harm to the patient.

Patient trauma

Even in less serious cases, patients can take weeks to recover from additional burn injury and be left with residual scarring, not to mention the trauma of waking up with an unexpected injury caused by – usually – incorrect or ineffective practices during surgery. Fire can result when fuel, an oxidiser and an ignition source come together – exacerbated by an oxygen-rich environment and the use of a heatproducing source, such as diathermy or laser. In an operating theatre, electrocautery and spirit-based preparations are both used routinely and this widespread use of alcohol-based agents for skin antisepsis, as well as hand cleaning, has significantly increased the risk of fire and burn injuries. Hot wire cautery generates enough heat to ignite any alcohol-based antiseptic – even those containing as little as 20% alcohol. Apart from the obvious devastation for the patient, there can be potential legal consequences for both the surgeon and hospital involved in such an event.