電池式メス使用中にエタノール含有消毒液が引火した1症例

A Surgical-field Fire Caused by an Ethanol-Based Antiseptic During Battery-Powered Cautery

要旨

　電池式メスにより，術野消毒に用いたエタノール含有消毒液が引火した症例を報告する。引火原因は消毒液が乾燥する前に電池式メスを使用したことである。火災予防訓練の実施，エタノール含有消毒液使用時の注意喚起，対応マニュアルの整備，教育プログラムの導入により対策を強化した。

　We describe the occurrence of a surgical-field fire during a patient’s sedation when a battery-powered cautery device（Bovie disposable cautery scalpel, Bioresearch center 10., Japan）ignited an ethanol-based antiseptic that had been applied to the surgical field. The lightly sedated patient moved, enabling the rapid extinguishing of the fire, but he sustained partial-thickness burns. Contributing factors included the antiseptic’s insufficient drying time and the presence of combustible materials and supplemental oxygen. In response to this fire, our institution implemented enhanced safety protocols, including fire-prevention training, standardized briefings, and educational programs concerning the use of flammable antiseptics. This case underscores the importance of comprehensive fire risk management in operating rooms, particularly when alcohol-based disinfectants and heat-generating devices are used concurrently.