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Fire in the Operating Room During Hypospadias Repair
Alessandro Boscarelli1, Simone Frediani1, Silvia Ceccanti1
1Pediatric Surgery Unit, Sapienza University of Rome, Azienda Policlinico Umberto I, Rome, RM, 00161, Italy.
Insights
Operating room (OR) fires are rare but dangerous. This case highlights a rare OR fire in a pediatric patient during hypospadias surgery, emphasizing the need for vigilance with alcohol-based solutions and electrocautery.
Area of Science:
- Medical Safety
- Pediatric Surgery
- Surgical Fire Prevention
Background:
- Operating room (OR) fires are infrequent but severe adverse events.
- Established safety protocols aim to prevent surgical fires.
- Pediatric OR fire cases are significantly underreported compared to adult cases.
Observation:
- A 16-month-old male underwent reconstructive surgery for penoscrotal hypospadias.
- An intraoperative fire occurred during the procedure.
- The fire was likely initiated by an alcohol-based solution and monopolar electrocautery.
Findings:
- This report details a rare instance of an operating room fire in a pediatric patient.
- The incident involved a 16-month-old undergoing hypospadias repair.
- The probable cause was the ignition of an alcohol-based prep solution by electrocautery.
Implications:
- Highlights the critical need for heightened awareness and adherence to safety protocols in pediatric ORs.
- Underscores the fire risks associated with alcohol-based solutions combined with electrocautery in young patients.
- Suggests a review of current safety guidelines for pediatric surgical fire prevention is warranted.
Abstract:
Fire in the operating room (OR) is a very distressful and shocking occurrence with potential dramatic consequences. Despite safety rules and rigorous recommendations, such unintentional events do occur every so often. Notably, the vast majority of cases have been reported in the adult population, with very few pediatric cases described to date. Herein, we report on a 16-month-old boy undergoing reconstructive surgery for penoscrotal hypospadias, who experienced an OR fire most likely related to the use of alcohol-based solution ignited by monopolar electrocautery.
