Playing with Fire

A fire in the OR is one of the most frightening events that a physician may have to handle.

Introduction

A well-known surgical colleague was performing endonasal surgery on a patient under local anesthesia when he encountered a bleeder at the base of the septum. Since electrocautery was connected and pinned to the drape, he picked up the hand piece with the needle point attached, put his suction device on the source of bleeding, placed the needle point on the spot, and pressed the cautery button. Instantly, there was a dull “poof,” a red-orange flare, and smoke filled the patient’s nasal cavity. What the surgeon did not realize was that the attending CRNA, who was administering the heavy IV sedation, had inserted narrow-gauge plastic tubing into the opposite nostril as a precaution against over-sedation and the resultant hypoxia and was administering O₂ at the time.

When the smoke cleared and the nasal cavity was suctioned out, it was apparent that the patient had sustained severe burns of the septal mucosa, turbinates, and nasopharynx that evolved into disastrous consequences and an indefensible lawsuit.

Sound unlikely? Unfortunately, airway fires and inadvertent burns in surgically unrelated parts of the body are far more common than anyone would like to think. In the overwhelming majority of cases, such events are indefensible—which is even worse, because most were avoidable. The serious cases have to be settled for very large amounts. The dangers of oxygen in the surgical suite, in the face of electrocautery or use of lasers, must always be kept in mind.

The true incidence of operating room fires is unknown as there is no reporting mechanism for this event, and only the sensational cases—that usually result in death—are reported in the press. These cases include well-publicized incidents at Cedars-Sinai in Los Angeles in 1988 and UCLA Medical Center in 1990 that raised public awareness of this complication.

There are two categories of fire in the OR:

1. External fires involving drapes, dressings, gauze sponges, or objects such as tubing or petroleum-based ointments, etc., in which immediate action by the surgeon can limit injury. The endonasal surgery incident described above illustrates an example of an external OR fire. (A further discussion of external OR fires is included in the case report later in this article.)
2. Internal airway fires involving the endotracheal tube in which immediate action by the anesthesiologist and surgeon is critical. A discussion of internal OR fires is included in the section immediately below pertaining to anesthesiology.
   

Fires in the OR and Anesthesia

Many anesthesiologists were taught in residency about the historical risks of operating room fires that were associated with the use of flammable anesthetics and static electricity. While flammable agents have largely disappeared from modern operating rooms, the risks of OR fires and the malpractice cases that can result from them unfortunately remain. Modern developments such as electrical cautery, lasers, and paper and plastic disposables have enhanced the surgical environment while adding new risks of fire.

While there are excellent textbook descriptions of the technical aspects of combustion available for the truly interested, suffice it to say here that the combination of an oxygen-enriched environment, a flammable material, and a heat source in the same place at the same time is an accident waiting to happen. It is not uncommon to find daily in ORs patients receiving oxygen-enhanced breathing mixtures while paper drapes, plastic endotracheal tubes, and lasers or electrical cauteries are in use. It is, therefore, not surprising that malpractice cases for fires continue to be seen. Anesthesia and surgical malpractice cases recently reviewed have involved airway fires, combustion of abdominal surgical drapes, and facial fires from the ignition of flammable prep solutions.

While some OR fires may truly be unpredictable—almost random—occurrences, the allegations in the resulting malpractice cases are bound to be that somehow steps should have been taken to prevent them. From an anesthesia standpoint, the most controllable variable is always the oxygen mixture delivered. Anesthesiologists named in claims involving fires may be called upon to justify the indications for the use of oxygen at the time of the fire as well as their decision regarding the flow of oxygen used. Often these are decisions made quickly following one’s own routine, but saying “because that’s the way I’ve always done it” does not usually go over well in court.

Problems have arisen defending claims in which an anesthesiologist was using oxygen prophylactically on a sedation case while the patient’s oxygen saturation was high. If you delivered several liters of oxygen by nasal cannula or mask to a patient when a surgeon was using a Bovie on the face, you might be asked why you did not temporarily discontinue the oxygen while the electrical device was in use. Awareness of the risk of fire and communication between the surgeon and the anesthesiologist can allow for turning the oxygen off at these times or switching to air to prevent stuffiness under the surgical drapes. Remember that oxygen tends to pool under the drapes and may take some time to disperse when switched off.

When airway fires occur, attention turns to whether the appropriate reinforced or laser endotracheal tube was used for the case and whether there might have been an unnecessary oxygen leak. Reviewers of cases involving pediatric airway fires sometimes find that the oxygen delivered was actually in the adult range, many liters above the maximum minute ventilation of the child, contributing to a large pooled oxygen leak. There will also be a determination of whether the tube size was appropriate for the age of the child and whether the pressure at which the cuff leaked was quantified and documented by the anesthesiologist.

While operating room fires may never be totally eradicated, no one wants to feel that they were involved in a case that might have been easily preventable. When electrical heat sources are in use, ask yourself if your patient might be at risk. In those cases where the heat source might contact the gas mixture, ask the surgeon to tell you before using it. When fire is a risk, consider administering oxygen like a drug: use when necessary at appropriate doses to maintain good patient oxygen saturation.

External OR Fires: A Case Report

An elderly patient was having a skin cancer removed from the nose under local infiltration and intravenous sedation. A board-certified anesthesiologist administered the medication and also delivered oxygen via nasal prongs at a flow of three liters. An electrocautery, used at a lowpower setting, provided hemostasis. A flash occurred between the cautery tip and the gauze sponge, which then caught alight and burned briskly in the oxygen-enriched atmosphere. The drapes then began to burn. The surgeon ripped off the drapes; this action also disconnected the tube delivering the oxygen, and the fire was extinguished. Fortunately, the patient sustained only superficial burns and subsequently healed with no evidence of the burn trauma. The patient was seconds away from a major injury, and only the prompt action by the surgeon prevented a more serious outcome.

External Fires

Three conditions need to be present for a fire to occur in the OR:

1. Fuel—All materials can burn in an oxygen-enriched environment. The list includes drapes, dressings, gowns, gauzes, syringes, hair, gastrointestinal gases, petroleum-based ointments, and most plastics.
2. Oxidizer—Both oxygen and nitrous oxide support a fire. Any concentration of oxygen in excess of 21 percent should be considered enriched. These gases can accumulate around the operative site as well as under drapes and in body cavities such as the oropharynx.
3. Ignition Sources—These include electrosurgical units (used in surgery for hemostasis, cutting of tissues, ablation of surface tissues, and coaptation of anatomical lumens), fiber-optic light sources (tips can become quite hot, so avoid contact with the drapes), and lasers.

Prevention

• Turn off nasal oxygen while using cautery and laser around the face as tolerated by the patient. Discuss this with the anesthesiologist, and check the pulse oximeter.
• Use moist sponges and towels to drape off a surgical field.
• Control electrosurgical units carefully. Use a holster to hold the electrocautery pencil while not in use. Only the surgeon should control the cautery; the device should be hand-controlled, with an on/off switch.
• Never use the drapes as a tent to enrich the oxygen atmosphere as a spark can ignite them. It is possible for the drapes to become engulfed in flames as if a bomb had been detonated.
• Do not use flammable agents such as alcohol or tincture-based products as skin preps on the surgical field.
• Avoid the use of petroleum-based eye ointments, as they are potentially flammable.

Operating Room Fire Management

• Immediately remove drapes, and protect the patient to limit injury.
• Immediately stop the delivery of oxygen or nitrous oxide until the fire is extinguished.
• Use sterile water to douse the fire.
• If the fire continues, use a gel-impregnated fire blanket that has been approved by your fire department to smother the fire.
• Know where your fire extinguishers are situated, and know precisely how to use them.
• Ongoing care involves management of the burn and a frank discussion with the patient and the family. Obtain all necessary consultations. Keep an accurate record of all events surrounding the incident, preferably in the patient’s medical record.
• Quarantine all the involved equipment, and have it checked for any operating faults.
• Debrief the professional staff involved in the incident, and evaluate systems and procedures to prevent fires in the OR and to effectively manage any fire that might occur.
• Continue to provide follow-up medical and/or surgical care until patient discharge is appropriate.

Conclusion

Always bear in mind that:

• Fires are preventable in most cases.
• Cases involving OR fires can be virtually indefensible and can result in substantial losses.

The most critical element in preventing OR fires is preoperative communication among the OR team:

• Surgeons, tell your anesthesiologist if you plan to use electrocautery.
• Anesthesiologists, warn your surgeon if you plan to use oxygen by cannula or any agent that supports combustion.