Surgical Fires

Introduction

• Surgical fires are fires that occur in, on, or around a patient while undergoing a surgical or medical procedure.^1,2 Based on data extrapolated from Pennsylvania, it is estimated that approximately 600 surgical fires occur in the United States every year.1 With underreporting of cases, the true incidence is probably higher.
• Surgical fires are “never” events and can be prevented.

Surgical Fire Triangle

• The basic elements of the fire triangle are ignition source, oxidizer, and fuel source.^1-4 A fire occurs when all the elements of the fire triangle come together in the right proportions and under the right conditions. Different members of the surgical team are primarily involved with different sides of the triangle.

• An oxygen-enriched atmosphere (OEA) exists when the oxygen concentration exceeds 21%. OEA is involved in most surgical fires, and it lowers the temperature and energy at which a fuel will ignite.¹ OEA fires are hotter, burn more vigorously, and spread more rapidly.
• According to ASA Closed Claims data, 85% of surgical fires occurred in the head, neck, or upper chest, and 81% of cases were under monitored anesthesia care.⁵ Open O₂ delivery and configuration of surgical drapes can result in an OEA, increasing the risk of surgical fires.
• N₂O also supports combustion. Fires involving N₂O are as severe as OEA fires.

Prevention of Surgical Fires

Managing Oxidizer^1-4

During head, neck, face, and upper chest surgery:

• If the patient can maintain safe SpO₂ without supplemental O₂, consider using air for open delivery. If not, consider securing the airway with a supraglottic airway or ETT.
• If open O₂ delivery is used, deliver the minimum O2 concentration necessary for adequate oxygenation. Begin with O₂ concentration < 30% and increase if necessary. If using > 30% O₂, deliver 5-10 L/min of air under the drapes to wash out excess O₂.
• Stop supplemental O₂ for at least one minute before using electrosurgical cautery.

Managing Ignition Source^1-4

When using an electrosurgical cautery, laser, or fiberoptic light source:

• notify surgeon of the presence of OEA;
• activate unit only when the tip is in view;
• deactivate unit before the tip leaves the surgical site;
• place unit in a holster when not in active use;
• do not use electrocautery to enter the trachea;
• do not use red rubber catheters to sheathe long electrocautery probes;
• place laser on stand-by mode when not in active use;
• turn off fiberoptic light source when not in use;
• do not allow fiberoptic light source to come in contact with fuel (drapes/gauze).

Managing Fuel^1-4

• Use nonalcohol-based skin preps (Povidone-Iodine), if possible
• With alcohol-based skin preps, avoid pooling of prep
• Allow prep to fully dry (at least 3 minutes) before draping
• Remove towels used to catch dripped flammable prep before draping
• Moisten sponges when used in proximity to ignition source
• When using laser for airway surgery, consider using laser resistant ETT, if appropriate. Use saline in the cuff to prevent cuff ignition and consider using dye in cuff to indicate puncture.

Fire Risk Assessment^1-4

• Open communication between operating room (OR) team members is crucial for the prevention and management of surgical fires.
• During the surgical time-out, a fire risk assessment must be performed to assess fire risk, develop a strategy to prevent fires, designate roles for team members in the event of a fire.
• The Silverstein fire assessment tool assigns one point for each risk factor present and stratifies the risk based on the total score.⁶

• High-risk surgeries include²
  • Tonsillectomy
  • Tracheostomy
  • Laryngeal papilloma removal
  • Cataract surgery
  • Burr hole surgery
  • Removal of lesions from head, neck, or face

Management of Surgical Fires

• When early warning signs of a surgical fire such as flame or flash, unusual sounds, odors, or smoke are noted, immediately inform the team and halt the procedure.