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Miscellaneous Problems 

Miscellaneous Problems
Miscellaneous Problems

Sara E. Neves

and Keith J. Ruskin

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date: 23 October 2020

Acute Transfusion Reaction


Intravascular hemolysis of red blood cells caused by recipient antibody binding to donor antigens, activating complement and causing hemolysis. Usually occurs in response to a major ABO-type mismatch, but can also occur with other red blood cell (RBC) antigens in patients with prior transfusion and alloimmunization.


  • Variable symptoms, many of which are masked by anesthesia.

  • Hypotension

  • Hemoglobinuria

  • Bleeding diathesis

  • An awake patient may complain of nausea, fever, chills, and chest and flank pain.


Antibodies in the recipient plasma bind to donor RBC antigens and activate the complement pathway, resulting in intravascular and extravascular hemolysis and the release of bradykinin and histamine. Severe transfusion reactions result in renal failure (likely due to hemoglobin precipitating in the distal tubules) and disseminated intravascular coagulation (DIC), which commonly occurs when RBC products are released and activate the intrinsic system of coagulation.

Differential Diagnosis

  • Sepsis

  • Delayed transfusion reaction (transfusions within 2–21 days)

  • Febrile transfusion reaction (direct antiglobin test)

Immediate Management

  • Stop the transfusion.

  • Maintain urine output at 75–100 cc/hour with generous intravenous (IV) fluid administration.

  • Consider mannitol 12.5–50 g IV.

  • Consider furosemide 20–40 mg IV.

  • Alkalinize the urine to pH of 8 with sodium bicarbonate (0.5–1 mEq/kg, then additional doses as necessary to achieve urine pH of 8).

  • Maintain blood pressure as needed.

Diagnostic Studies

  • Send suspected unit to blood bank with another sample of patient’s blood for repeat cross-match.

  • Send a blood sample to blood bank for direct antiglobulin test and hemoglobinemia.

  • Send urine for hemoglobinuria.

Subsequent Management

  • Maintain normotension (using fluids and vasoactive drugs as necessary) to ensure adequate renal blood flow.

  • Send urine and serum samples for hemoglobin concentration.

  • Send blood samples for platelet count, partial thromboplastin time, and fibrinogen level.

  • Consider a hematology consult.

Risk Factors

  • The majority of transfusion reactions are due to ABO incompatibility. Most errors occur after the blood products have left the blood bank and are committed by physicians and nurses.

  • Rushed or incomplete check-in, especially during rapid blood loss or trauma surgery.

  • Labeling errors: Check the patient’s unit number and blood serial number carefully.


Use extra caution when administering blood products.

Special Considerations

Delayed hemolytic transfusion reactions may occur between 2 days and 3 weeks after administration of blood products, and usually manifest as a drop in hematocrit. They are difficult to prevent, since they require very low levels of antibody that may be undetectable. Severe hemolytic reactions are fatal in 20%–60% of patients.

Further Reading

Carabini LM, Ramsey G. Hemostasis and transfusion medicine. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical anesthesia, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013:425–427.Find this resource:

Miller RD. Transfusion therapy. In: Miller RD, ed. Miller’s anesthesia. 7th ed. Philadelphia: Elsevier Churchill Livingstone; 2010:1739–1766.Find this resource:

Bone Cement Implantation Syndrome


Hypoxia, hypotension, cardiac dysrhythmias, or increased pulmonary vascular resistance following methyl methacrylate cement implantation.


  • Decreasing end-tidal carbon dioxide (ETCO2) in ventilated patients

  • Dyspnea and/or altered mental status in patients under regional anesthesia

  • Cardiac dysrhythmias or cardiac arrest may occur.


The pathophysiology of bone cement implantation syndrome (BCIS) is unknown. Proposed mechanisms include embolic showers causing either a direct mechanical effect or release of vasoactive or proinflammatory mediators. Complement activation has also been proposed as a mechanism.

Differential Diagnosis

  • Anaphylaxis

  • Massive pulmonary thromboembolus (prolonged hypoxemia)

  • Myocardial infarction or cardiac failure (electrocardiogram changes, prolonged hypotension, pulmonary edema, minimal response to fluids or vasopressors)

Immediate Management

  • Increase FiO2 to 100%.

  • Initiate aggressive resuscitation with IV fluids.

  • Support blood pressure with ephedrine (5 mg IV) or phenylephrine (100-mcg IV) boluses. If refractory, consider phenylephrine or epinephrine infusion.

Diagnostic Studies

  • Bone cement implantation syndrome is a clinical syndrome without specific confirmatory diagnostic studies.

  • Transesophageal echocardiography or precordial Doppler ultrasonography may reveal the presence of emboli.

Subsequent Management

  • Advise the surgical team of the event and make a decision as to whether to proceed if a second joint replacement is planned.

  • Bone cement implantation syndrome is usually transient and resolves spontaneously.

  • Prolonged episodes may occur and should be treated as right ventricular failure. In this case, consider placement of a central venous catheter for monitoring and administration of vasoactive drugs.

Risk Factors

  • Rare in healthy patients

  • More common in elderly or debilitated patients

  • May be associated with surgical technique


The severity of BCIS may be reduced by generous fluid administration, increased vigilance during and immediately after prosthesis implantation, and consideration of invasive blood pressure monitoring in high-risk patients.

Special Considerations

Intravascular emboli of air, bone marrow, or fat can be seen on transesophageal echocardiography during implantation of orthopedic prostheses. Some of these patients develop transient hypotension or hypoxemia.

Further Reading

Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. Br J Anaesth. 2009; 102(1): 12–22.Find this resource:



First-degree burns involve epidermis and upper dermis and heal spontaneously. Second-degree burns involve the deep dermis and require excision and grafting. Third-degree burns involve complete destruction of the dermis and must be excised and grafted. Fourth-degree burns involve muscle, fascia, and bone.


  • Thermal trauma after exposure to flames in an enclosed space

  • Thermal trauma after airplane, motor vehicle, or industrial accidents

  • Chemical burns after industrial accidents

  • Partial-thickness burns are red, blanch when touched, and heal spontaneously. Full-thickness burns do not blanch and are insensate.

  • Airway injury from smoke inhalation present with dyspnea and airway obstruction (airway injury may not be immediately apparent)


Severe burns cause multiple systemic reactions, including release of interleukins and tumor necrosis factor, resulting in immunosuppression, sepsis, multiple organ failure, and protein catabolism. Hypoxemia may result from lung injury, atelectasis, and airway edema. Extensive fluid loss from the injury and massive fluid shifts may cause hypovolemic shock.

Immediate Management

  • Immediately administer 100% O2 by face mask in patients with a patent airway.

  • Secure the airway with an endotracheal tube. Awake fiberoptic intubation with topical anesthesia is preferred in patients with severe facial or airway injury, but other techniques may be considered.

  • After intubation, maintain a high FiO2 due to the risk of CO toxicity.

  • Begin aggressive fluid resuscitation in patients with burns >15% total body surface area (TBSA). Crystalloid resuscitation is preferred in the first 24 hours following burn injury. Estimate requirements according to the Parkland formula:

    Fluid requirements=TBSA burned  (%× Wt (kg) × 4 mL

  • Administer one-half of the total requirement in first 8 hours; give the second half over the next 16 hours.

  • Fluid management is guided by urine output, central venous pressure (CVP), or pulmonary artery pressures.

  • If cyanide toxicity is suspected, administer sodium thiosulfate, sodium nitrate 3% solution, and hydroxycobalamin.

  • If a chemical burn is suspected, use caution to prevent contamination of unit or staff.

Diagnostic Studies

  • Surface area can be estimated by the Rule of 9s: Head 9%; each upper extremity 9%; each lower extremity 18%; torso front and back 18% each.

  • Blood electrolytes

  • Arterial blood gas, including co-oximetry to determine carboxyhemoglobin level

  • Lactic acid level (lactic acidosis may indicate cyanide poisoning from burning plastics).

Subsequent Management

  • Maintain normothermia. Use warming blankets, forced-air warmers, fluid warmers as necessary. Keep the room temperature as high as possible.

  • Use topical antibiotics to prevent infection.

  • Consider hyperbaric oxygen therapy if the patient is stable, a pressure chamber is available, and severe CO poisoning is suspected.

Risk Factors

Fires in the operating room due to electrocautery or lasers. “Fire resistant” plastic drapes will burn in the presence of O2 and release toxic smoke.


See Operating Room Fires (page [link]).

Special Considerations

  • Full-thickness burns appear white, waxy, or leatherlike and may be confused with unburned skin. Full thickness burns do not bleed.

  • Succinylcholine is generally safe to use within the first few hours after a burn, but after that must be avoided for 12 months after the burn injury.

  • Resistance to nondepolarizing neuromuscular blocking agents may occur for up to 10 weeks postinjury.

Further Reading

Hettiaratchy S, Papini R. Initial management of a major burn: I—overview. BMJ. 2004; 328(7455): 1555–1557.Find this resource:

Hettiaratchy S, Papini R. Initial management of a major burn: II—assessment and resuscitation. BMJ. 2004; 329(7457): 101–103.Find this resource:

Dental Trauma and Oral Injury


Lacerations, abrasions, and perforation of oral tissues or mucosa, and fracture or avulsion of teeth.


  • Occurs most often during airway management: placement/removal of oral airways, laryngeal mask airways (LMAs), endotracheal tubes, laryngoscope blades.

  • Glidescope intubation with a rigid stylet can cause laceration or perforation of soft palate and other structures due to poor visibility.

  • Procedures such as endoscopy, bronchoscopy, and maxillofacial or otorhinolaryngeal surgery may result in non–anesthesia related oral/dental injury.

  • Shivering can result in masseter muscle spasm, which can damage teeth.

  • Injury may be recognized immediately as it occurs, present with symptoms of aspiration during surgery, or only be noticed in the postoperative period in the postanesthesia care unit or later by the patient or his oir her family members.


Patients with pre-existing dental conditions are more likely to have dental damage during surgery and maxillary incisor teeth are at greatest risk for trauma during anesthesia. Poor oral hygiene compromises the integrity of the tooth, weakening tooth structure and making the tooth more prone to fracture. Periodontal disease makes teeth more susceptible to avulsion because it affects the gingiva, bone, and ligaments that keep the teeth in place. Aggressive suctioning, forceful insertion or removal of oral airways, and accidental contact of the laryngoscope blade with the teeth can also cause damage such as breaking or dislodging of teeth and dental restorations (e.g., adhesive bondings, caps/crowns, bridges, and dentures). Such injuries are more likely to occur in patients who are difficult to intubate. Aspiration of teeth, blood, tissue, or hardware can cause significant respiratory injury, and sometimes can cause GI injury when ingested. Dental damage can incur significant cost as well as emotional distress for the patient.

Immediate Management

  • If the injury occurs during airway management, secure the airway first before examining the teeth for injury.

  • After the airway is secure, examine oral cavity carefully. If a tooth has been avulsed, ascertain that it is intact with no pieces missing. If a tooth is fractured or hardware is broken, look for any missing pieces.

  • If any teeth or hardware cannot be accounted for, obtain an intraoperative chest X-ray to exclude aspiration or ingestion.

  • If a tooth has been aspirated or ingested, request an intraoperative ear-nose-throat (ENT) or pulmonary medicine consult (to remove an aspirated tooth) or a GI consult (to determine if endoscopy is necessary). Consider aborting the surgery if it cannot be retrieved.

  • If a soft tissue injury has occurred, carefully examine the area, clean with normal saline. If necessary, request an intraoperative ENT consult.

  • For an avulsed tooth, place the tooth and any pieces in normal saline and request a dental consult. Do not attempt to clean or scrub the tooth with alcohol or other cleansers and try to avoid holding tooth by the root because this may damage ligaments needed for reattachment.

Diagnostic Studies

  • Chest X-ray to determine location of missing teeth or hardware.

Subsequent Management

  • Document injuries carefully and thoroughly.

  • Discuss with surgical team the presence and cause of any injury prior to discussion with patient and family.

  • Have a frank and thorough discussion with the patient about the injury, and involve risk management personnel according to the hospital protocols.

Risk Factors

  • Pre-existing dental disease and poor oral hygiene.

  • Hardware or prosthetics, which are not as strong as original dentition.

  • Emergency airway management

  • Difficult airway

  • Pediatric patients between the ages of 5–12 who have both primary and permanent teeth.


  • Include a preoperative dental history and examination as part of airway examination, paying particular attention to the maxillary anterior teeth, because dental treatment of these teeth may not be readily apparent and these teeth are at greatest risk. In a high-risk patient, a more thorough physical examination of the gingiva and teeth may offer insight into the likelihood of dental trauma. Document prior dental damage and existing restorations precisely. Having a discussion with the patient specifically addressing the risk of oral injury and dental trauma preoperatively may prevent emotional distress and legal action later. If necessary, obtain preoperative consultation by a dentist to extract any loose or infected teeth.

  • Use care when manipulating airway devices to avoid pinching or lacerating lips or soft tissue. If a videolaryngoscopy device is used for intubation, maintain direct visualization of endotracheal tube as it enters the oral cavity and the back of the pharynx until tube is visible on video screen. Avoid blind, forceful insertion of the blade or endotracheal tube.

  • Maintaining normothermia can prevent masseter muscle spasm due to shivering, and the use of soft bite blocks can prevent dental trauma resulting from clenching down on oral airways, LMAs, and endotracheal tubes. Bite blocks also prevent the need to forcibly pull the airway device out when it is no longer needed.

Special Considerations

  • Patients with poor dentition may have an unrecognized abscess or otherwise prove an infection risk for surgery, especially in immunosuppressed patients or for procedures in which hardware is being implanted.

  • Time elapsed to reimplantation after avulsion of a tooth is the main determinant of success. It is especially important that the avulsed tooth be kept moist in saline to improve likelihood of reattachment later. A dental consultation should be requested as soon as possible after the injury.

Further Reading

Newland MC, Ellis SJ, et al. Dental injury associated with anesthesia: a report of 161,687 anesthetics given over 14 years. J Clin Anesth. 2007; 19(5): 339–345.Find this resource:

Yasny JS. Perioperative dental considerations for the anesthesiologist. Anesth Analg. 2009; 108(5): 1564–1573.Find this resource:

Drug Extravasation


Unintentional injection of drugs or fluids into the subcutaneous tissue or perivascular space.


  • Pain on injection or during infusion of fluids.

  • Discomfort, swelling, or hyperemia at the site of the catheter.

  • Paresthesias or local induration of the skin (late signs).

  • Severe cases: Compartment syndrome; muscle, tendon, or nerve injury.


Tissue injury occurs for a variety of reasons, including hydrostatic pressure, fluid osmolality or cytotoxicity, vasoconstriction.

Differential Diagnosis

Intra-arterial injection (severe burning pain, discoloration, or absence of pulse distal to injection site)

Immediate Management

  • There is no definitive treatment for extravasation injury.

  • Stop drug injection or fluid administration if the patient complains of severe pain or signs of extravasation are noted.

  • Consider vascular or plastic surgery consultation.

  • Specific treatment depends on the extravasated substance.

  • In the case of vesicants (e.g., adriamycin), stab incisions and flushing with 500 mL of normal saline has been recommended.

  • Extravasation of vasopressors has been treated with phentolamine infiltration.

Diagnostic Studies

  • Clinical diagnosis: No diagnostic studies are necessary.

  • Subsequent management

  • Document the injury in the patient’s chart.

  • Observe the site carefully for at least several days.

Risk Factors

  • Location of catheter

  • High infusion pressure

  • Multiple punctures of the same vein

  • Access sites in close proximity to tendons, nerves, or arteries


Avoid placing IV catheters over joints (e.g., antecubital fossa). Whenever possible, place IVs where they can be visually inspected throughout the surgical procedure. Avoid using “positional” IVs. If there is any doubt, administer a small test dose of drug first.

Special Considerations

  • Although elevating the extremity and applying warm or cold compresses are commonly recommended, there is little evidence to support these practices. Extravasation can occur even when a central venous catheter is used because the proximal port may exit the vessel if the catheter is withdrawn even a few centimeters. Therefore, vessicants should be given through the distal lumen.

Further Reading

Reynolds PM1, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014; 34(6): 617–632.Find this resource:

Schummer W, Schummer C, Bayer O, Müller A, Bredle D, Karzai W. Extravasation injury in the perioperative setting. Anesth Analg. 2005; 100(3): 722–727.Find this resource:

Intra-arterial Injection


Unintentional injection of drugs or fluids into an artery, usually by injection into an indwelling intra-arterial catheter, or after accidentally inserting an intravenous catheter into an artery.


  • Pain on injection or during infusion of fluids, possibly in the distribution of the vessel.

  • Anesthesia or muscle weakness may occur distal to the injection site in an awake patient.

  • Skin pallor or cyanosis distal to the injection site.


Pallor, ischemia, and pain may occur due to vasospasm, chemical arteritis, or drug-induced tissue injury.

Differential Diagnosis

  • Drug extravasation (discomfort, swelling or hyperemia at the site of the catheter; late signs include paresthesias or local induration of the skin)

  • Some drugs (e.g., propofol) cause pain on injection. This will not be associated with distal blanching or mottling of the skin.

Immediate Management

  • Stop drug injection or fluid administration if the patient complains of pain or distal pallor is noted.

  • Leave the catheter in place for subsequent diagnostic studies and treatment. Begin a slow infusion of isotonic saline solution if the catheter can be flushed and there is no clot.

  • Consider anticoagulation with intravenous heparin infusion.

  • Consider intra-arterial lidocaine 2 mg/kg and papaverine (30 mg).

Diagnostic Studies

  • Clinical diagnosis

  • Transduce the catheter. High pressures or an arterial waveform implies that the catheter is intra-arterial. If the patient has an arteriovenous fistula, this test is nondiagnostic.

Subsequent Management

  • Document the injury in the patient’s chart.

  • Extremity should be elevated to decrease edema and reduce the risk of compartment syndrome.

  • Consider sympatholysis with a stellate ganglion block or continuous brachial plexus block (if catheter is located in upper extremity).

  • Consider intra-arterial thrombolytic injection.

  • Observe the site carefully for at least several days.

Risk Factors

  • Morbid obesity

  • Darkly pigmented skin

  • Thoracic outlet syndrome (pulse decreases with internal rotation of the arm)

  • Pre-existing vascular anomaly


  • Always verify that drugs are being injected into the correct tubing in a patient with an arterial catheter.

  • Never assume that an indwelling catheter is in the correct location.

  • When inserting an intravenous catheter, the tourniquet should not be so tight as to occlude arterial blood flow.

  • Before injecting a drug, carefully observe IV tubing for backflow of blood.

Special Considerations

Although many treatment strategies have been recommended, none has been definitively proved to work. All recommendations are based on individual case reports or small series. Vigilance, immediate recognition of the problem, discontinuation of the irritant, and rapid initiation of treatment offer the best chance of a good outcome.

Further Reading

Sen S, Chini EN, Brown MJ. Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clin Proc. 2005; 80(6): 783–795.Find this resource:

Magnetic Resonance Imaging Emergencies


Anesthesia is commonly required for magnetic resonance imaging (MRI), whether for pediatric patients or adult patients unable to remain stationary for the required amount of time. Increasingly, MRI-guided procedures are being performed that require the anesthesiologist to work in this high-risk environment.


  • Injuries to staff or the patient can occur when magnetic resonance unsafe equipment is brought into the magnetic field.

  • Respiratory failure or cardiac arrest during the scan when there is limited access to the patient can be life threatening.

  • Burns can occur during a scan due to conductive materials present on the patient’s skin.

  • Quenching the magnet results in the release of heat as well as boiling off of the cryogenic fluid; usually helium. If the exhaust mechanism malfunctions, the gas produced poses an asphyxiation risk to anyone in the room.


Magnetic resonance imaging relies on the energy difference of the magnetic field of the scanner and the tiny magnetic fields of the atomic nuclei in every cell in the body. The scanner applies an oscillating magnetic field to excite the nuclei, and then as they relax back to their original state a receiving coil detects that energy difference. These data are then converted to usable clinical information as the MRI image. Typical scanners have magnetic fields between 0.5 and 3 Tesla; the areas around the scanner are demarcated to indicate safe limits and are described in Gauss (G). Any magnetic resonance unsafe equipment or personnel not cleared for MRI should remain outside the 5G line. The magnetic field of the scanner is always present, even when not actively scanning; therefore, a high degree of vigilance is required at all times.

Immediate Management

  • Call for help.

  • Quickly verify one’s own magnetic resonance safety before approaching a patient in the scanner (no scissors in pocket, for example).

  • Determine if there is time for a controlled shut-down of the scanner, or if an emergency quench is necessary.

  • Despite the unusual environment, refer to basic training: ABCs, presence of suction prior to intubation, etc.

  • If the magnet must be quenched, quickly locate source of oxygen for oneself as well as for the patient.

  • For any burns related to MRI scanner, see section on Burns.

Diagnostic Studies

  • Typically there are no diagnostic studies other than those needed for pre-MRI evaluation (computed tomography or X-ray if there is a question of metallic foreign body) or those needed for a patient who has a medical emergency during a scan.

Risk Factors

  • Staff that is not trained in the risks of working in an MRI environment.

  • Magnetic resonance–unsafe or conditional equipment left in an inappropriate area.

  • Incomplete or erroneous evaluation of the patient’s safety for MRI.

  • Lack of preparation for working in an MR environment.


  • All staff, including attending physician, residents, medical students, and cleaning personnel, should be trained in MRI safety before entering an MRI suite.

  • Patients should be evaluated carefully before receiving MRI scan to ensure they have no ferromagnetic foreign bodies. If this information cannot be verified, alternative imaging techniques should be considered.

  • All equipment should be checked for MR compatibility prior to start of case.

  • An emergency plan should be formulated before starting the scan. The location and availability of emergency equipment should be verified and forms of communication (intercom, phone) should be reviewed.

  • Do not quench the magnet unless a person is in immediate danger.

Special Considerations

The MRI scanner is associated with significant acoustic noise. Although the noise level does not present an emergency, it is at a level higher than the noise level designated as safe by the Occupational Safety and Health Adminstration. Patients (whether awake or anesthetized) and providers should always wear ear protection during a scan. It may be difficult to hear alarms or to communicate with other personnel while a scan is in progress.

Further Reading

Reddy U, White MJ, Wilson SR. Anaesthesia for magnetic resonance imaging. Contin Educ Anaesth Crit Care Pain. 2012; doi:10.1093/bjaceaccp/mks002Find this resource:

Occupational Exposure


Inoculation of a health care worker (HCW) with infectious blood or body fluids by puncturing the skin with a contaminated object (e.g., needle) or splashing fluids into exposed mucosa.


  • Injury with a needle or other sharp object.

  • Blood or body fluids splashed into the eyes, mouth, or an open wound.


Exposure to blood-borne pathogens results in infection of a health care worker. Twenty-five percent of all percutaneous sharps injuries among health care workers occur in OR personnel.

Immediate Management

  • Wash the wound liberally with soap and water. Use of antiseptics is not contraindicated, but there is no evidence that use will reduce risk of infection.

  • If exposure was through exposed mucous membranes, they should be irrigated copiously with normal saline.

  • All health care institutions have an occupational exposure protocol; this protocol should be followed.

  • Federal (US) and state reporting requirements also must be followed.

  • Postexposure prophylaxis depends on the type of suspected pathogen.

Diagnostic Studies

  • The patient should be tested for the presence of blood borne pathogens hepatitis B surface antigen (HBsAg), hepatitis C virus antibody (anti-HCV), and HIV antibody if his or her status is unknown. Testing usually requires patient consent.

  • If exposure to HCV is suspected, the health care worker should undergo baseline testing for anti-HCV and alanine aminotransferase with follow-up in 4–6 months.

  • If exposure to HIV is suspected, the health care worker should undergo baseline testing for HIV antibody and further testing at 6–12 weeks and 6 months.

Subsequent Management

  • If the exposure was to hepatitis B and the HCW is susceptible, hepatitis B immune globulin should be administered within 24 hours, and the hepatitis B vaccine should be offered to confer active immunity.

  • There is no prophylaxis for exposure to hepatitis C.

  • If the source patient is HIV positive, the HCW should be placed on a two- or three-drug regimen depending on the risk of HIV transmission. Prophylaxis should begin within 24 hours of exposure and be continued for 4 weeks if tolerated.

Risk Factors

  • Use of large, hollow-bore needles without engineered protection

  • Use of straight suture needles for securing vascular access devices

  • Two-handed recapping of needles (13% of exposures in one study)

  • Long work hours and fatigue have been reported to increase the risk of needle stick injuries in medical personnel.


  • Always use standard precautions.

  • Do not recap needles if possible. If recapping is necessary, a one-handed scoop technique should be used.

  • Needleless or protected needle devices should be used when available. Use blunt-tipped needles when possible.

  • Sharp objects such as needles or scalpels with engineered safety systems should be used when practical.

  • Needles should not be held while tying sutures.

  • Barrier precautions (gloves, masks, eye shields) should be used whenever risk of exposure is present. Consider using a double-glove technique.

Special Considerations

A copy of the health care institution’s occupational exposure protocol is maintained in the policy and procedures manual. A copy of this document should be available at all clinical locations. There is no need to modify the patient care responsibilities of an individual who has been exposed to hepatitis B or C or HIV, although the exposed individual should be counseled regarding infection control. Exposed health care workers should not donate blood, plasma, or tissue during the postexposure follow-up period. A health care worker who develops hepatitis B or C should modify his or her patient care responsibilities as recommended by the Centers for Disease Control and Prevention.

Further Reading

Berry AJ. Needle stick and other safety issues. Anesthesiol Clin North Am. 2004; 22(3): 493–508, vii.Find this resource:

DeGirolamo KM, Courtemanche DJ, Hill WD Kennedy A, Skarsgard ED. Use of safety scalpels and other safety practices to reduce sharps injury in the operating room: what is the evidence? Can J Surg. 2013; 56(4): 263–269.Find this resource:

Fisman DN, Harris AD, Rubin M, Sorock GS, Mittleman MA. Fatigue increases the risk of injury from sharp devices in medical trainees: results from a case-crossover study. Infect Control Hosp Epidemiol. 2007; 28(1): 10–17.Find this resource:

Operating Room Fire


An infrequent but catastrophic event that can involve the airway, head and neck, or any other portion of the surgical field.


  • A puff of smoke and possibly a flash of light in an endotracheal tube

  • Appearance of smoke on the surgical field or from under the drapes

  • A “popping” sound may be heard.

  • Flames may not be visible, especially if alcohol (from prep solutions) is the fuel.


Three elements must be present: fuel (e.g., alcohol or plastic), oxidizer (O2 or N2O), and an ignition source (electrocautery or laser). Operating room fires can produce significant amounts of toxic smoke, but not enough heat to activate overhead sprinkler systems. Burning plastic (e.g., surgical drapes) can produce CO, hydrogen chloride (HCl), and cyanide.

Immediate Management

  • Specific actions depend upon the location of the fire and source of fuel and oxidizer.

  • RACE: Rescue, Alert, Contain, Extinguish.

  • Rescue patients or staff in immediate danger.

  • Activate the fire alarm.

  • Contain the fire by removing the oxidizer from the fuel. Disconnect anesthesia circuit from patient for airway fire, discontinue O2.

  • Extinguish flames if it is safe to do so.

  • Evacuate the room if necessary.

  • PASS: Pull the pin to activate the extinguisher, Aim at the base of the fire, Squeeze the trigger, and Sweep the extinguisher back and forth across the fire.

Differential Diagnosis

There is no differential diagnosis. It is important to determine the ignition source, fuel, oxidizer, and location of the fire immediately.

Subsequent Management

  • Subsequent management depends on the location of the fire.

  • Determine whether evacuation of the operating room is necessary.

  • Abort the surgical procedure as soon as it is safe to do so.

Risk Factors

  • Use of laser surgical devices

  • Use of electrocautery after application of alcohol-based prep solutions

  • Use of O2 enriched gas adjacent to electrocautery or laser

  • Bringing hot items (i.e., halogen lamps or camera light sources) into contact with other flammable items


  • Minimize FiO2 whenever surgery will take place near the airway.

  • Be certain that flammable prep solutions have been removed from the patient or allowed to dry before using electrocautery.

  • A response plan should be formulated before the patient is brought into the operating room. Know the location of fire extinguishers and fire blankets.

Special Considerations

There are three types of fire extinguishers: A (paper, cloth, plastics), B (liquids or grease), and C (electrical). Be sure to use the right extinguisher for the fire in progress. Most extinguishers in the OR are type ABC (can be used on all fires).

Further Reading

Ehernwerth J, Siefert HA. Electrical and fire safety. In: Barash PG, Cullen BF, Stoelting RK, eds. Clinical anesthesia, 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2013:209–216.Find this resource:

Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol. 2008; 21(6): 790–795.Find this resource: