Mattresses have been the cause of serious skin damage to patients undergoing long procedures.
Skin lesions can be caused by such mechanisms as excessive temperature,pressure necrosis, chemical attack, electrical current, and laceration. The author unraveled
a mysterious, full-backside skin lesion that a patient suffered while undergoing a six-hour
cardiovascular procedure. Typical sources of insult such as hyperthermia, mattresses, and
electrosurgical generators were first considered. It was only when the staff during interview
admitted that the OR table mattress had recently been sterilized by ethylene oxide
(EtO) and that, because of the OR scheduling demands, was returned to service immediately
upon completion of the sterilization, that the author realized that the lesion was
caused by EtO that had remained in the mattress after sterilization. The central sterile supply
and OR staff had not taken adequate precautions to ensure that the mattress had been
sufficiently aerated after EtO sterilization to allow the elution of the caustic sterilant.