Surgical Fires &Thermal Injury
Surgical fires are relatively rare, with an incidence of about 1:87,000 cases, which is close to the inci-dence rate of other events such as retained for-eign objects after surgery and wrong-site surgery.
Almost all surgical fires can be prevented. Unlike medical complications, fires are aproduct of simple physical and chemical proper-ties. Occurrence is guaranteed given the proper combination of factors but can be eliminated almost entirely by understanding the basic principles of fire risk. Likely the most common risk factor for surgical fire relates to the opendelivery of oxygen.
Situations classified as carrying a high risk for a surgical fire are those that involve an ignition source used in close proximity to an oxidizer. The simple chemical combination required for any fire is com-monly referred to as the fire triad or fire triangle. The triad is composed of fuel, oxidizer, and ignition source (heat). Table 2–2 lists potential contributors to fires and explosions in the operating room. Surgical fires can be managed and possibly avoided completely by incorporating education, fire drills, preparation, prevention, and response into educational programs provided to operating room personnel.
For anesthesia providers, fire prevention edu-cation should place a heavy emphasis on the risk relating to the open delivery of oxygen. The Anes-thesia Patient Safety Foundation has developed an educational video and online teaching module that
provides fire safety education from the perspective of the anesthesia provider.
Operating room fire drills increase awareness of the fire hazards associated with surgical procedures. In contrast to the typical institutional fire drill, these drills should be specific to the operating room and should place a greater emphasis on the particular risks associated with that setting. For example, con-sideration should be given to both vertical and hori-zontal evacuation of surgical patients, movement of patients requiring ventilatory assistance, and unique situations such as prone or lateral positioning and movement of patients who may be fixed in neuro-surgical pins.
Preparation for surgical fires can be incorpo-rated into the time-out process of the universal protocol. Team members should be introduced and specific roles agreed upon should a fire erupt. Items needed to properly manage a fire can be assembled or identified beforehand (eg, ensuring the proper endotracheal tube for patients undergoing laser surgery; having water or saline ready on the surgi-cal field; identifying the location of fire extinguish-ers, gas cutoff valves, and escape routes). A poster or flowsheet to standardize the preparation may be of benefit.
Preventing catastrophic fires in the operating room begins with a strong level of communication among all members of the surgical team. Different aspects of the fire triad are typically under the domain of particular surgical team members. Fuels such as alcohol-based solutions, adhesive removers, and surgical drapes and towels are typically con-trolled by the circulating nurse. Ignition sources such as electrocautery, lasers, drills, burrs, and light sources for headlamps and laparoscopes are usually controlled by the surgeon. The anesthesia provider maintains control of the oxidizer concentration of oxygen and nitrous oxide. Communication between personnel is evident when a surgeon enters the air-way and verifies the concentration of oxygen before using cautery, or when an anesthesiologist asks the circulator to configure drapes to prevent the accu-mulation of oxygen in a surgical case that involves sedation and use of a nasal cannula.
Administration of oxygen in concentrations of greater than 30% should be guided by clinical presentation of the patient and not solely by proto-cols or habits. If oxygen is being delivered via nasal cannula or face mask, and if increased oxygen lev-els are needed, then the airway should be secured by either endotracheal tube or supraglottic device. This is of prime importance when the surgical site is above the level of the xiphoid.
When the surgical site is in or near the airway and a flammable tube is present, the oxygen concen-tration should be reduced for a sufficient period of time before use of an ignition device (eg, laser or cautery) to allow reduction of oxygen concentration at the site. Laser airway surgery should incorporate either jet ventilation without an endotracheal tube or the appropriate protective tube specific for the wavelength of the laser. Precautions for laser cases are outlined below.
Alcohol-based skin preparations are extremely flammable and require an adequate drying time.
Pooling of solutions must be avoided. Large pre-filled swabs of alcohol-based solution should be used with caution on the head or neck to avoid both oversaturation of the product and excess flammable waste. Product inserts are a good source of infor-mation about these preparations. Surgical gauze and sponges should be moistened with sterile water or saline if used in close proximity to an ignition source.
Should a fire occur in the operating room it is important to determine whether the fire is located on the patient, in the airway, or elsewhere in the operating room. For fires occurring in the airway,the delivery of fresh gases to the patient must be stopped. Effective means of stopping fresh gases to the patient can be accomplished by turning off flowmeters, disconnecting the circuit from the machine, or disconnecting the circuit from the endotracheal tube. The endotracheal tube should be removed and either sterile water or saline should be poured into the airway to extinguish any burning embers. The sequence of stopping gas flow and removal of the endotracheal tube whenfire occurs in the airway is not as important as ensuring that both actions are performed quickly. Often the two tasks can be accomplished at the same time and even by the same individual. If car-ried out by different team members, the personnel should act without waiting for a predetermined sequence of events. After these actions are carried out, ventilation may be resumed, preferably using room air and avoiding oxygen or nitrous oxide– enriched gases. The tube should be examined for missing pieces. The airway should be reestablished and, if indicated, examined with a bronchoscope. Treatment for smoke inhalation and possible trans-fer to a burn center should also be considered.
For fires on the patient, the flow of oxidizing gases should be stopped, the surgical drapes removed, and the fire extinguished by water or smothering. The patient should be assessed for injury. If the fire is not immediately extinguished by first attempts, then a carbon dioxide (CO2) fire extinguisher may be used. Further actions may include evacuation of the patient and activation of the nearest pull station. As noted previously, prior to an actual emergency, the location of fire extinguishers, emergency exits,and fresh gas cutoff valves should be established by the anesthesia provider.
Fires that result in injuries requiring medi-cal treatment or death must be reported to the fire marshal, who retains jurisdiction over the facility. Providers should gain basic familiarity with local reporting standards, which can vary according to location.
Cases in which supplemental delivery of oxy-gen is used and the surgical site is above the xiphoid constitute the most commonly reported scenario for surgical fires. Frequently the face or airway is involved, resulting in life-threatening injuries and the potential for severe facial disfigurement. For the most part, these fires can be avoided by the elimi-nation of the open delivery of oxygen, by use of an oxygen blender, or by securing the airway.