Medical Device: Facial Burn During Surgery


Ted Milo, B.E.E.E. ::::

Case Synopsis: Plaintiff was undergoing cosmetic facial reconstruction surgery following tumor removal. The plaintiff was prepped with a sterile draping. Oxygen was being fed to the patient via a plastic oxygen mask. Upon activation of the electro-cautery/surgical device, the drapes and mask caught fire resulting in burns to the patient’s face and neck. Plaintiff asserted the anesthesiologist caused the incident by failing to remove the flow of oxygen in advance of cautery activation resulting in the ignition of the drapes and mask. Plaintiff also alleged the cautery device was defective due to the resulting ignition of the drapes.

Expert Analysis: Paper drapes, plastic materials, skin, and hair are highly combustible in an oxygen enriched environment. Studies confirm that the combustibility of sterile drapes and the endotracheal tubes, etc., as well as the required flow and concentration of oxygen is necessary to support as well as prevent this occurrence, especially during head and neck surgery.

Result: The analysis confirmed the cause of injury was the result of miss-managed oxygen just prior to use of the electro-cautery/surgical device, as well as, the failure to warn of these well documented events by several of the device manufacturers.

Categories: Case Studies


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