Description of Event or Problem · 1
A SIGNIFICANT FULL THICKNESS BURN WAS NOTICED UPON UN-DRAPING THE PATIENT BY CSI RN, AND THE SURGICAL TEAM REVIEWED. AN ASSUMPTION WAS MADE BY THE RESIDENT THAT IT WAS CAUSED BY NEUROMONITORING WHILE IN THE MRI. UPON RECEIVING NOTIFICATION, WE ASSEMBLED A CROSS-FUNCTIONAL FACT-FINDING TEAM COMPRISED OF NEUROMONITORING (IOM), MRI RESEARCH TECH, CSI RNS, AND CSI OPERATIONS. OUR DISCUSSION PRODUCED THE FOLLOWING FACTS AND OBSERVATIONS: FACTS: 12 HR SURGERY; 28 IOM LEADS WERE PLACED ON THE PATIENT; PLASTICS REQUIRED THAT THE ENTIRE BACK AND BACK OF THE LEFT UPPER LEG AND ENTIRE RIGHT LEG OF THE PATIENT BE PREPPED (STERILE FIELD) FOR POTENTIAL FLAP HARVEST. COMMENT: THIS SIGNIFICANTLY REDUCED THE REAL ESTATE FOR BOVIE PAD AND LEAD PLACEMENT (AGE AND SIZE OF PATIENT); BOVIE PAD WAS PLACED ON LEFT THIGH APPROXIMATELY 1 1/2 TO 2" FROM IOM LEAD LQD (LEFT QUADRICEPS); IOM LEAD LQD WAS AT OR NEAR THE CENTER OF THE BURN; THE IOM LEAD LQD WAS COVERED WITH A MEPILEX 3"X3" PAD; BURN WAS DISCOVERED WHEN DRAPES WERE REMOVED AFTER SURGERY; BURN WAS LOCATED ON LEFT LEG, LATERAL THIGH JUST ABOVE KNEE; 2 PLASTIC DRAPES TO COVER PATIENT WERE USED PRIOR TO MRI SCAN, THE FIRST DRAPE WAS CUT AND OPENED TO FORM A CYLINDER WHILE THE SECOND DRAPE WAS LEFT INTACT. (COMMENT)THE PURPOSE WAS TO CREATE A LONGER PLASTIC BARRIER TO PROTECT THE LONG STERILE FIELD. TOTAL MRI SCAN TIME = 78 MINUTES; 2 EXTRA MRI SEQUENCES WERE RUN FOR A TOTAL OF 17:38 MINUTES; THE MRI COIL WAS FOUND TO BE ON THE RIGHT SIDE OF THE PATIENT WHEN THE SCANNER WAS REMOVED FROM THE OPERATING ROOM. IOM DID NOT REPORT ANY ABNORMALITIES DURING THE CASE. HOWEVER, AS THE CASE PROGRESSED THERE WAS A REDUCTION IN THE AMPLITUDE OF THE TRANS-CRANIAL MOTOR EVOKED POTENTIAL RESPONSE FROM THE LEFT QUADRICEPS MUSCLE AND LATER IN THE CASE THE LEFT GASTROCNEMIUS MUSCLE WHICH WERE REPORTED TO THE SURGEON AT THE TIME THEY OCCURRED. ANESTHESIA MADE AT LEAST 2 TRIPS IN TO ADMINISTER TO THE PATIENT DURING MRI SCAN; CHLORAPREP WAS USED TO PREPARE THE PATIENT'S STERILE FIELD. OBSERVATIONS: THE MRI COIL APPEARED TO HAVE SLIPPED OFF THE PATIENT DURING THE SCANNING PROCESS. (ASSUMPTION) SINCE THE COIL WAS TAPED TO THE DRAPE, THE SLIPPERY SURFACE CAUSED BY THE 2 BAGS JOINING OVER A 18" WIDE SECTION PRODUCED THE SLIPPAGE. ADDITIONALLY, THE DRAPES WERE NOT SECURED CIRCUMFERENTIALLY WITH TAPE. MRI SCAN TOOK ABOUT 15-20 MINUTES LONGER DUE TO RE-RUNNING SEQUENCES DUE TO POOR IMAGE QUALITY (ASSUMPTION) DUE TO COIL SLIPPAGE; THE PATIENT WAS SATURATED IN PERSPIRATION AFTER THE MRI WHEN THE PLASTIC DRAPES WERE REMOVED. THIS SAME GROUP PLUS ONE ADDITIONAL STAFF MEMBER REASSEMBLED ON THURSDAY IN THE CSI WITH THE INTENT OF RE-CREATING THE SCENARIO UNDER WHICH THE EVENT OCCURRED. OUR WORKING THEORY WAS THAT THE BOVIE PAD WAS PLACED TOO CLOSE TO THE IOM LEAD AND THAT THE PAD BECAME COMPROMISED OR THE PROXIMITY OF THE BOVIE PAD IN RELATION TO THE IOM LEAD IN SOME WAY SHUNTED THE CURRENT FROM THE BOVIE PAD THROUGH THE IOM LEAD. WE REPLICATED (AS BEST WE COULD) THE CONDITIONS, EQUIPMENT, AND LOCATIONS OF BOVIE PAD AND LEAD. A LARGE TURKEY BREAST WAS USED AS OUR SUBJECT. WE WERE NOT ABLE TO REPRODUCE ANY CONDITION THAT SAW A RISE IN TEMPERATURE ON THE IOM LEAD EITHER WITH NEAR-CONTINUOUS BOVIE USE (~1HR) OR THE EXACT SAME MRI SEQUENCES. AFTER OUR EXPERIMENT, WE HAD BIOMED RE-CERTIFY THE ECU'S FROM THE CSI OPERATING ROOM AND NOTHING WAS FOUND OUT OF THE ORDINARY. IOM ALSO RE-VALIDATED THEIR EQUIPMENT AND FOUND NO ANOMALIES. THIS GROUP UNANIMOUSLY AGREED THAT WHILE WE COULD NOT PROVE OUR HYPOTHESIS IN A LAB EXPERIMENT, OUR WORKING THEORY WAS THE PROBABLE CAUSE OF THE BURN AND THEREFORE SUBMITS THE FOLLOWING RECOMMENDATIONS FOR CONSIDERATION FOR ALL SURGERIES THAT INCLUDE NEUROMONITORING IN THEIR SURGERIES: BOVIE PLACEMENT SHOULD BE AS FAR AWAY AS PRACTICAL FROM LEAD PLACEMENT. IOM SHOULD HAVE FINAL APPROVAL ON BOVIE AND LEAD PLACEMENT. IOM LEADS, ALTHOUGH TAPED, SHOULD NOT BE COVERED BY MEPILEX OR ANY OTHER FULL PLACEMENT COVERING ALLOWING ENTRAPMENT OF MOISTURE, PERSPIRATION, ETC AROUND LEAD AREA. CARE SHOULD BE TAKEN TO FULLY DRY OR WIPE AWAY ANY OXIDIZING COMPOUND (IN THIS CASE, CHLORAPREP) NEAR ANY ELECTRICAL COMPONENT (IOM LEAD, BOVIE PAD, ETC).