Professional Documents
Culture Documents
ABSTRACT
Operating room fires are rare but devastating events. Guidelines are available
for the prevention and management of surgical fires; however, these recom-
Operating Room Fires mendations are based on expert opinion and case series. The three compo-
nents of an operating room fire are present in virtually all surgical procedures:
an oxidizer (oxygen, nitrous oxide), an ignition source (i.e., laser, “Bovie”), and
Teresa S. Jones, M.D., Ian H. Black, M.D., a fuel. This review analyzes each fire ingredient to determine the optimal clin-
Thomas N. Robinson, M.D., Edward L. Jones, M.D. ical strategy to reduce the risk of fire. Surgical checklists, team training, and
(Anesthesiology 2019; 130:492–501) the specific management of an operating room fire are also reviewed.
(Anesthesiology 2019; 130:492–501)
This article has been selected for the Anesthesiology CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue.
Submitted for publication January 5, 2018. Accepted for publication October 5, 2018. From the Departments of Surgery (T.S.J., T.N.R., E.L.J.) and Anesthesiology (I.H.B.), the
University of Colorado and the Denver Veterans Affairs Medical Center, Denver, Colorado.
Copyright © 2019, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. (Anesthesiology 2019; 130:492–501)
Fig. 2. Example of a fire risk assessment tool. A robust fire risk assessment tool that includes recommended interventions within each compo-
nent of the fire triangle updated from the fire risk assessment utilized at Memorial Medical Center (Springfield, Illinois) made in conjunction with
the Emergency Care Research Institute. ETT, endotracheal tube; Fio2, fraction of inspired oxygen; SGA, supraglottic airway. Original available
from SurgicalFire.org.12
Care Research Institute, this recommended oxygen concen- The interruption of air exchange by surgical drapes also
tration has not been verified, but should be used as a marker significantly affects oxygen concentration. For example, the
to “establish guidelines for minimizing oxygen concentration draping for a neurosurgical procedure and use of an oxygen
under surgical drapes.” These recommendations are echoed mask with 6 L/min of oxygen resulted in oxygen concen-
by the Anesthesia Patient Safety Foundation, which suggests trations of 35 to 50% in the operative field.21 Redraping so
the use of endotracheal intubation or laryngeal mask airway that no “tent” covered the field resulted in normal oxygen
in any procedure above the xiphoid or if oxygen supplemen- content. A similar study recreating operating room condi-
tation greater than 30% is required.9 tions during a facial surgery that resulted in a fire found
Determining the relationship between oxygen supple- that supplemental oxygen increased oxygen concentration
mentation and room oxygen content is not a simple task. under the drapes to over 50%.22 These findings highlight
Operating rooms have a federal requirement of at least 20 the dangers of open oxygen sources and surgical draping
air exchanges per hour, which creates enough circulation and have led to the recommendations for an open draping
to disperse oxygen delivery by nasal cannula for the entire technique whenever surgery is required close to the oxygen
room.17 What is more important, however, is the oxygen con- source.23
tent at the site of the procedure.With respect to nasal cannula Closed systems can maintain atmospheric oxygen
delivery, local oxygen concentrations can increase by more levels near, or at, normal room air concentration while
than 5% at low flow rates (less than 4 L/min) and can become still providing increased levels of supplemental oxygen to
disastrous with levels up to 60 to 70% at higher flow rates.18,19 the patient.18,19 Endotracheal tubes (ETTs) are the most
Further complicating matters is that measurement of common delivery method; however, laryngeal mask air-
inhaled gas composition (i.e., oxygen content) at delivery ways are also considered a closed system. Inflating the
is not standard on all anesthesia machines. Reducing oxy- cuff of the ETT can decrease oxygen leakage but is not
gen concentration by blending 100% oxygen with room always feasible.24 With a closed system, the utilization of
air and delivery via a common gas outlet can be done in elevated oxygen content remains risky as the ETT cuff
some cases, but may also require an add-on gas blender.16 In itself can be damaged or even ignited by heat sources
addition, there is often a lag between reductions in oxygen (energy devices) when operating on or near the air-
delivery and exhaled oxygen content. In a closed circuit way.25 In “closed” sources, a recent review in otolaryn-
model, it took up to 5 min to reduce inspired and expired gology procedures identified inspired oxygen delivered
oxygen from 60% to 30%.20 If one is lacking the capability was greater than 30% in 97% of surgical fires in general
to measure oxygen content as it is delivered and returns anesthesia cases.26 Even reinforced, “laser resistant” ETTs
from the patient, the current recommendation is to discon- are not recommended to be used with oxygen content
tinue 100% oxygen supplementation for at least 60 s and up greater than 30% because of the risk of fire if damaged
to 3 min before (and during) energy use.7 or leaking.27
Unique methods have been developed to decrease oxy- It is important to note that monopolar energy takes
gen concentration around the operative field due to its many forms, including the handheld “Bovie,” radiofre-
massive impact on the risk of fire. A suction system for quency ablation catheters, and the argon plasma coagula-
excess oxygen under drapes significantly reduces ambient tor. In particular, forced spark gaps can be easily created
oxygen concentrations, and our most recent testing demon- with monopolar devices, especially the handheld Bovie
strated that utilization of combined energy/suction devices and the argon plasma coagulator device. Education in the
significantly reduced the incidence of fires.28,29 “Flooding” appropriate techniques of use, including fire prevention, is
the surgical field with carbon dioxide has been shown to available from the Society of American Gastrointestinal and
prevent fires during tracheostomy in an animal model.30 A Endoscopic Surgeons through their Fundamental Use of
carbon dioxide projecting sleeve has been developed for uti- Surgical Energy program.
lization around the monopolar, “Bovie” unit and eliminated The second most common ignition source is the “light
the fire risk when tested with 100% oxygen.31 Utilization amplification by stimulated emission of radiation,” com-
Table 1. Fuel Sources in the Operating Room Fires Table 2. Comparison of Alcohol vs. Non–Alcohol-based Preps
In light of these findings, the use of a non–alcohol-based was the fuel source in 49% of fires in the operating room
prep (2% chlorhexidine or 0.7 to 1% iodine) may seem during surgery on the airway.26 Similarly, nasal cannu-
like an attractive alternative in order to reduce fire risk. las and supraglottic airways are also composed of poly-
Unfortunately, this runs counter to recent 2017 recom- vinylchloride, a combustible material, as defined by the
mendation for the use of alcohol-based antiseptic agents American Society of Testing Materials.23 In high risk situ-
(for intraoperative skin preparation to decrease superfi- ations, particularly laser surgery of the larynx, metal rein-
cial and deep surgical site infections) by the Centers for forced “laser-safe” tubes are recommended. Unfortunately,
Disease Control and Prevention (Atlanta, Georgia).57,63–66 these tubes are not foolproof, and fires were easily started
As more data emerge regarding alcohol-based preps, cli- in models with laser-safe tubes when the cuff is damaged
nicians will need to compare the risk of fire to the risk of or the laser is directed at the tip of the tube (which lacks
surgical infections to appropriately protect their patients metal reinforcement).67
from fire and/or infection. In sum, clinicians can reduce the risk of surgical fires
Fig. 4. Operating room (OR) fire prevention and management algorithm. CO2, carbon dioxide; ETT, endotracheal tube. Revised algorithm from
the 2013 American Society of Anesthesiologists Practice Advisory on the Prevention and Management of Operating Room Fires.7
strictly avoid allowing alcohol-based skin preps to pool; extinguished with fire extinguishers.53 Of importance, fire
(3) utilize moistened surgical gauze when appropriate; (4) blankets should not be used in the operating room since
utilize a non–mannitol-based mechanical bowel prep with they can concentrate both heat and oxygen on the patient,
or without concomitant antibiotics when bowel surgery is potentially worsening the fire.73
indicated; and (5) utilize laser-safe tubes in upper airway Use of a fire extinguisher is exceedingly rare, but all
surgery with careful attention to cuff integrity. operating suites are required to maintain them for use.
Should one be required, please remember the “PASS”
Management of a Surgical Fire method of use: Pull the safety pin from the handle; Aim at
the base of the fire; Squeeze slowly to discharge the extin-
A fire in the operating room is a terrifying event, but it
guishing agent; Sweep side-to-side, keeping a safe distance
can be stopped quickly with early identification and man-
from the fire.74
agement. In addition to a fire risk assessment and checklist
Surgical fires also present a unique microcosm of mod-
before surgery, cognitive aids such as emergency manu-
31. Culp WC Jr, Kimbrough BA, Luna S, Maguddayao operating room. Int J Pediatr Otorhinolaryngol 2011;
AJ: Operating room fire prevention: Creating an elec- 75:227–30
trosurgical unit fire safety device. Ann Surg 2014; 47. Tanner J, Norrie P, Melen K: Preoperative hair removal
260:214–7 to reduce surgical site infection. In: Cochrane Database
32. Liu NT, Salter MG, Khan MN, Branson RD, Enkhbaatar of Systematic Reviews 2011
P, Kramer GC, Salinas J, Marques NR, Kinsky MP: 48. Kretschmer T, Braun V, Richter HP: Neurosurgery
Closed-loop control of FiO2 rapidly identifies need without shaving: Indications and results. Br J Neurosurg
for rescue ventilation and reduces ARDS severity in a 2000; 14:341–4
conscious sheep model of burn and smoke inhalation 49. Ladas SD, Karamanolis G, Ben-Soussan E: Colonic gas
injury. Shock 2017; 47:200–7 explosion during therapeutic colonoscopy with elec-
33. Saihi K, Richard JC, Gonin X, Krüger T, Dojat M, trocautery. World J Gastroenterol 2007; 13:5295–8
Brochard L: Feasibility and reliability of an automated 50. Bellevue OC, Johnson BM, Feczko AF, Nadig DE,
JS, Mazuski JE, Dellinger EP, Itani KMF, Berbari EF, Peyre S, Nelson S, Boorman DJ, Smink DS, Ashley SW,
Segreti J, Parvizi J, Blanchard J, Allen G, Kluytmans Gawande AA: Crisis checklists for the operating room:
JAJW, Donlan R, Schecter WP; Healthcare Infection Development and pilot testing. J Am Coll Surg 2011;
Control Practices Advisory Committee: Centers for 213:212–217.e10
Disease Control and Prevention guideline for the pre- 69. Group SACA: Emergency manual: Cognitive aids for
vention of surgical site infection, 2017. JAMA Surg perioperative critical events. 2nd ed. BY-NC-ND:
2017; 152:784–91 Creative Commons; 2014.Available at: https://stanford-
64. Darouiche RO, Wall MJ Jr, Itani KM, Otterson MF, medicine.qualtrics.com/jfe/form/SV_cFKheoidGN-
Webb AL, Carrick MM, Miller HJ,Awad SS, Crosby CT, We8o5?Q_JFE=qdg. Accessed May 3, 2018
Mosier MC, Alsharif A, Berger DH: Chlorhexidine- 70. Anesthesia Patient Safety Foundation: OR fire hand-
alcohol versus povidone-iodine for surgical-site anti- outs & algorithms. Available at: https://www.apsf.org/
sepsis. N Engl J Med 2010; 362:18–26 newsletters/html/Handouts/. Accessed May 3, 2018