VOLUME 30, ISSUE 2

William C. Culp, Jr., MD

Professor
Scott & White Medical Center
Texas A&M University College of Medicine
Temple, TX

Operating Room Fire Safety: Prevention and Treatment

Disclosure: The author has patent interests in medical safety devices related to fire prevention.

Background

Operating room fires continue to present a real hazard to our patients undergoing surgical procedures, and occur more than 600 times annually in the United States- more often than wrong-site surgery.1 Frequently, these fires go unreported and therefore are likely far more common than is suggested by the published literature. Operating room fires may injure our patients and/or those caring for them, and occasionally even lead to patient death. The Joint Commission, Anesthesia Patient Safety Foundation, American Society of Anesthesiologists, and other patient advocacy organizations have all recognized the potential patient harm caused by these sentinel events and have developed strategies to mitigate this risk.

The Fire Triad

The fire triad describes the three elements required for combustion: fuel, an oxidizer, and an ignition source. (Figure 1) When all three components are present, the possibility of fire exists. The operating room presents a specialized environment that frequently exposes the patient to each fire triad component. Surgical drapes, alcohol-based skin prepping solutions, gauze, gowns, towels, laparotomy sponges, and even patient hair can all serve as potential fuel sources. Of these, surgical drapes are likely the most common fuel source in the operating room.2 Oxidizers (typically oxygen gas and/or nitrous oxide) are used in nearly all anesthetic cases. Potential ignition sources make up the third leg of the fire triad, and include electrosurgical units and lasers. Though we commonly think about lasers increasing fire risk, the electrosurgical unit is the ignition source for nearly 90% of operating room fires.3 Customarily, the surgeon is responsible for the tools that ignite fires, the nurse provides potential fuels, while the anesthesiologist controls oxidizer administration. Therefore, each member of the team should be aware of his role in contributing to the conditions that may lead to fires. The anesthesiologist should be acutely aware that increased ambient oxygen concentrations surrounding a fuel and ignition source dramatically increase both the ease of fuel ignition and the speed of fire propagation. Materials that don’t readily ignite in room air with 21% oxygen may burn very rapidly when placed in an oxygen-enriched environment. Moreover, flash fires may readily ignite and quickly spread.4

Prevention Strategies

Identification of high risk procedures will help the anesthesiologist prepare for and prevent fires, and should be completed during the pre-operative time out. Closed claims study data demonstrate that, of fire claims during sedation cases, 97% were procedures located primarily on the head, neck, or upper chest. Nearly 99% of these patients received supplemental oxygen through “open” oxygen delivery systems (face mask or nasal cannula), potentially spilling oxygen onto the surgical field. Other high-risk procedures include intra-airway or intra-oral interventions with electrosurgical units and/or surgical lasers.3 Airway fires will be covered in more detail in an accompanying article.

Practice advisories concerning operating room fire prevention and management stress a multi-faceted approach to reducing fire risk. Education efforts should include operating room fire safety training for all anesthesiologists. Superb materials have been developed by the Anesthesia Patient Safety Foundation and are available for download.5 Fire drills involving the operative team should be rehearsed periodically. Alcohol-based antiseptic skin prep solutions must be allowed to dry completely prior to draping.6 Draping should be performed in a manner that minimizes oxygen accumulation.7 Anesthesiologists should identify each high-risk case, and then discuss with the operative team a fire prevention and treatment plan pre-operatively. Anesthesiologists should minimize the potential for an oxygen-enriched atmosphere near the surgical site, particularly minimizing the use of open oxygen sources in high-risk cases. Anesthesiologists should also consider using a “sealed gas delivery device” such as a laryngeal mask airway or endotracheal tube if the patient exhibits oxygen dependence or if moderate or deep sedation is required. If an open gas delivery device (face mask or nasal cannula) is used, the surgeon should give adequate notice prior to engaging a potential ignition source to allow oxygen flow to be temporarily stopped. The surgeon should clearly warn the anesthesiologist prior to activating the laser to allow adequate time to reduce the oxygen concentration and discontinue nitrous oxide administration. 8

Treatment Strategies

Operating fires can ignite and spread very rapidly, particularly in oxygen-enriched environments, and serious injury can occur before personnel have time to respond. Therefore, fire prevention remains paramount. If fire occurs, the surgery should be stopped and all team members immediately perform their prearranged fire treatment tasks. For fires not involving the airway, airway gases should be discontinued, fuels removed, and the fire extinguished by water, saline, or smothering. If the fire persists, a carbon dioxide fire extinguisher should be used. If the fire continues, the fire alarm should be sounded and evacuation plans executed, including turning off the room’s medical gas supply.8

Future Developments

Continuing education efforts led by the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists have raised operating room fire awareness. Current research is focused on disrupting the fire triad to prevent fire ignition rather than developing different treatment strategies. The fire suppressant gas carbon dioxide has been used to displace oxygen away from the electrosurgical unit pencil tip, thereby effectively preventing fire. Initial testing of this concept with a modified ESU pencil has shown promising results, though such a device is not yet commercially available.9,10

Summary

Operating room fires represent a frequent threat to our patients, as components of the fire triad (fuel, oxidizer, and ignition source) are present in nearly all surgical procedures. Surgeons, nurses, and anesthesiologists should all be aware of the role they play in both contributing to the conditions that can lead to fire and how they can prevent and treat fire in the operating room environment.

References:

  1. Emergency Health Care Research Institute: 2012 Top 10 Technology Hazards. Health Device 2009; 38:11.
  2. Bhananker SM, Posner KL, Cheney FW, Caplan RA ,Lee LA, Domino KB. Injury and Liability Associated with Monitored Anesthesia Care. Anesthesiology 2006; 104: 228-34.
  3. Mehta SP, Bhananker SM, Posner KL, et al. Operating Room Fires: A Closed Claims Analysis. Anesthesiology 2013; 118:1133-1139.
  4. Culp Jr. WC, Kimbrough BA, Luna S. Flammability of Surgical Drapes and Materials in Varying Concentrations of Oxygen. Anesthesiology 2013; 119:770-6.
  5. Prevention and Management of Operating Room Fires. Available at http://www.apsf.org/resources_video.php . Accessed 29 March 2018.
  6. Bonnet A, Devienne M, De Broucker V, et al. Operating room fire: Should we mistrust alcoholic antiseptics? Ann Chir Plast Esthet 2015; 60:255-61.
  7. Kung TA, Kong SW, Aliu O, et al. Effects of vacuum suctioning and strategic drape tenting on oxygen concentration in a simulated surgical field. J Clin Anesth 2016; 28:56-61.
  8. Apfelbaum JL, Caplan RA, Barker SJ, et al. Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013; 118: 271-90.
  9. Culp Jr. WC, Kimbrough BA, Luna S, Maguddayao AJ. Mitigating Operating Room Fires: Development of a Carbon Dioxide Fire Prevention Device. Anesth Analg 2014; 118:772-5.
  10. Culp Jr. WC, Kimbrough BA, Luna S, Magaddayao AJ. Operating Room Fire Prevention: Creating an Electrosurgical Unit Fire Safety Device. Ann Surg 2014.

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