Ignition of chlorhexidine by an electrocautery unit is rare but can have devastating consequences for the patient and the surgeon. A case involving a 77-year-old man who underwent removal of an indwelling artificial urethral sphincter is presented. The chlorhexidine was ignited when the urologist activated the electrocautery unit, causing third-degree burns to the patient. A plastic surgeon treated the burns with surgical debridement and split-thickness skin grafting. A systematic review of the literature was performed with best practice recommendations. To the authors' knowledge, the present case is the ninth such case reported.
TooherR.MaddernG.SimpsonJ.. Surgical fires and alcohol-based skin preparations.ANZJ Surg2004; 74: 382–5.
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UetakeA.NakaigawaY.KohoY.YamadaM.IshiiR.. Fire caused by a spark of electric scalpel igniting alcoholic antiseptic containing chlorhexidine.Masui2007; 56: 718–9.
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HoshjimaH.TakeuchiR.SatoE.KikuchiH.. Accidental skin burns by fire of an antiseptic agent ignition by the spark of electric cautery.Japanese J Anesthesiol2010; 59: 1138–40.
