$12 Million after Baby's Oxygen Mask Ignites and severely burns

[Impromptu]

A Baby's Oxygen Mask Ignited During Surgery

I have never been involved in an airway fire. I never want to have one. From just the information in the newspaper article, I think that this airway fire was avoidable.

---

Members don't see this ad.

 

[deleted126335]

Rightly or wrongly, All OR fires are considered avoidable. Hence the term “never event”.

 

[DM27]

From the minimal description it sounds entirely avoidable. I wonder how necessary the supplemental O2 was in the first place aside from being "standard".

 

[okayplayer]

From the minimal description it sounds entirely avoidable. I wonder how necessary the supplemental O2 was in the first place aside from being "standard".

Presumably it was a MAC.

 

[deleted126335]

Presumably it was a MAC.

Or a mask anesthetic with the mask intermittently removed for surgical access and/or less than perfect mask seal.

 

[deleted171991]

The 3 most important things for patient safety: communication, communication, communication! That's why surgeons people with attitude don't belong in the OR.

 

[aneftp]

Most updated link

Madigan must pay $12.3M in operating-room fire that disfigured child

The child was undergoing a routine procedure to remove a cyst from his forehead when a surgeon's electric scalpel ignited a high-concentration of oxygen being used by an anesthesiologist, engulfing the child's boy's face in a fireball and disfiguring him...

www.seattletimes.com

 

[aneftp]

They lucky it’s government paying. Feel bad for child. But in private sector. Highly unlikely to ever get the 12 million dollars.

 

[sevoflurane]

Doubt they’ll get it as a lump sum either. Sad tho. Very sad.

 

[deleted126335]

Unless case tried in Philadelphia, Bronx, D.C., south Florida and a few other locations.

 

[coffeebythelake]

What was the thing about nurse anesthetist in training?

 

[Twiggidy]

I'm not peds anesthesiologist and I haven't done peds in a while, but in my head this is where peds LMAs or intubation with spontaneous breathing seems it would come in handy. I only post this so that this thread can maybe become a teaching point for residents and out of touch attendings like myself. As FFP said, one of the worst enemies of an anesthesiologist in an OR is a surgeon who doesn't communicate or wants something done out of THEIR convenience with a disregard for safety.

So let's M&M this case......is 13 mos to small for the smallest LMA if availabe? Would any of the peds people on here had dropped a tube? Again, I'm just curious for teaching sakes, and since the take on here is that "it's avoidable" can we talk about how to avoid it?

 

[deleted59964]

I'm not peds anesthesiologist and I haven't done peds in a while, but in my head this is where peds LMAs or intubation with spontaneous breathing seems it would come in handy. I only post this so that this thread can maybe become a teaching point for residents and out of touch attendings like myself. As FFP said, one of the worst enemies of an anesthesiologist in an OR is a surgeon who doesn't communicate or wants something done out of THEIR convenience with a disregard for safety.

So let's M&M this case......is 13 mos to small for the smallest LMA if availabe? Would any of the peds people on here had dropped a tube? Again, I'm just curious for teaching sakes, and since the take on here is that "it's avoidable" can we talk about how to avoid it?

Sad case,

A 13 month old usually weighs a bit over 10kg so an LMA 1.5 or even 2 would work.
I might have put a tube, or an LMA -- don't need NMBA in this age group - so a south facing RAE is a nice option

Can see how this might have happened though.

Surgeon -- "this will be real quick"
Anesthesiologist -- gas induction, IV looks tricky / don't want to slow things down / give kid bruises from trying ... therefore just hold a mask and don't manipulate the airway.
Surgeon -- diathermy --> fire

 

[HalO'Thane]

Sad case,

A 13 month old usually weighs a bit over 10kg so an LMA 1.5 or even 2 would work.
I might have put a tube, or an LMA -- don't need NMBA in this age group - so a south facing RAE is a nice option

Can see how this might have happened though.

Surgeon -- "this will be real quick"
Anesthesiologist -- gas induction, IV looks tricky / don't want to slow things down / give kid bruises from trying ... therefore just hold a mask and don't manipulate the airway.
Surgeon -- diathermy --> fire

You can still do a facemask with 30% or less FiO2 to minimize your risk of an airway fire. However, like other people have commented I probably would have put in either an LMA or an ETT. Even with an LMA I probably still would’ve run the patient on lower FiO2 in case it does not seat well and there is a leak. Perhaps I am more paranoid than other people but I trust no one, especially surgeons.

 

[WholeLottaGame7]

That surgeon is FOS. 100% preventable.

No reason for a healthy kid to need 90% oxygen unless you're about to intubate or extubate, and even then, that's being overly (unnecessarily?) cautious.

No reason to not communicate fire risk between the surgeon and the anesthesia team.

You could do this case with a mask, with an LMA, or with a tube. If they're draping everything out and I can't see the airway/kid, I'm at least putting an LMA in.

 

[coffeebythelake]

That surgeon is FOS. 100% preventable.

No reason for a healthy kid to need 90% oxygen unless you're about to intubate or extubate, and even then, that's being overly (unnecessarily?) cautious.

No reason to not communicate fire risk between the surgeon and the anesthesia team.

You could do this case with a mask, with an LMA, or with a tube. If they're draping everything out and I can't see the airway/kid, I'm at least putting an LMA in.

Surgeon is either a complete *****, or pretending to be one. I dont know what is worse

 

[2010houston]

Are we even sure it *wasnt* an LMA? Article is not totally clear and certainly “laryngeal mask airway” = mask would not be the craziest medical misinformation that has been accidentally reported. Agree w LMA for most of these types of cases.

 

[MediCane2006]

As FFP said, one of the worst enemies of an anesthesiologist in an OR is a surgeon who doesn't communicate or wants something done out of THEIR convenience with a disregard for safety.

As a peds surgeon, a case like this just baffles me but also makes me realize I have a great relationship with our anesthesiology physicians. We usually are talking about the anesthetic plan for the next kid with the anesthesiologist while we are finishing up a case. If we are thinking about mask only, we plan to not fully drape and we don’t even open a cautery. And for facial cases around the nose and mouth if there is an LMA in place we have a discussion about fire risk in the time out and a verbal confirmation before cautery is used. Maybe I am jinxing myself a little bit but it seems like this could have been avoided with good communication and proper safety checks.

 

[deleted171991]

Surgeon is either a complete *****, or pretending to be one. I dont know what is worse

The anesthesiologist wasn't a genius either. No reason a healthy toddler can't be on 100%... air (except for sevo).

 

[coffeebythelake]

The anesthesiologist wasn't a genius either. No reason a healthy toddler can't be on 100%... air (except for sevo).

agree this was bad all around
i was specifically referring to the quote from the article where the surgeon said this was not preventable.

 

[HighPriest]

Facial cyst on a kid this age - no reason to use electrocautery. If you think you need to do so, talk to your anesthesiologist. If I knew my anesthetist was using only a mask, I wouldn’t.

In general, I wouldn’t use cautery in a case like this (making some assumptions). More collateral damage, more scarring. Cold steel - not that much bleeding. If it’s THAT big - kid should be intubation anyway. If it isn’t, cold steel, maybe bipolar if absolutely necessary, but usually not necessary.

 

[midazzoler]

As a peds surgeon, a case like this just baffles me but also makes me realize I have a great relationship with our anesthesiology physicians. We usually are talking about the anesthetic plan for the next kid with the anesthesiologist while we are finishing up a case. If we are thinking about mask only, we plan to not fully drape and we don’t even open a cautery. And for facial cases around the nose and mouth if there is an LMA in place we have a discussion about fire risk in the time out and a verbal confirmation before cautery is used. Maybe I am jinxing myself a little bit but it seems like this could have been avoided with good communication and proper safety checks.

Coworker Reports of Unprofessional Behavior by Surgeons and Surgical Complications in Their Patients

This cohort study assesses the association between surgeons with higher numbers of reports from coworkers about unprofessional behaviors and the risk for postoperative complications in their patients.

jamanetwork.com

Not trying to blame surgeons but I think this article is evidence of what we all know. If there isn’t a good relationship with people in the room patients can suffer.

 

[Urzuz]

You can still do a facemask with 30% or less FiO2 to minimize your risk of an airway fire. However, like other people have commented I probably would have put in either an LMA or an ETT. Even with an LMA I probably still would’ve run the patient on lower FiO2 in case it does not seat well and there is a leak. Perhaps I am more paranoid than other people but I trust no one, especially surgeons.

Really? It’s easy to play Monday morning quarterback but I have done tons of facial cases with LMAs and have never thought of 1.0 FiO2 being contraindicated. This is a good learning point for me to be aware of going forward though...will be a little more apprehensive about it now!

 

[deleted171991]

Coworker Reports of Unprofessional Behavior by Surgeons and Surgical Complications in Their Patients

This cohort study assesses the association between surgeons with higher numbers of reports from coworkers about unprofessional behaviors and the risk for postoperative complications in their patients.

jamanetwork.com

Not trying to blame surgeons but I think this article is evidence of what we all know. If there isn’t a good relationship with people in the room patients can suffer.

This surgeon deserves to be blamed. The man lied under oath that the accident was not preventable. Either that, or he is so incompetent he doesn't deserve a medical license.

 

[HighPriest]

Yeah, again I’m making assumptions because I don’t know exactly what happened, but I think you have to blame the surgeon and poor communication. As much as I like to blame you guys for everything, this really isn’t the time. Could O2 have been decreased? Probably. That’s a communication issue.
But the rest of it?
If I do a small facial case like this (I’m assuming it’s small simply because they used a mask instead of intubating), I try not to use cautery, I try not to use chlorhexidine (or if I do, we time it), and I don’t drape over the face specifically to prevent this. In an adult I’d do a case like this in clinic without a full drape, so adding one in the OR is just asking for a fire.

This is a textbook way to set someone on fire (unless, again, there are missing pertinent details).

I definitely can’t think of any reason you could honestly say this “wasn’t avoidable.” Even if you ran in to unexpected bleeding and had to bovine your way out (hypothetically), it’s a face. There isn’t a vessel big enough where you can’t hold pressure until the O2 blows off.

 

[caligas]

Oxygen Leakage Around the Laryngeal Mask Airway During... : Anesthesia & Analgesia

we are aware of four cases in which either the eyebrows or eyelashes were ignited during the administration of general anesthesia via a face mask. The laryngeal mask airway (LMA) recently has become widely available and this device might decrease the risk of fire during treatment of these...

journals.lww.com

Error - Cookies Turned Off

onlinelibrary.wiley.com

 

[anbuitachi]

I dont know about other places but fire risk is part of our time out before surgery starts.

 

[anbuitachi]

Oxygen Leakage Around the Laryngeal Mask Airway During... : Anesthesia & Analgesia

we are aware of four cases in which either the eyebrows or eyelashes were ignited during the administration of general anesthesia via a face mask. The laryngeal mask airway (LMA) recently has become widely available and this device might decrease the risk of fire during treatment of these...

journals.lww.com

Error - Cookies Turned Off

onlinelibrary.wiley.com

I dont understand the summary of this study. "During spontaneous ventilation, high concentrations of oxygen leaked around the mask in every case (mean 63% ± 16%), but in only one case was a concentration more than 21% detected around the LMA (P < 0.001). "

The high concentrations of oxygen leak which happens 63% of the time, couldn't bump O2 levels around the LMA above Room air except in 1 case???

"Anesthesia via a mask with oxygen and nitrous oxide should not be used while lesions around the eyes are treated, due to the risk of igniting the eyebrows or eyelashes. "

Didn't the study just say only 1 case of > 21% was detected around the LMA?? The eye is far from the LMA. So why not.

 

[nimbus]

I dont understand the summary of this study. "During spontaneous ventilation, high concentrations of oxygen leaked around the mask in every case (mean 63% ± 16%), but in only one case was a concentration more than 21% detected around the LMA (P < 0.001). "

The high concentrations of oxygen leak which happens 63% of the time, couldn't bump O2 levels around the LMA above Room air except in 1 case???

"Anesthesia via a mask with oxygen and nitrous oxide should not be used while lesions around the eyes are treated, due to the risk of igniting the eyebrows or eyelashes. "

Didn't the study just say only 1 case of > 21% was detected around the LMA?? The eye is far from the LMA. So why not.

There’s oxygen leak with face mask but not with LMA or ETT. That paper is from 1994. People we’re still doing mask generals then.

 

[IlDestriero]

There’s oxygen leak with face mask but not with LMA or ETT. That paper is from 1994. People we’re still doing mask generals then.

Apparently they still are in Madigan.

 

[sbhfl]

The anesthesiologist wasn't a genius either. No reason a healthy toddler can't be on 100%... air (except for sevo).

Genuinely curious. Do you share the airway with surgeons say clipping a tongue tie in otherwise healthy toddler on less than 100% FiO2? There's always the chance they'll need electrocautery but I've never seen it. I do work with rotating surgeons from time to time (don't know them extremely well) but most would get it done within maybe 2 or 3 apneas-- potentially needing more if on just room air.

 

[nimbus]

Genuinely curious. Do you share the airway with surgeons say clipping a tongue tie in otherwise healthy toddler on less than 100% FiO2? There's always the chance they'll need electrocautery but I've never seen it. I do work with rotating surgeons from time to time (don't know them extremely well) but most would get it done within maybe 2 or 3 apneas-- potentially needing more if on just room air.

That’s a different situation. When the surgeon is working, the mask and the oxygen source are away from the baby.

 

[WholeLottaGame7]

Genuinely curious. Do you share the airway with surgeons say clipping a tongue tie in otherwise healthy toddler on less than 100% FiO2? There's always the chance they'll need electrocautery but I've never seen it. I do work with rotating surgeons from time to time (don't know them extremely well) but most would get it done within maybe 2 or 3 apneas-- potentially needing more if on just room air.

Uh, yes? Can you tell me why you need a PO2 of 500 for any case? People realize that hyperoxia has deleterious effects, yes? Does it matter for a short case, probably not.

 

[coffeebythelake]

Presumably it was a MAC.

Even if MAC, you can adjust your FiO2 by hooking up the NC to a blender device or to your circuit

 

[sbhfl]

Uh, yes? Can you tell me why you need a PO2 of 500 for any case? People realize that hyperoxia has deleterious effects, yes? Does it matter for a short case, probably not.

I'm hoping for a more serious answer. PaO2 drops like a rock when you're apneic with little lungs full of room air. Like I said, I've never seen an intermittent apnea case done without 100% FiO2. Do you do these cases with RA or are you just giving your two cents?

 

[coffeebythelake]

I'm hoping for a more serious answer. PaO2 drops like a rock when you're apneic with little lungs full of room air. Like I said, I've never seen an intermittent apnea case done without 100% FiO2. Do you do these cases with RA or are you just giving your two cents?

There's kind of a big range between room air and 100% fio2

 

[aneftp]

Sad case,

A 13 month old usually weighs a bit over 10kg so an LMA 1.5 or even 2 would work.
I might have put a tube, or an LMA -- don't need NMBA in this age group - so a south facing RAE is a nice option

Can see how this might have happened though.

Surgeon -- "this will be real quick"
Anesthesiologist -- gas induction, IV looks tricky / don't want to slow things down / give kid bruises from trying ... therefore just hold a mask and don't manipulate the airway.
Surgeon -- diathermy --> fire

It’s the govt hospital. No one is in a rush. Nothing is quick or hurry.

No excuses.

 

[sbhfl]

There's kind of a big range between room air and 100% fio2

Let me spell things out because I think you're missing the point. Keep in mind you're talking to an anesthesiologist seeking advice from other professionals who I wouldn't otherwise have access to. This advice could change my practice and care of real, living human beings.

To be clear, in an intermittent apnea case you are generally sharing the airway with an ENT surgeon. The surgeon needs access to the mouth or nose or nearby skin. 100% FiO2 during mask ventilation maximizes the time the surgeon has during apneas. Of course, you can do less than that. So the question is, and for people who actually do these cases, do you do less than that? What do you do and why?

 

[pgg]

I'm hoping for a more serious answer. PaO2 drops like a rock when you're apneic with little lungs full of room air. Like I said, I've never seen an intermittent apnea case done without 100% FiO2. Do you do these cases with RA or are you just giving your two cents?

You're right, apneic oxygenation requires 100% FiO2 and thorough denitrogenation, but the key there is that those cases don't leave flammable objects in the airway or surgical field.

If there's a fuel source there and a laser/electrocautery going on, the FiO2 simply must be under 30. And the apnea periods just have to be short sometimes.

 

[deleted59964]

It’s the govt hospital. No one is in a rush. Nothing is quick or hurry.

No excuses.

1. I work in a government hospital - we work in an inefficient system where it is a constant grind to get things done, good surgeons, anesthesiologists, and yes even some nurses push against this constantly trying to get stuff done - because we have people waiting for operations.

2. Hurrying is never an excuse for suboptimal care.

3. Choosing not to place an IV in a child for a case where surgical time < anaesthetic is sometimes in and of itself good practice

 

[WholeLottaGame7]

So the question is, and for people who actually do these cases, do you do less than that? What do you do and why?

Let me spell things out because I think you're missing the point. Keep in mind you're talking to a (pediatric) anesthesiologist (who does these cases for a living).

Yes. Because nobody needs a PaO2 of 500. Kids do not drop like a rock on RA just because they go apneic. The only time I run kids on 100% FiO2 is if they are doing an airway eval where they are instrumenting the airway (without electrocautery).

 

[Hoya11]

That surgeon is FOS. 100% preventable.

No reason for a healthy kid to need 90% oxygen unless you're about to intubate or extubate, and even then, that's being overly (unnecessarily?) cautious.

No reason to not communicate fire risk between the surgeon and the anesthesia team.

You could do this case with a mask, with an LMA, or with a tube. If they're draping everything out and I can't see the airway/kid, I'm at least putting an LMA in.

yes the kid should have been intubated for this procedure and masking here is the lazy option with this unintended consequence

 

[jwk]

Let me spell things out because I think you're missing the point. Keep in mind you're talking to a (pediatric) anesthesiologist (who does these cases for a living).

Yes. Because nobody needs a PaO2 of 500. Kids do not drop like a rock on RA just because they go apneic. The only time I run kids on 100% FiO2 is if they are doing an airway eval where they are instrumenting the airway (without electrocautery).

Speaking as someone who practiced before pulse oximetry was available - this is why we have pulse oximetry. SaO2 99%? I'm happy.

 

[Neopolymath]

How does this not get brought up in timeout? Is there no fire risk assessment everywhere at this point in time?

 

[deleted126335]

Fire risk assessment is not part of our time out.

 

[Neopolymath]

Fire risk assessment is not part of our time out.

Hmm. We had a quick form for calculating a fire risk score that essentially just prompted/forced thinking about this at the start of each case.

 

[Arch Guillotti]

Fire risk assessment is not part of our time out.

Time out is a point to voice any concerns about the case.