Surgical Fires:

Prevention &
Management
Debnath Chatterjee, MD, FAAP
Children’s Hospital Colorado
University of Colorado

Updated 4/2017
Disclosure
• Nothing to disclose
 Learning Objectives

• Identify components of the surgical fire triangle

• Explain the risks of an oxygen-enriched atmosphere

• Describe strategies for the prevention of surgical fires

• Perform a preoperative surgical fire risk assessment

• Discuss appropriate steps in the management of
surgical fires
Outline

• Overview of surgical fires

• High risk procedures

• Components of the surgical fire triangle

• Preoperative fire risk assessment

• Prevention of surgical fires

• Management of surgical fires

 Surgical Fires

Fires that occur in, on or around a patient while

undergoing a surgical or medical procedure

~ 550-650 surgical fires occur in US every year1

Pennsylvania Patient Safety Advisory2

1/3rd of reported events indicated harm to patient

1. Health Devices 2009 Oct;38 (10):314-332

2. Clarke JR, Bruley ME. Pa Patient Safety Advis 2012
 Surgical Fires
• Equipment involved
• 70%- Electrosurgical device

• 10%- Laser

• Other- Fiberoptic light source, defibrillator, high speed burrs

• Oxidizer and fuels

• 75% - Oxygen enriched atmosphere

• 4% - Alcohol based prep solutions

Health Devices 2009 Oct;38 (10):314-332

Location of Surgical Fires

Health Devices 2009 Oct;38 (10):314-332

Reprinted with permission from ECRI Institute
 High Risk Procedures
When ignition source can come in proximity to an
oxidizer- enriched atmosphere
Tonsillectomy
Tracheostomy
Removal of laryngeal papillomas
Cataract/other eye surgery
Burr hole surgery
Removal of lesions on head, neck or face

ASA Practice Advisory for the Prevention & Management of

OR Fires. Anesthesiology 2013; 118 (2): 271-90
 Initiatives to Prevent Surgical Fires

Joint Commission ASA Practice FDA Initiative

Sentinel Event Advisory 2008 2011
Alert 2003

Joint Commission APSF Fire

National Patient Safety Video
Safety Goal 2010
2006-2009
Initiatives to Prevent Surgical Fires

Anesthesiology 2013; 118(2): 271-290.

Anesthesia Patient Safety Foundation Fire Safety video

www.apsf.org/resources/fire-safety/

FDA Initiative
www.fda.gov/Drugs/DrugSafety/SafeUseInitiative/
PreventingSurgicalFires
 Surgical Fire Triangle

Reprinted with permission from ECRI Institute

 Controlling Oxidizers
Oxidizers support combustion
Include oxygen, nitrous oxide and air

Oxygen enriched atmospheres (OEA)

involved in majority of surgical fires

when O2 concentration exceed 21% by volume

lowers temperature and energy at which a fuel will ignite

Health Devices 2009 Oct;38 (10):314-332

Oxygen Enriched Atmosphere

• OEA fires are

• hotter

• more vigorous

• spread more rapidly

Health Devices 2009 Oct;38 (10):314-332

Reprinted with permission from ECR Institute
 Oxygen Enriched Atmosphere
• Configuration of surgical drapes + open delivery of O2
can result in O2 build up, increasing the risk of fires

Reprinted with permission from ECRI Institute

Flammability of Surgical Materials in Varying
Concentrations of Oxygen

Culp WC et al. Anesthesiology 2013: 119 (4)

5 surgical materials were ignited in 3 O 2 concentrations

Time to ignite and total burn time decreased as O2

concentration increased (P < 0.001)
O2 Median ignition O2 Median burn
conc times conc times
21% 0.9 s 21% 20.4 s
50% 0.4 s 50% 3.1 s
100% 0.2 s 100% 1.7 s
Controlling Oxidizer

Nitrous Oxide

Supports combustion

Fires involving O2/N2O mixtures can be as easily

ignited and as severe as fires involving 100% O2

Controlling Oxidizers
Ambient Air
21% oxygen/78% Nitrogen

Supports combustion

Medical Air
Supports combustion

Not O2 enriched at ambient pressure when delivered

to patient
Health Devices 2009 Oct;38 (10):314-332
During Head, Neck, Face and Upper Chest Surgery:

Can patient maintain safe SpO2 without

supplemental O2?

Yes No

Use air for Secure airway with

open delivery LMA or ETT

Health Devices 2009 Oct;38 (10):319

When is it OK to Use Open O2 Delivery on Face?

Certain procedures require verbal responses from

patient intraoperatively
Carotid artery surgery
Neurosurgery
Pacemaker insertion

Health Devices 2009 Oct;38 (10):319

Prevention Strategies During Open O2 Delivery

• Deliver minimum O2 concentration necessary for adequate

oxygenaton

• Begin with 30% FiO2 and increase up if necessary

• If using > 30% FiO2, deliver 5-10 L/min of air under drapes

to wash out excess O2

• Stop supplemental O2 at least one minute before and

during use of electro surgery unit (ESU) or laser
Health Devices 2009 Oct;38 (10):319
Options for Blending Air and O2 for Open Delivery

• Use an independent O2-air blender

• Use blended gas from common gas

outlet (CGO) on anesthesia machine

• For anesthesia machines that don’t

have a CGO, use breathing circuit to
deliver blended gas

Health Devices 2009 Oct;38 (10):314-332

Reprinted with permission from Silverstein, KL.
Ignition Sources
Electrosurgical units -most common

Surgical laser- 2nd most common

Electrocautery (hot wire) devices

Fiberoptic light source

Defibrillators

High speed burrs

Health Devices 2009 Oct;38 (10):314-332
When Using Electrosurgery, Electrocautery or Laser:
• Notify surgeon of the presence of, or an increase in oxidizer-
enriched atmosphere
• Activate unit only when the active tip is in view Deactivate
unit before the tip leaves the surgical site
• Place unit in a holster when not in active use
• Place lasers in standby mode when not in active use
• Do not place rubber catheter sleeves over electrosurgical
electrodes
Health Devices 2009 Oct;38 (10):319
Fuels in the OR
Patient Hair (face, scalp, body), make-up
Prepping Alcohol-based prepping agents (DuraPrep,
agents* ChloraPrep, Hibitane) all are > 70% alcohol
Degreasers (ether, acetone)
Tinctures
Linens Drapes, gowns, patient clothes
Mattresses, pillows, blankets
Masks, hoods, caps, shoe covers
Dressings Adhesive tape (cloth, plastic, paper)
Gauzes, sponges, pledgets

* Betadine skin prep is not flammable

Health Devices 2009 Oct;38 (10):314-332
Fuels in the OR

Ointments Petroleum jelly

Tincture of benzoin (74-80% alcohol)
Aerosols (e.g. Aeroplast)
Collodion
White wax
Equipment/ Anesthesia- ETT, breathing circuits, nasal
supplies cannula, masks
ESU and EKG leads
Flexible endoscope
Gloves

Health Devices 2009 Oct;38 (10):314-332

 Managing Fuels
• Be aware that alcohol-based preps are flammable

• Avoid pooling, spilling or wicking of flammable preps

• Allow flammable liquid preps to dry fully before draping- 3 min

• Remove towels used to catch dripped flammable prep before
draping

• Moisten sponges when used in proximity to ignition source

Health Devices 2009 Oct;38 (10):314-332

Prevention Strategies During Open O2 Delivery on Face

• Use an adherent incise drape, to help isolate the incision

from possible O2 enriched atmosphere

• Keep fenestration towel edges as far from the incision as

possible

• Arrange drapes to minimize O2 buildup underneath

• Coat head hair and facial hair with water soluble

lubricating jelly to make it nonflammable
Health Devices 2009 Oct;38 (10):314-332
Reprinted with permission from ASA Practice Advisory for the
Prevention & Management of OR Fires. Anesthesiology 2013
 NEW APSF Prevention Algorithm 2012
Anesthesia Patient Safety Foundation. Surgical fire injuries continue to occur:
Prevention may require more cautious use of oxygen.

APSF Newsletter Winter 2012;26(3):42-43

 Fire Risk Assessment
• Should be included in ‘Surgical Time Out’ to identify and
assess fire risks

• Enables a discussion among all team members on:

• Identifying elements of surgical fire triangle pertinent to case

• Assessing the risk of a surgical fire

• Developing strategies for the prevention of a surgical fire

• Designating roles for each team member in the event of a

surgical fire
 Silverstein Fire Risk Assessment Tool

Link to Christiana Care Health System Surgical Fire Risk Assessment Tool:
www.christianacare.org/FireRiskAssessment (Accessed 12/23/13)
Reprinted with permission from Silverstein, KL.
 Silverstein Fire Risk Assessment Tool

Reprinted with permission from Silverstein KL,

Christiana Care Health Systems, Newark, DE
Preventing Airway Fires
While using electrosurgery units (ESU)

Do not use ESU to cut into the trachea

If long, insulated ESU probes are needed to prevent

mouth burns (e.g. tonsillectomy):
Use only commercially available insulated probes

Do not use red rubber catheters to sheathe probes

 Preventing Airway Fires
While using electrosurgery units (ESU)

When operating in oropharynx,

Scavenge deep with a metal suction cannula to catch leaking
O2 and N2O

Use moistened sponges

 Preventing Airway Fires
While using laser:
Limit laser output to the lowest clinically acceptable power
density and pulse duration
Place laser in standby mode when not in use
Activate laser only when the active tip is in view
Consider using laser resistant tracheal tube during upper
airway surgery, if appropriate
Use saline in cuff to prevent cuff ignition
Use dye in cuff to indicate puncture
Management of Surgical Fires
Recognizing early signs of a surgical fire

•Unusual sounds (“pop, snap or foomp”) or odors

•Unexpected smoke/heat

•Unexpected movement of drapes

•Discoloration of drapes or breathing circuit

•Unexpected patient movement or complaint

•Unexpected flash or flame

ASA Practice Advisory for the Prevention & Management of OR Fires.
Anesthesiology 2013; 118 (2): 271-90
 Airway Fire
For a fire in the airway or breathing circuit, ASAP:
Perform rapidly &
•Remove the tracheal tube
simultaneously
•Stop the flow of all airway gases
• Disconnect breathing circuit

•Remove all flammable and burning materials from airway

•Pour saline or water into the patient’s airway

ASA Practice Advisory for the Prevention & Management of OR

Fires. Anesthesiology 2013; 118 (2): 271-90
Airway Fire
If the airway or breathing circuit fire is extinguished:

Reestablish ventilation by mask

Avoid supplemental O2 & N2O, if possible

Extinguish and examine ETT to assess for fragments

Consider rigid bronchoscopy to assess injury & remove

debris
ASA Practice Advisory for the Prevention & Management of
OR Fires. Anesthesiology 2013; 118 (2): 271-90
Non Airway Fire
For a fire elsewhere on or in the patient, immediately
Stop the flow of all airway gases

Remove all drapes, flammable and burning material from the

patient
Extinguish all burning materials in, on or around the patient
with saline or water
Assess for smoke inhalation injury if patient not intubated

ASA Practice Advisory for the Prevention & Management of OR

Fires. Anesthesiology 2013; 118 (2): 271-90
 Extinguishing: Pat out if very small.

Reprinted with permission from ECRI Institute

 Extinguishing: Rip off!

Reprinted with permission from ECRI Institute

Reprinted with permission from ASA Practice Advisory for the Prevention & Management
of OR Fires. Anesthesiology 2013; 118 (2): 271-90
 Extinguishers: Rarely Needed in OR
For placement in each OR
and use on patient:
CO2 Extinguisher

Not:*
Water, dry chemical,
water mist, or fire
blanket
*For published rationale for not using these in

the OR see: www.ecri.org/surgical_fires

Reprinted with permission from ECRI Institute
Reprinted with permission from Sharon Hill Fire Co
If Evacuation is Necessary

Rescue Rescue the patient from the fire and OR

Rescuers should not place themselves at severe
risk
Alert Alert staff in nearby OR
Activate fire alarm system
Confine Contain the smoke and fire by closing all doors
Shut off medical gas supply to OR
Turn off electric power to involved OR
Evacuate Evacuate in an orderly manner

Health Devices 2009 Oct;38 (10):314-332

 Summary

• Surgical fires are preventable

• Fire safety in the OR is every
member’s responsibility and requires
a team approach
• Minimizing or eliminating enriched
oxygen delivery is fundamental
• Comprehensive fire safety program is
critical
References
1. New Clinical Guide to Surgical Fire Prevention. Health
Devices 2009 Oct;38(10): 314-32
2. Clarke JR, Bruley ME. Surgical Fires: Trends associated with
prevention efforts. Pennsylvania Patient Safety Advisory
2012 Dec;9(4):130-5
3. Apfelbaum JL et al. Practice Advisory for the Prevention and
Management of Operating Room Fires. Anesthesiology
2013;118(2): 271-90
4. Culp WC, Kimbrough BA, Luna S. Flammability of surgical
drapes and materials in varying concentrations of oxygen.
Anesthesiology 2013;119(4): 770-6