[Endotracheal tube fire during laryngeal surgery: analysis of the root cause of a sentinel event]. / Ignición del tubo endotraqueal durante cirugía laríngea. análisis causa-raíz de un suceso centinela.

Endotracheal tube fire during laryngeal surgery is a rare complication but one that has serious consequences. Surgeons, anesthesiologists and others involved with this type of surgery should become familiar with how to manage this difficult situation, which should be considered a sentinel event requiring prompt analysis of the root cause and surrounding circumstances. Measures to improve management should be implemented and training provided in order to prevent the recurrence of a similar unfortunate event. We report a case in which a patient's airway caught fire during use of an electrocautery device. The patient died as a result of the lesions sustained. We report the results of the investigation and the protocols for prevention and response implemented in our surgical department, in the hope that the experience will be of interest to others working in similar settings.

Ignición del tubo endotraqueal durante cirugía laríngea. Análisis causa-raíz de un suceso centinela / Endotracheal tube fire during laryngeal surgery: analysis of the root cause of a sentinel event

El riesgo de fuego asociado a ignición del tubo endotraquealdurante cirugía laríngea es una complicaciónpoco frecuente pero de graves consecuencias. Cirujanos,anestesiólogos y otros profesionales implicados en elmanejo de estos pacientes deben de estar formados yfamiliarizados con esta difícil situación. Se trata de unacomplicación que debe ser considerada como un eventocentinela y se debe realizar de forma inmediata un análisiscausa-raíz que permita investigar las circunstanciasen las que se produce, implementar medidas de mejoray formación que impidan que se dé este desgraciadoaccidente. Presentamos el caso clínico de un paciente quedurante cirugía laríngea sufrió una combustión de la víaaérea con el empleo de electrobisturí y que como resultadode las lesiones falleció. Aportamos la investigaciónrealizada y los protocolos de prevención y actuaciónimplantados en nuestra área quirúrgica considerandoque pueda ser de interés para otros profesionales denuestro ámbito(AU)

Endotracheal tube fire during laryngeal surgery is arare complication but one that has serious consequences.Surgeons, anesthesiologists and others involved with thistype of surgery should become familiar with how tomanage this difficult situation, which should beconsidered a sentinel event requiring prompt analysis ofthe root cause and surrounding circumstances. Measuresto improve management should be implemented andtraining provided in order to prevent the recurrence of asimilar unfortunate event. We report a case in which apatient’s airway caught fire during use of anelectrocautery device. The patient died as a result of thelesions sustained. We report the results of theinvestigation and the protocols for prevention andresponse implemented in our surgical department, in thehope that the experience will be of interest to othersworking in similar settings(AU)