April issue.indd

J.B. Webb S. Balaratnam A.J. Park
Department of Plastic Surgery, George Eliot Hospital, College Lane, Nuneaton, Warwickshire, CV10 7DJ, U.K.

Correspondence to: A.J. Park, Department of Plastic Surgery, George Eliot Hospital, College Lane, Nuneaton, Warwickshire, CV10 7DJ, U.K. Email: alan.park@geh-tr.wmids.nhs.uk

Introduction

Keywords: Diathermy, adverse effects, flame burns, spirit skin preparations, intra-operative complications
Surg J R Coll Surg Edinb Irel., 1 April 2003, 111-113

Diathermy and spirit-based skin preparations are both used on a daily basis in most hospital theatres. We report a case illustrating the potential hazards of this combination and discuss the management of its complications and possibilities of their prevention

INTRODUCTION
Diathermy is a useful tool and is commonly used in daily practice by surgeons of all specialities. However, the dangers associated with it are often disregarded, and rarely taught to junior surgeons. Furthermore, the treatment of diathermy injuries often requires expertise in the management of the burns sustained. We report an incident which illustrates these facts. A patient sustained diathermy burns but referral to a plastic surgeon was delayed and, as a result, the patient received sub-optimal treatment of the burns.

CASE REPORT
A 67-year-old male was admitted for an examination under anaesthesia, sigmoidoscopy, banding of haemorrhoids and excision of anal skin tags. He was anaesthetised, and placed in the lithotomy position. A 70% spirit-based chlorhexidine skin preparation was used. Following the sigmoidoscopy and treating the haemorrhoids, the surgeon continued by excising the anal skin tags using monopolar diathermy. A spark ignited residual spirit that had pooled beneath his buttocks and a fire lasting several seconds followed. The patient sustained burns of the scrotum, perineum and buttocks (Figure 1a and 1b). Cold saline soaks were applied as first-aid.

The burns were treated conservatively with 1% silver sulphadiazine cream and paraffin-gauze dressings. He was also given a course of co-amoxyclav, although no clinical signs of infection were recorded.

After seven days the patient was referred to a plastic surgeon, the senior author who visited the hospital weekly. Therefore, it was not until 13 days after the injury that the plastic surgical team saw him, as an outpatient. Examination on that day showed that he had deep dermal burns on each buttock that were 5cm in diameter and also had a full-thickness burn on his scrotum that was approximately 6 x 4cm. The patient was offered surgery (excision of the burn and split skin grafting [SSG]). This would lead to significant healing within seven days after which it was probable that he would require dressings for minor unhealed patches for a few days longer but that there was a small possibility of complete graft loss. He elected to continue with conservative treatment despite the information that healing would take several weeks or months. He understood that he would require frequent dressing changes which are normally associated with significant pain or discomfort. The patient felt that he had had ‘quite enough of theatres’ at that time.

DISCUSSION
The dangers of diathermy use are well-described and represent a significant cause of morbidity that often results in delayed discharge.⁷ Sudhindra et al (2000) recently demonstrated that both consultants and juniors can be ignorant of the potential hazards of diathermy.² Frequently, the placement of the diathermy plate is delegated and the surgeons are not familiar with the details of safe practice. We describe an incident that has not been mentioned in the literature for some time. The annual reports from the medical defence societies have often described similar events (Medical Protection Society annual reports 1980, 1982, 1988), but not for several years. Aigner et al (1997) reviewed the complications of the use of diathermy but failed to mention flash or flame burns.³ Only one of four popular basic surgical texts discusses diathermy and the complications of its use.^4-7

The solution employed to prepare a site for surgery varies according to the surgeon’s preference. There is evidence that there is a greater reduction in the perineal bacterial population after the use of detergent or spiritbased antiseptics, compared with water-based ones.⁸ However, there is no evidence that using a spirit-based skin preparation reduces the rate of post-operative infective complications. Inherent with the use of spirit-based solutions is the risk of fire.⁹

Currently, surgical drapes tend to be waterproof rather than absorbent. This increases the risk of excess fluid lying in pools near the operative field. Extra care must be taken to ensure that the dependent areas are dry if spirit-based solutions are used.

In view of the risk of burn injuries during surgery, it is imperative that all personnel have knowledge of basic first-aid. Heat is generated in flash and flame burns. The object of first-aid is to stop the burning process by extinguishing the flames and by taking the heat from the tissues using cold wet soaks for at least 10 minutes.¹⁰ Some have argued that fire extinguishers should be available in theatres and that personnel should be trained in their use.¹¹ After applying first-aid, advice regarding further management should be sought from a plastic surgeon. Conservative management involving topical antiseptics (e.g. silver sulphadiazine) and non-adherent dressings (e.g. paraffin-impregnated gauze) are the mainstay of treatment. However, silver sulphadiazine makes the burn depth difficult to assess and, therefore, its use should be delayed until the burns have been seen by a plastic surgeon. Antibiotics rarely have a place in the early management of small burns. They should be used only when there is evidence of clinical infection, and not routinely following a positive swab culture. Patients with deepdermal or full-thickness burns and those that fail to heal with conservative management are offered surgical intervention. Surgical debridement of the burn (i.e. excision or shaving of the burn) and the application of SSG is normally the treatment of choice. This hastens healing and, thereby, reduces scarring. Healing by secondary intention typically leaves thicker scars which take longer to mature and cause more contraction. If early advice had been sought in the case presented here, the burn would have been easier to assess and antibiotics almost certainly would have been avoided. The patient chose not to have surgery and, thus, complete healing was delayed.

Figure 2a: Appearance of burn on the buttocks when healed, but before scar maturation.

Figure 2b: Appearance of burn on the scrotum when healed, but before scar maturation.

CONCLUSION
In the current climate of clinical governance and revalidation, surgeons must be seen to be learning from former mistakes and accidents. Confirmation of pertinent core knowledge and emergency practice needs to be a part of the revalidation process. We believe that this should include basic first-aid, safety procedures in theatre that encompasses the use of diathermy, and the acceptance that we need to seek advice early when a problem is outside our normal practice.

REFERENCES
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