Severe burn injury associated with misuse of forced-air warming device

Abstract

To the Editor:A 64-year-old male was admitted to our department witha third-degree burn on his left ankle. His medical historyrevealed type 2 diabetes of 12 years’ duration and coronarybypass surgery 3 weeks previously. The patient claimedthat he had noticed large blisters on his left ankle when heawoke from anesthesia after coronary bypass surgery. Afterdetailed questioning it became evident that because thepatient began complaining of cold after surgery, he washeated with a forced-air warming system. The nozzle of thedevice was not connected to the blanket, however, and hotair at 40–43 C was blown directly on to the patient’s legsfor nearly 2 h. On examination, a third-degree burn of12 9 5 cm in size and surrounding hyperemia was docu-mented (Fig. 1). His pedal pulses were absent bilaterally.The 10-g-Semmes–Weinstein monofilament test revealedreduced sensation suggestive of diabetic peripheral neu-ropathy. The patient required 3 months of wound care andhyperbaric oxygen therapy to heal the wound.Forced-air warming is one of the most frequently usedmethods of patient warming in the operating room [1]. Thisdevice comprises an electrical heater unit, a hose, and ablanket. Hot air generated by the electrical heater istransferred to the blanket via the hose. Burn injuriesassociated with forced-air warming systems are extremelyrare when the device is used according to the manufac-turer’s instruction [2]. However, improper use of thedevices exposes patients to a considerable risk of burninjury [3]. Moreover, even if the device had been usedadequately, the connection could have come off acciden-tally. General misuse of this system is detaching the hosefrom the blanket and blowing hot air directly on to thepatient’s skin. This practice is called ‘‘hosing’’. Hosingcauses concentration of hot air at a single spot for anextended time period. Although a few cases including asevere burn injury of lower extremities have been reported[4], the dangers of ‘‘hosing’’ are not known by everyone.The Food and Drug Administration has issued a warningand requested submission of hosing-associated hazards [5].In addition, one of the manufacturers has started a cam-paign by posting a website (http://stophosing.com)toinform clinicians about the dangers of the use of forced-airwarming units without blankets [4].Our patient had both diabetic angiopathy and sensoryneuropathy. We think that diabetes also increased the riskof burn injury in our patient. Diabetic angiopathy andneuropathy makes skin more vulnerable to injuries.Because of diabetic sensory neuropathy in his lowerextremities, the patient did not perceive the temperature ofthe hot air correctly and hence could not warn the techni-cian to stop hosing.