Photos courtesy Phil Zeltzman
"It was a small dog spay," recalls a colleague. "My nurse asked an assistant to heat up two IV bags in the microwave. No one told her how long to heat them up. No one checked their temperature. An IV bag was placed on each side of the patient. The dog was severely burned on both sides of her thorax. It took weeks of very intensive care (at no charge) and a very understanding owner to get the wounds to heal. It's one of my worst memories in practice."
Such is the horror of iatrogenic burn wounds. Not only can they cause significant harm to patients (including death), they also can seriously damage a practitioner's reputation.
Common heat sources used in clinics are water-filled exam gloves, "rice socks," IV fluid bags, reusable discs, "hard" electric heating pads, heating blankets, water or air blankets, and surgery tables. These devices are used multiple times a day without a second thought given to them. Yet, reports of iatrogenic burn wounds keep landing on the desk of our colleagues at state boards and the Professional Liability Insurance Trust (PLIT).
Most of the complaints reported to PLIT involve the following issues:
- C-sections;
- dental procedures;
- various microwaveable devices; and
- electric heating pads sold for human use, which PLIT strongly discourages using in a veterinary setting.
The best way to avoid complications starts with a basic understanding by all team members of the different heat sources, their intended use, and their risks.
Forced-air and warming blankets
Some of the safest warming devices on the market are forced-air and warming blankets. These devices evenly disperse heat across the body's surface, have several temperature settings, and are reusable. The patient's temperature should be monitored regularly to correct hypo- or hyperthermia as needed.
Warm-water blankets
Electric warm-water blankets heat distilled water, which is forced through it. Most units have different temperature settings. These must be used with care, and proper maintenance is required. Malfunctions occur when:
- there is a hole in the blanket;
- the tubing is occluded or kinked;
- the connections between blanket and tubing are faulty or loose;
- liquid other than distilled water is used; and/or
- the water level is low.
These issues can result in overheating or leakage. Patients coming in contact with hot water are at risk for burns.
Heated blankets
These devices provide heat when an element is warmed to a preset temperature. Electrical malfunctions and overheated sections are the most common issues. The use of an electric blanket made for humans on veterinary patients is never recommended.
Hard heated pads
Hard heated pads work the same as heated blankets. Their issues are similar, with the addition of increased heat at the patient's pressure points (Figure 1).
Heated surgery tables and cages
Heated surgery tables and cages have elements under the stainless steel surface that heat to a preset temperature. Hard contact points, malfunctions, and lack of uniform temperature can put your patient at risk.
Microwaveable devices
Rice socks, hot water gloves, and warmed IV bags are used due to their low cost and easy access. All pose a risk of being overheated when warmed in a microwave.
All heating devices, expensive or thrifty, have the ability to burn your patient if not used properly. Regardless of which you use, there are a few standard precautions that should be implemented across the board.
1) Always use equipment according to the manufacturer's recommendations.
2) Always perform the recommended maintenance at the appropriate time frames.
3) Always have an adequately thick barrier between the patient and the heat source. This seems straightforward, yet experience shows it isn't always done properly. The patient should be checked regularly for position shifting. If a device, such as a warming disc, comes with a cover, be sure to use it (Figure 2).
4) The longer the patient is exposed to the heat source, the greater the chance for injury to occur. Temperatures above 113 F can cause irreversible damage. Temperatures above 158 F can cause a full thickness burn (see the article titled, "Different burns, different depths" on the opposite page) after only one second.
5) If using a water-based warming device, check it for leaks before every use and regularly during use. When applicable, the water level should be maintained at the recommended amount. If there is any question of a leak, it should not be used. If a leak occurs during its use, remove it immediately and dry the patient to the best of your ability.
6) Take the guesswork out of heating microwaveable products for your staff. Post clear microwave guidelines. Items like gloves or IV bags may take some trial and error. Update the recommendations if you get a new microwave. Use the manufacturer's recommendations for commercially produced products such as heated discs. This prevents overheating to a dangerous temperature. Make it standard protocol.
7) One of the biggest myths out there is that a warming device is safe because it's not hot to the touch. This is incorrect. Temporarily feeling a heat source does not replicate being on that source for an extended period. Further, it doesn't adequately show the effect on different pressure points.
8) A patient's temperature, although helpful when monitoring for systemic hypo- or hyperthermia, has no bearing on whether one area of the body is being harmed.
9) Avoid using devices only because they're cheap. For example, heating lamps used for reptiles may be inexpensive, but they can cause severe burns (and not only to patients). Surely your patient and your reputation are worth more than that.
10) Ego and blind habits have no place when you are dealing with patient safety. Comments such as, "This is how we've always done it and we've never had a problem," won't take you far in a court of law.
While treating burn wounds is lengthy and costly, they are easily preventable. Follow these rules to stay out of trouble and to keep your patients safe.
| DIFFERENT BURNS, DIFFERENT DEPTHS |
| Depending on their depth, there are three different types of burns in pets.
1) Superficial burns only affect the outer layer of the epidermis. The skin is red and painful with no blisters. It is the human equivalent of a first-degree burn. 2) Whether superficial or deep, partial thickness burns affect the epidermis and the dermis. The skin is painful, denuded, and exudative with blisters. It is the human equivalent of a second-degree burn. 3) Full thickness burns extend through the epidermis, dermis, and subcutaneous tissue. They can be accompanied by systemic effects such as shock. The skin is painless and does not bleed. It is the human equivalent of a third-degree burn. |
| ANOTHER CASE OF BURNS |
 Although not heat-support-related, improper electrocautery usage also puts the patient at risk being burned. Even though hardly anybody reads the user's manual, most issues can be prevented by following the manufacturer's protocols and maintenance schedules. A common mistake is the improper use of the grounding plate. Many ground plates require conductive gel or gauze saturated with saline for a proper connection. Using an esophageal ECG probe with cautery is not recommended because of the risk of esophageal burns, which can be catastrophic. |
Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and author whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. Visit his website at www.DrPhilZeltzman.com. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance. For more information visit, www.vetfinancialsummit.com.
AJ Debiasse, Chris Longenecker, and Kelly Serfas, veterinary nurses in Pennsylvania, contributed to this article.
