Last updated June 3, 2019 at 4:47 pm
A conference has heard of a case where a flash fire broke out in a man’s chest cavity, in the middle of an emergency heart surgery.
A surgery went awry when the patient’s chest cavity caught on fire.
Infections or perforations are not uncommon complications that arise from surgery. A flash fire in the chest cavity on the other hand? That might be a little more than a complication.
The idea seems well outside the realm of possibility. But for one patient it was a reality, when his chest caught on fire in the middle of emergency heart surgery.
Electrocautery spark ignited surgical pack
The 60 year old patient, who had a history of chronic obstructive pulmonary disease (COPD) went in for an emergency repair of a tear in the inner layer of the aorta wall in his chest.
In the early stages of the surgery, the operating team noticed that the man’s right lung was stuck to the overlying sternum. There were also areas of over-inflated and destroyed lung.
Despite careful dissection, an air-filled sac in the lung, known as a bulla, was punctured, causing a significant air leak.
In order to prevent respiratory distress, the operating team increased the flow of anaesthetic gases to 10 litres per minute. The proportion of oxygen was also increased to 100 per cent.
That was where it all went wrong for the operating team.
The combination of increased oxygen and a spark from the electrocautery device – which is used to stop bleeding- caused a dry surgical pack to ignite.
Then, the patient’s chest caught on fire.
Thankfully, the team jumped into action and extinguished the fire. The patient didn’t suffer any injuries and the heart surgery was completed without any other hiccups.
It’s not known how the surgeons explained what happened to the patient.
The dangers of dry surgical packs
The case, which occurred in late 2018, was presented at a conference in Vienna, Austria by Dr Ruth Shaylor from Austin Health, where the incident took place.
In the report presented to the conference, Shaylor points out that chest cavity fires are not a common event in the operating theatre.
However, she warns that this case highlights the dangers of dry surgical packs in the oxygen-rich operating theatre where electrocautery devices are used.
“This case highlights the continued need for fire training and prevent 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,” she says.
