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Reminder of important clinical lesson
Ortho-phthalaldehyde-induced skin mucous membrane damage from inadequate washing
  1. Masaru Horikiri1,
  2. Susam Park1,
  3. Takahiro Matsui1,
  4. Komei Suzuki2,
  5. Takanori Matsuoka2
  1. 1Department of Plastic and Reconstructive Surgery, Shizuoka Children's Hospital, Shizuoka City, Shizuoka, Japan
  2. 2Department of Pediatric Surgery, Shizuoka Children's Hospital, Shizuoka City, Shizuoka, Japan
  1. Correspondence to Masaru Horikiri, hioka-naoki{at}ah.wakwak.com

Summary

Because body fluids and blood have a tendency to adhere to transesophageal echo devices, a high level of sterilisation is required when cleaning them. Ortho-phthalaldehyde (OPA) has been widely used in Japan since being approved as a high-level sterilant. The authors report a patient with widespread, severe skin and mucous membrane damage of the lip, tongue, pharynx and oesophagus areas that was attributed to inadequate washing after the sterilisation of a transesophageal echo device with OPA. This patient experienced sequelae, which did not improve after more than 1 year of continuous treatment. When using medical devices sterilised with OPA, the use of a probe cover, when applicable, is recommended and complete washing prior to use is required.

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Footnotes

  • Competing interests None.

  • Patient consent obtained.

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