Dr H, an orthopaedic specialist, was operating to remove metalwork from the leg of Miss P, a dancer in her twenties.
The operating department assistant applied a tourniquet over a bandage proximal to the operation site, to minimise intraoperative haemorrhage. Meanwhile, the operation site was painted with alcohol-based antiseptics containing chlorhexidine and povidone-iodine.
The surgery ran into difficulties and lasted for about two hours. When the tourniquet was removed it was immediately apparent that the antiseptics had leaked under it, badly blistering the skin compressed by the ligature.
The injury later took on the appearance of a severe burn and Dr H sent Miss P to see a cosmetic surgeon, who diagnosed a chemical burn. It affected the full thickness of the dermis in some areas and caused Miss P a lot of pain as well as unsightly scarring.
Miss P initiated a claim against Dr H. She alleged that he had breached his duty of care towards her by allowing the antiseptic to get under the tourniquet. Furthermore, according to the allegation, the assistant had not applied the tourniquet with sufficient care and Dr H had not adequately supervised him.
A dermatology expert commented that the chemical burn was caused by the prolonged compression of a strong alcohol-based solution against the skin. Miss P had previously had eczema which the expert thought might be a predisposing factor.
In effect, the expert agreed that the responsibility for the injury rested with Dr H, so we compensated Miss P for her suffering and scarring.
- Many topically applied preparations, particularly those containing alcohols, can cause damage by inducing contact dermatitis through allergy or irritation. They are also flammable, so their proximity to diathermy equipment must be monitored.
- In this case the antiseptic was in prolonged contact with the skin because the surgery was not as quick and simple as had been anticipated.
- The damage could have been prevented by applying the antiseptic distal to the ligature, which should have been shielded from seepage with water-repellent tape or a drape. We have also settled claims arising from ischaemic injury caused by tourniquets. If tourniquets will be used during a procedure, patients should be informed as part of the consenting process.
- Record the times at which a tourniquet is applied and released and avoid keeping it in use for overlong periods.
- Take care to apply tourniquets to skin over an appropriate protective membrane that is not in contact with any noxious material and, ideally, spreads the skin pressure over a larger area than the often thin band of standard tourniquets.
- Staff who work in theatre are also prone to injury by noxious substances. Those with responsibility for health and safety in operating theatres should ensure they have effective precautions in place to protect patients and staff alike, in line with current legislation in the relevant legal jurisdiction.
A recent review paper published by the Association of Operating Room Nurses, an American organisation, contains useful theatre-safety information and a self-assessment exercise.
- Pugliese G, Bartley JM, ‘Home Study Program. Can We Build a Safer OR?’ AORN J, 79(4):764–79; quiz 780–2, 785–6 (2004).