Burn injury by displacement of electrocautery plate.

Sir,

We report a case of burn injury caused by monopolar electrical cautery. A 21-year-old, 48-kg male underwent septorhinoplasty under general anaesthesia. Anaesthesia was induced using Propofol, Fentanyl, Midazolam and Vecuronium. After intubation, the endotracheal tube was secured and metallic plate of electrical cautery (Jehangir, ISS, India) was applied to the legs [Figure 1]. As the legs of the patient were protruding outside the edge of the table, the technician placed pillows under the protruding legs.

Figure 1

Jehangir electrocautery

Anaesthesia was maintained using O2/N2O/Isoflurane/Vecuronium/Fentanyl. Intraoperatively, surgeons complained of cautery being ineffective and, hence, the current was increased up to 70 mA. The cautery still being ineffective, the cautery plate was now checked to discover only a small portion of the cautery plate being in contact with the patient. While placing pillows, the technician inadvertently pushed the cautery plate. A burn was present in this part of the leg.

Understanding the principle of electrocautery is important for the surgeon, anaesthesiologist and technical staff. A high-frequency, high-voltage, alternating electrical current from a generator heats up the tip of the electrode, which burns the local tissue and achieves bleeding control. Lower frequencies can stimulate patient's nerves and muscles, causing twitches and cramps. The current disperses and flows harmlessly through the patient's body to return to the electrosurgical unit via the grounding plate attached at a remote location thus completing the circuit.

Electrocautery interferes with the monitoring of ECG and pulse oxymeter. It can cause malfunction of pacemaker and implanted implantable cardioverter defibrillator (ICD). Various hazards reported with its use include burn injury, operating room fire, inhalation of diathermy smoke and gene mutation.[1-3] Burn injuries in the operation theatre occur from cautery, warming devices and airway fires. Cautery fires made up 19% of the burn claims.

Burns can be caused by: (1) use of electrocautery near inflammable and wet antiseptic cleansing agent, (2) contact of skin with broken insulation of electric circuit of cautery and (3) accidental direct contact of skin with the active electrode, e.g. puncture in the surgical gloves. We report another mechanism of cautery burn due to displacement of the electrical plate. Areas of discontinuity can burn the area of contact due to concentration of current in a small area, as in this case. This signifies the importance of rechecking the position of the cautery plate after final positioning of the patient.

The grounding plate should be applied on dry, hairless skin, using a conductive jelly. Newer electrosurgical generators incorporate a monitoring circuit, which continuously monitors the integrity of the grounding plate. Loss >25% integrity of grounding plate will automatically shut off power to the device and give an audio and visual alarm, until the plate is reattached. Use of fire-retardant surgical drapes and installing over-current protection devices on the electrical equipment is recommended.[4]

This case highlights the importance of using the electrical cautery plate properly. We need to be vigilant and use the cautery alarm systems, if feasible, to avoid such mishaps.