Recognizing Nosocomial Burn Injury in Patients after Coronary Artery Bypass Surgery (CABG)

There is growing expansion of public awareness surrounding facility acquired pressure ulcers, but scant information on burns associated with intraoperative procedures.  Distinguishing between pressure necrosis and burn injury is difficult but critical to prevention of patient injury.   Although published studies are scarce, many authors anecdotally cite the underreporting and misdiagnosis of OR burn injury.  

Within a three month period, three patients who underwent a CABG (coronary artery bypass graft) at our facility exhibited atypical sacral/intergluteal ulcers postoperatively.  The CT surgeons diagnosed these lesions as pressure necrosis and requested immediate resolution of the cause by nursing.   The Wound Team presumed these to be chemical/thermal burns from the OR prep in combination with the OR heating pad.  Heated debate ensued.  After a fourth and fifth patient developed lesions that clearly exhibited a six sided outline consistent with the design on the heating pad, the stalemate ended.   A careful retrospective review of the prior patient photos showed a similar pattern.   Pressure ulcers and burns are similar in appearance and course of injury; differences are subtle.   There can be a mild erythema (blanchable with burn, nonblanchable with pressure ) and/or blistering, such as stage II ulcer or  second  degree burn, to a deep open wound with black eschar, as in stage III or IV ulcer or third degree burn. In general, pressure ulcers are localized areas of injury/ischemia over bony prominences, whereas a burn injury can occur anywhere. 
Although there is anecdotal information regarding OR burns associated with betadine and alcohol, there is very little research.  Several authors opine that OR burns may be more frequent than reported and misdiagnosed as pressure ulcers.   Available retrospective studies which illustrate incidence of OR prep solution injury are included with our case studies.   Lessons learned:

1)  CWCN expertise is invaluable in assessment of unique lesions

2)  All sacral lesions are not necessarily pressure ulcers and awareness of the etiology is  critical to prevention of further patient injury

3)  More literature needs to be available and research conducted on the incidence and etiology of OR lesions, especially in areas vulnerable to surgical PREP pooling.

4)  Chemical burn should always be included in the differential of post operative patients who present with atypical pressure ulcers