During a laser
procedure, always place the laser in the standby mode when it is
not being used.
In a case reported to the ECRI, inadvertent activation
of a laser footpedal by the assistant surgeon caused a patient injury.
In this case a laser was used to remove a brain tumor. After completing
the procedure, the circulating nurse failed to place the laser in
standby mode. Also, the scrub person left the handpiece pointing
toward the patient's left shoulder. The surgeon proceeded to coagulate
bleeders using bipolar
electrosurgery. The surgeon directed the assistant surgeon to
activate the bipolar unit by depressing the footpedal. Unfortunately,
the operating surgeon instinctively depressed the laser footswitch
at the same time, firing the laser into the patient's left shoulder
area and igniting the vertical surgical drapes. The fire spread
very rapidly. Within about 40 seconds the operating room was filled
with dense smoke, requiring evacuation of all personnel in the room.
As the fire continued to burn on the patient, someone responded
with a dry chemical fire extinguisher, spraying the patient and
equipment. The patient received burns over 7 percent of his body,
and subsequently recovered.
Additionally, the use of anodized, dull, non-reflective instruments
will decrease the reflectivity of laser beams, thus reducing the
risk for an ignition incident.
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