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Burns from warming devices in anesthesia. A closed claims analysis
F W Cheney1, K L Posner, R A Caplan
1Department of Anesthesiology, University of Washington School of Medicine, Seattle 98195.
Anesthesiology
|April 1, 1994
Summary
Warming patients during surgery can cause burns, especially from IV fluid bags heated in ovens. These burns are preventable and suggest safer warming methods are needed for patient safety.
Area of Science:
- Anesthesiology
- Patient Safety
- Medical Device Safety
Background:
- Hypothermia prevention is crucial during anesthesia.
- Warming methods can inadvertently cause patient burns.
- Review of the American Society of Anesthesiologists (ASA) Closed Claims Project database for burn patterns.
Purpose of the Study:
- To identify recurrent injury patterns from intraoperative patient warming methods.
- To analyze burn incidents linked to specific warming techniques.
Main Methods:
- Analysis of the ASA Closed Claims Project database.
- Inclusion of all reviewed burn claims.
- Categorization of burns by warming method and patient demographics.
Main Results:
- 54 burn claims identified from 3,000 total claims.
- 28 burns resulted from warming devices; 18 from IV fluid bags/bottles heated in ovens.
- Burns from warmed IV fluids predominantly affected young, healthy women undergoing routine surgery.
Conclusions:
- Warming intravenous fluid bags/bottles in operating room ovens poses a significant burn risk to anesthetized patients.
- The inefficiency of this warming method offers little justification for its continued use.
- Highlights the need for safer intraoperative patient warming strategies.