Acute vesicular eruption postoperatively after use of a forced-air warming device

Abstract

Thermal burn injuries are a known complication of forced-air warming devices but rarely occur when the device is used in accordance with the manufacturer’s instructions. Here we present a case of a 3-year-old girl who in the immediate postoperative period was found to have prominent linear, evenly spaced vesicles and bullae in a pattern that distinctly matched the air-exit perforations of the Bair Hugger device. Clinicians should be aware of potential complications arising from even proper use of a medical device and take all necessary precautions to prevent such incidents.

Forced-air warming (FAW) devices, such as the Bair Hugger (Arizant Healthcare, Eden Prairie, MN), are an important tool in the operating room for the prevention of intraoperative hypothermia. Thermal burn injuries are a known complication of FAW devices, but injuries are rare when the device is used in accordance with the manufacturer’s instructions. Most known cases of FAW device thermal burn injuries have been associated with misuse of the system’s attachment hose leading to “hosing” of the skin.¹ However, there are cases in which intraoperative burns have been attributed to air exit holes, leading to diffuse, regularly spaced, and well-demarcated burns, though a past medical history of poor distal perfusion may explain susceptibility to thermal injury in these patients.^2,3 Here, we report an uncommon case of diffuse thermal burn injuries in a child following proper use of a FAW device.

CASE PRESENTATION

A healthy 3-year-old girl presented for elective bilateral lateral rectus recession for strabismus. Postoperatively, she was found to have an acute blistering skin eruption, which prompted a dermatology consultation to rule out a drug rash. Physical examination revealed parallel rows of prominent linear, evenly spaced vesicles and bullae measuring 3 to 12 mm overlying stellate erythematous patches, extending from the bilateral proximal thighs to distal feet and to a lesser degree on the arms and abdomen (Figure 1). At least 50 distinct evolving vesicles and bullae were noted along with approximately 100 expanding stellate patches, signifying first- and second-degree burns.

Figure 1.

(a) Acute vesicular eruption seen immediately postoperatively. (b) Healing, heme-crusted vesicles seen during a wound check 4 days after the operation.

Intraoperatively, a Bair Hugger warming device had been applied to the full body. Upon examination, the linear pattern and spacing of the vesicles and erythema correlated with manufactured warm air exit perforations in the Bair Hugger device. Intraoperative documentation showed the Bair Hugger air device was used at a high setting (44°C) for approximately the first half hour, after which the patient was found to be warm with a core temperature of 39°C and the device was shut off for the duration of the surgery. No erythema was appreciated by the surgical team at that time.

DISCUSSION

Though FAW devices are commonly used and are generally safe, caution should be taken to avoid direct contact between the device and the patient.³ Our consultation service recommended burn care with mupirocin wraps, and the patient received follow-up care in the outpatient burn clinic. Taking a thorough preoperative past medical history, addressing potential allergies and adverse reactions, and carefully documenting the use of intraoperative medications and devices, as well as their timing and application, is important in differentiating the cause of vesicular eruption due to an adverse drug reaction or a thermal burn injury. A linear pattern of evenly spaced vesicles and erythema should prompt consideration for external etiology of a FAW device-related injury.