Kosin Med J.  2023 Dec;38(4):288-292. 10.7180/kmj.23.136.

Perioperative cutaneous complications in an elderly patient due to inappropriate use of a forced-air warming device and underbody blanket: a case report

• Kim M
• Lee SJ
• Choi B
• Lee G
• Ki S

• KMID: 2549502
• DOI: http://doi.org/10.7180/kmj.23.136

Abstract

Forced-air warming is commonly utilized to prevent perioperative hypothermia. Underbody warming blankets are often employed to secure a larger area for patient warming. While forced-air warming systems are generally regarded as safe, improper usage poses a risk of cutaneous complications. Additionally, the influence of underbody blankets on cutaneous complications remains uncertain. We present a case of cutaneous complications resulting from the improper utilization of a forced-air warming device and an underbody blanket. A 79-year-old man presented to the hospital for robotic proctectomy under general anesthesia. The surgery lasted for 7 hours, and the forced-air warming device with underbody blanket operated continuously for 5 hours intraoperatively. The surgery was completed without any incidents. However, first-degree burns on the patient’s back, along with superficial decubitus ulcers on his right scapula, were observed after surgery. To prevent cutaneous complications, clinicians must adhere to the manufacturer's guidelines when utilizing a forced-air warming system. Compared to overbody blankets, underbody blankets have limitations in monitoring cutaneous responses. Ensuring patient safety requires selecting an appropriate blanket for scheduled operations.

Keyword

Case reports; Intraoperative complications; Patient safety; Intraoperative monitoring; Perioperative care

Figure

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  Fig. 1. Changes in body temperature and surgical position. (a) Start of induction of general anesthesia. (b) Start measuring body temperature. (c) Turning off the forced-air warming system. The changes in the patient's position during surgery are differentiated by boxes of different colors.

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  Fig. 2. Lithotomy-Trendelenburg position. Bilateral shoulder supports (black arrowheads) were used so that the patient would not slip from the bed intraoperatively.

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  Fig. 3. Skin erosions on the right scapula. The areas of erosion measured 10×5 and 5×8 cm. The image has been altered to obscure any personal identifying information of the patient.

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  Fig. 4. Reddish linear skin lesions around the shoulder. The image has been altered to obscure any personal identifying information of the patient.

Reference

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