Fuego en sala de operaciones asociado a jett plasma: reporte de caso

Fires in the operating room are relatively rare and may be catastrophic. Most are mild, however, some result in severe damage, disfiguration and even death. All surgeries are at risk of fire specially in high oxygen concentration areas. Fires in the operating room can be preventable with adequate attention to oxygen supply. Jett Plasma Medical is a DC low-power electrocauter used in dermatology and ophthalmology for aesthetic treatments. Unlike other similar products, Jett Plasma covers a surface area of 1 mm2 per beam. A 67-year-old woman scheduled for a blepharoplasty and Jett Plasma in periocular area under sedation. The patient is provided with supplementary oxygen at 3 L/min through nasal cannula. Sedation is initiated maintaining a Ramsay 3 and spontaneous ventilation with supplementary oxygen. ChloraPrep is used to clean the surgical areas before starting the blepharoplasty. After this procedure is done, the surgical drapes are removed. ChloraPrepis used to clean skin before using Jett Plasma. A spark of Jett Plasma starts a fire on the patient’s face which rapidly expands towards the nasal cannula, immediately burning them. The anesthesiologist quickly removes the burning nasal cannula while turning the oxygen off and the surgeon removes the Jett Plasma from the patient. A nasal and oropharyngeal exploration is performed which revealed burnt nostrils and philtrum, the rest is normal. In the recovery room the patient refers pain at inspiration and when swallowing; her vital signs remain normal and her oxygen saturation without supplementary oxygen is normal. The patient is referred to otorhinolaryngologist who diagnoses second degree burns in both nostrils and continues with outpatient treatment. The incidence of fire in the operating room associated to Jett Plasma had not been reported previously; however, it must be used cautiously considering it may potentially ignite a fire especially if applied on patients with supplementary oxygen.