Description of Event or Problem · 1
DURING A SURGICAL PROCEDURE (THORACIC LAMINECTOMY FOR SYRINX) A SUSPECTED BURN DEVELOPED AT THE INCISION SITE, AND AFTER INVESTIGATION AND RESEARCH, IT IS POSSIBLE THE REACTION MAY BE DUE TO A COMBINATION OF THE HEAT FROM THE MICROSCOPE'S XENON LIGHT SOURCE, THE USE OF DURAPREP AND THE IOBAN ANTIMICROBIAL DRAPE.THERE WAS NO IGNITION OR CHARRING OF THE DRAPE. THE NURSE CIRCULATING IN THIS CASE STATES THAT AT THE CONCLUSION OF THE CASE, UPON REMOVAL OF THE IOBAN DRAPE, IT APPEARED THAT THE SKIN LOOKED SOMEWHAT RED, AND THE IOBAN DRAPE WAS DIFFICULT TO REMOVE. THERE WAS SOME DISCUSSION BETWEEN THE SURGEON, THE PA, AND THE NURSE RELATED TO THE INTEGRITY OF THE SKIN AND WHETHER OR NOT IT WARRANTED MORE ATTENTION AT THAT TIME, BUT ACCORDING TO THE NURSE IN THE ROOM IT WAS DETERMINED THAT THERE WAS NO SERIOUS DAMAGE THAT THEY OBSERVED AT THE TIME. A DRY, STERILE DRESSING WAS APPLIED AND THE PATIENT HAD A TWO DAY STAY.THE MICROSCOPE USE IN THE CASE WAS LESS THAN 30 MINUTES. THERE WAS NO CHARRING, FIRE OR DRAPE IGNITION. THE LIGHT OF THE MICROSCOPE WAS 50% AND THE CIRCLE WAS RESTRICTED TO THE INTRADURAL AREA OF MICROSURGERY. IT IS NOT CLEAR THAT THE SKIN LESIONS ARE LIGHT RELATED BURNS. EQUALLY POSSIBLE IS A CHEMICAL BURN FROM THE DURA-PREP.HEALING IS PROGRESSING QUITE WELL. THERE HAVE BEEN NO ADDITIONAL SURGERIES REQUIRED.