A Fire in the Operating Room: It Could Happen to You! - Vtr

A Fire in the Operating Room: It Could
Happen to You!
Learning Objectives:
As a result of completing this activity, the participant
will be able to:
Describe the risks of operating room fires
Construct strategies that decrease the risk of an
operating room fire
Prioritize care for the patient involved in an
operating room fire
Summarize the risks of the new volatile prep
solutions
Author Disclosure Information:
Dr. Ehrenwerth has disclosed that he has no financial
interests in or significant relationship with any
commercial companies pertaining to this educational
activity.
Operating room (OR) fires are probably more common
today than when anesthesiologists used explosive
agents. This is the result of more combustible
materials in the OR, more ignition sources, and the prevalent
Parts of this chapter were reproduced from Ehrenwerth J, Seifert HA.
Electrical and Fire Safety, in Clinical Anesthesia, 6th ed, edited by Barash
PG, Cullen BF, Stoelting RK, Cahalan MK, Stock MC. Philadelphia:
Lippincott Williams & Wilkins; 2009. With permission from Lippincott
Williams & Wilkins.
Supplemental digital content is available for this article. Direct URL
citations appear in the printed text and are available in both the HTML
and PDF versions of this article. Links to the digital files are provided in
the HTML and PDF text of this article on the Journal’s Web site
(www.asa-refresher.com).
Jan Ehrenwerth, MD
Department of Anesthesiology
Yale University School of Medicine
New Haven, Connecticut
26
use of open oxygen during monitored anesthesia care. The
Emergency Care Research Institute (ECRI) estimates that
500 to 600 OR fires occur each year in the United States. 1
Most are self-limited and do not result in significant injury to
the patient. However, there are many instances of a patient
receiving a serious burn and occasionally death has been
reported. As recently as 2009, a 65-year-old woman in
southern Illinois died a few days after she was burned in an
OR fire. Approximately 65% of fires today involve surgery
on the head, neck, and upper chest area. 1–3
THE FIRE TRIANGLE
A fire is actually a chemical reaction in which a fuel rapidly
combines with an oxidizer (usually oxygen) to produce
light and heat energy. The higher the concentration of
oxygen, the hotter the fire will burn and the more energy
that will be released. For a fire to start, three elements must
come together at the same time; this is referred to as the fire
triangle or fire triad 1,4,5 (Figure 1). The elements are: (1) a
heat source, (2) an oxidizer, and (3) a source of fuel (Supplemental
Digital Content 1, http://links.lww.com/ASA/A244).
In the OR, the heat source is usually the electrosurgical
unit (ESU), which is the ignition source in almost 70% of
fires. Other common heat sources include the laser, fiberoptic
light cords, and hot wire cautery. The fuel for the fire
can be almost anything, including plastics, paper drapes,
the patient’s hair, volatile prep solutions, and even bowel
gas. The oxidizer is usually oxygen, but nitrous oxide
(N2O) will support combustion equally as well as oxygen.
Clearly, the best strategy to prevent a fire is by isolating
the components of the fire triad. This includes minimizing
risk by decreasing the oxygen concentration, avoiding use

AFireintheOperatingRoom
FIGURE 1. The fire triangle. rECRI Institute. Used with permission.
of N2O, and eliminating residual volatile liquids. The
problem in the OR is that no single person is looking at all
three parts of the fire triangle. Usually the heat or ignition
source is in the hands of the surgeon, the fuel is overseen by
the nursing staff, and the oxidizer is controlled by the anesthesia
team. The danger of fires is mostly smoke and toxic
products of combustion, which can include carbon monoxide,
ammonia, and cyanide. Although ORs today contain
sprinkler systems, it is rare that a fire gets hot enough to
activate the sprinkler. Once a fire is started, if it is not quickly
extinguished, the smoke from burning materials can quickly
fill the OR and present a risk of asphyxia to OR personnel.
Clearly, the best strategy to prevent a fire is by
isolating the components of the fire triad. This
includes minimizing risk by decreasing the
oxygen concentration, avoiding use of N2O,
and eliminating residual volatile liquids.
PREPARATION AND PREVENTION
Preparing for an OR fire is probably one of the best ways to
help prevent it. It is always important to determine
whether or not a high-risk situation exists. If it does, the
team should discuss the strategy to prevent a fire and how
to manage one should it occur. Ideally, this can be covered
during the surgical timeout, when it is extremely important
FIGURE 2. A fire on the patient can involve the drapes, surgical towels, and
the gel pad. rECRI Institute. Used with permission.
to have a patient safety discussion in which the specific fire
risk can be addressed.
OR fires can be classified into two types: those that occur
in the patient and those that occur on the patient. Fires
in the patient include those in the tracheobronchial tree, in
the chest during open heart and thoracic surgeries, and
intraabdominal fires. Fires on the patient will include those
with burning drapes, gel pads, the patient’s hair, and prep
solutions (Figure 2). In modern times, the most serious
intraoperative fires have occurred with laser or electrocautery
in an oxygen-enriched environment in the airway.
6–14 If an endotracheal tube with a high concentration
of O2 or O2/N2O is set on fire, it produces a ‘‘blowtorch’’
effect and a large amount of debris will be deposited into
the lungs (Figure 3A, B).
In modern times, the most serious
intraoperative fires have occurred with laser
or electrocautery in an oxygen-enriched
environment in the airway.
Lasers
Laser is an acronym for light amplification by stimulated
emission of radiation. Laser light is produced when energy
is aimed at the ‘‘lasing medium.’’ The medium then becomes
the name of the laser. For instance, electrical energy
aimed at carbon dioxide (CO2) molecules is a CO2 laser.
Laser light is coherent, which means it can be focused into
very small spots with very high powered densities. Common
devices used in the OR are the Nd:YAG and the CO 2
lasers. A helium-neon low-power laser is also frequently
used to aim these other lasers.
When performing upper airway surgery, it is common to
use an endotracheal tube to ventilate the patient. In these
instances, the tracheal tube must be specifically resistant to
the laser that is being used. It should consist of two cuffs
27

28 Ehrenwerth
FIGURE 3. A, A burning endotracheal tube with a high concentration of O 2
or O 2/N 2O will produce a ‘‘blowtorch’’ effect. B, A burning endotracheal tube
will generate a large amount of debris. rECRI Institute. Used with
permission.
that are filled with saline tinted with methylene blue to
alert the surgeon in case one of the cuffs is ruptured by the
laser. PVC, red rubber, and silicone endotracheal tubes are
all combustible when a FiO2 greater than 27% is being
used. 15,16 Endotracheal tubes should never be wrapped
with any sort of metal foil. If it is necessary to use an uncuffed
endotracheal tube in a pediatric patient, the FiO2
needs to be decreased to as low a value as possible and the
airway should be sealed with saline-soaked pledgets. It is
also possible to perform upper airway surgery with a rigid
laryngoscope and using jet ventilation. However, this
technique almost always involves ventilating with some
sort of Venturi, which makes it impossible to precisely
control the inspired oxygen concentration.
Surgery on the lower airway with a laser is usually done
with the Nd:YAG device. In most circumstances, a fiberoptic
bronchoscope is used and the laser fiber is passed
through the suction channel of the bronchoscope. Because
the bronchoscope is being placed through the endotracheal
tube, there is no special tube for this type of surgery.
However, the tube should be placed just below the vocal
cords and the FiO2 kept below 30%. It may be necessary to
tolerate oxygen saturations in the 90 to 95% range in the
patient in order to keep the FiO2 below 30%. Even so, the
FIGURE 4. The LaserFlexä laser-resistant endotracheal tube.
plastic coating of the bronchoscope is flammable and can
be set on fire from hot pieces of lasered tissue. Another
technique for lower airway surgery with the laser is to use a
rigid bronchoscope and no endotracheal tube. Again, the
FiO2 is not adjustable with jet ventilation.
The LaserFlext is a very good endotracheal tube to use
when operating with a CO 2 laser (Figure 4). It consists of a
double-cuff design on a flexible metal tube. It is not resistant
to the Nd:YAG laser, however, and if that device is going to
be used, then the Lasertubust is a safer choice (Figure 5).
The Lastertubus endotracheal tube has a metal foil wrapping
that is covered with a Merocelt coating. That coating must
be kept moist during the entire case. The tube has a doublecuff
design but only the lower half of the tube is laser resistant.
17 Therefore, the surgeon and the anesthesiologist
must monitor the tube position to make sure that the
protective part of the tube is always in the surgical field.
Electrocautery
Another procedure during which a fire can occur is a tracheostomy.
18,19 Occasionally, the surgeon will use the ESU
FIGURE 5. The Lasertubusä laser-resistant endotracheal tube.

AFireintheOperatingRoom
to enter the trachea. This is an extremely risky practice and
it is far better to use a knife or scissors. The surgeon may
request that the FiO 2 be decreased, but this can take several
minutes because of the volume of the anesthesia circuit.
Also, many of these patients are on high oxygen concentrations
and will not tolerate even a brief decrease in FiO2.
There has already been a death reported in Japan related to
using the ESU during a tracheostomy.
Another example of a fire in the patient occurred when a
child was having a tonsillectomy. 13 The anesthesiologist
was administering 70% N 2O and 30% O 2 through an
uncuffed endotracheal tube. The O2/N2O leaked out
around the tube, and while the surgeon was using the ESU,
sparks and a fire occurred. Clearly, a lower FiO2, a cuffed
endotracheal tube, or sealing the airway with salinesoaked
pledgets would have prevented this problem.
N2O could be the oxidizer for a fire during laparoscopic
surgery. Because bowel gas may contain very high levels of
methane or hydrogen, and because N 2O will diffuse into
the peritoneum, if the surgeon accidentally enters the
bowel, then the ESU could ignite the methane or hydrogen.
Greilich 20 reported an intraoperative fire that occurred
when a tank containing both O2 and CO2 was accidentally
used to inflate the abdomen instead of 100% CO2.
Absorbents
Desiccated CO 2 absorbent has been reported to be the
source of several OR fires. 21–24 The desiccated absorbent
was composed of monovalent bases (KOH and NaOH)
and reacted with sevoflorane to produce very high temperatures.
This was a particular problem with the Baralymet
brand of CO2 absorbent. In a laboratory experiment,
Laster et al. 25 showed that sevoflurane produced sustained
temperatures greater than 2001C, whereas with isoflurane
and desflurane the temperatures never exceeded 1001C
and had a rapid decay. Several canister fires were reported
before Baralyme was removed from the market. A newer
absorbent called Amsorbt contains calcium hydroxide
[Ca(OH2)], has no monovalent bases, and does not break
down any of the inhalation anesthetic agents. 26
Oxygen
Currently, the majority of OR fires occur with monitored
anesthesia care during head and neck surgery. Invariably,
this involves an oxygen-enriched atmosphere since 75% of
surgical fires are oxygen enriched (Supplemental Digital
Content 2, http://links.lww.com/ASA/A245). Currently, the
Anesthesia Patient Safety Foundation recommends that there
be no open delivery of oxygen during these cases 27 (Supplemental
Digital Content 3, http://links.lww.com/ASA/A246). If
the patient needs increased levels of sedation during a time
when the surgeon is using the ESU or laser, then the airway
needs to be secured with a laryngeal mask airway or an endotracheal
tube. Occasionally there are exceptional cases in
which the patient and the anesthesiologist need to communicate,
such as during a carotid endarterectomy or an awake
craniotomy. In these instances, it may be safe to use an FiO2
up to 30%. Preferably the patient should receive only room
air during these cases.
Currently, the majority of OR fires occur
with monitored anesthesia care during
head and neck surgery.
Air can be delivered from the anesthesia machine or
from an air/oxygen blender. There are several ways to deliver
air to a nasal cannula or a face mask. The simplest is
to put a small endotracheal tube connector into the end of
the Y-piece on the circle system and completely close the
adjustable pressure relief valve. If oxygen must be used, the
anesthesiologist should start with air and then slowly add
oxygen while keeping the FiO 2 at less than 30% (Supplemental
Digital Content 4, http://links.lww.com/ASA/A247).
If the oxygen concentration exceeds 30%, then several minutes
must be allowed for oxygen to wash out before the
surgeon uses the ESU. Oxygen should be diluted with 5 to
10 L/min of air next to the patient; open draping with an
incise drape can also be helpful. It should be remembered
that 30% O 2 is achieved by adding 0.2 L/min of O 2 to 1.8 L/
min of air. Also, on some machines, such as the GE-Ohmeda
Aestiva, there is an alternate fresh gas outlet. By activating
the lever next to the CO2 canister, a nasal cannula can be
attached to the outlet via a small endotracheal tube connector
(Figure 6). This is preferable to using the circle system
as it greatly decreases the dead space of the system.
PREPPING SOLUTIONS
Another extremely dangerous situation is when the surgeon
uses a volatile prepping solution (Figure 7). Dura-
Prept is one such commonly used solution and it contains
74% alcohol. Alcohol, especially in an oxygen-enriched
FIGURE 6. A nasal cannula connected to the alternate fresh gas outlet on a
GE-Datex-Ohmeda Aestiva anesthesia machine.
29

30 Ehrenwerth
FIGURE 7. Demonstration of the flammability of alcohol. rECRI Institute.
Used with permission.
environment, is extremely flammable. After a fire at the
University of Arizona, Barker and Polson 28 did a recreation
in which they used supplemental oxygen and made
an ‘‘incision’’ before the prepping solution was completely
dry. Within a few seconds, a very vigorous fire ensued.
In addition, using alcohol prep solutions is a particular
problem in emergency cases or when reprepping is necessary.
If the prepping technique is sloppy, the solution may
pool beside the patient. Frequently, not enough time is allowed
for the prep solution to dry, and if the solution
pools, it can give off alcohol vapors which are extremely
flammable. 29 One of the problems with an alcohol-based
fire is that the flames can be extremely difficult to see. This
is particularly true in the OR, where a bright OR light
makes it almost impossible to see an alcohol fire. Thus, a
very hot alcohol fire could be burning on a patient and the
OR staff may not even be aware that it is occurring.
WHAT TO DO IF A FIRE OCCURS
If an OR fire should occur, it is important that all of the
team members know what to do (Supplemental Digital
Content 5, http://links.lww.com/ASA/A248). The anesthesiologist
should immediately stop the flow of oxygen,
the drapes should be removed from the patient and thrown
on the floor, and saline or water should be poured onto the
fire on the patient. A fire extinguisher can be used to extinguish
the burning drapes. The CO2 type of extinguisher
is currently recommended for use in the OR. The acronym
for using a fire extinguisher is PASS: Pull, Aim, Squeeze,
Sweep (Supplemental Digital Content 6, http://links.lww.
com/ASA/A249). The extinguisher should be aimed at the
base of the fire and the nozzle should be rapidly swept back
and forth across the fire until it is extinguished.
A fire at New York Medical Center in 1992 will serve to
illustrate several important points about fire safety. 30 The
case involved a patient having a craniotomy during which
the surgeon was using both the laser and the ESU. The two
devices were controlled by foot pedals that looked very
similar. The surgeon placed one device on the drapes and
picked up the other one. Although he thought he was activating
the ESU in his hand, he actually activated the laser
that was sitting on the drapes. The drapes, mattress, and
gel pad immediately ignited and filled the room with
smoke. The OR staff had to evacuate the room and left
the patient behind. Eventually they were able to return to
extinguish the fire and rescue the patient.
Clearly, recognizing a safety risk and making sure the
laser was in standby mode and the ESU was put in a proper
holder would have prevented this fire. Also, using a foot
pedal for the laser and having a hand-activated ESU would
have made it clear that the foot pedal only controlled the
laser. Other fires have occurred when staff failed to recognize
potential problems, there was no plan to deal
with the fire, team members did not know where the
fire extinguishers were located, and the fire cabinets were
actually blocked by equipment in the hallway.
In 2008, the American Society of Anesthesiologists
published a practice advisory for the prevention and
management of OR fires. 31 Several important points were
brought out in this advisory.
The first is preparation: the staff should identify if a
high-risk situation exists.
Second, they should discuss strategies to avoid a fire and
give each person a specific task in the event a fire occurs.
Prevention requires effective communication among the
OR staff and is enhanced by allowing flammable prep
solutions to dry, using moist gauze sponges, and making
sure the surgeon knows when an oxidizer is present in
close proximity to an ignition source. When that occurs,
the oxidizer needs to have time to dissipate before the
surgeon uses the ignition source.
Third, if a fire does occur, it should be immediately
doused with water or saline, and the patient should be
mask ventilated and endotracheally intubated so that the
status of the airway can be assessed and the burn can be
treated.
In the event of an airway fire, the endotracheal tube
should be simultaneously removed and oxygen discontinued.
Saline should be poured into the airway, the
patient reintubated, and the airway assessed for
damage.
If the fire is on the patient, the drapes should be
immediately removed, the fire extinguished with water
or saline, and a fire extinguisher used to extinguish the
drapes. If the fire is not immediately extinguished,
aCO 2 fire extinguisher needs to be obtained.
The fire alarm should be activated and a decision made
whether or not to evacuate the OR. If the room is
evacuated, all medical gases should be turned off using
the shutoff valves outside the room.
Finally, the hospital risk manager should be notified,
the scene should be preserved, and all local regulatory
reporting requirements should be followed.

AFireintheOperatingRoom
CONCLUSIONS
Fortunately, virtually all OR fires are preventable. However,
prevention requires that all OR team members recognize a
high-risk situation and effectively communicate an understanding
of that situation and what they are going to do to
reduce the possibility of a fire. The guiding principle is to
keep the three legs of the fire triangle from coming together.
Should an OR fire occur, it is important that all team members
know their role and act quickly to extinguish the fire
and rescue the patient. It is highly recommended that the OR
staff have yearly instruction on fire safety and that fire drills
be conducted so that everyone has the opportunity to practice
proper procedures.
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