Fire Safety in the Surgical Suite

Susan K. Palmer, MD, Oregon Anesthesiology Group, and Ernest E. Allen, Account Executive, Patient Safety Department, The Doctors Company.

In 2007, the Pennsylvania Patient Safety Authority calculated the likelihood of surgical fires in Pennsylvania. Using these statistics, the ECRI Institute projected the national number of surgical fires to be as many as 550 to 650 annually, based on U.S. population data and the estimated 65 million surgeries performed each year.1 Many fires now are occurring in association with minor cases, often being performed using local anesthesia and/or sedation.2

The increase in fires in these minor cases may be related to the increased use of propofol with open sources of oxygen. Propofol can produce brief, deep sedation and has made it possible to perform many cases that, in the past, would have required general anesthesia and control of ventilation.

Any surgical fire that harms a patient is considered a “hospital-acquired condition (HAC)” and a “never event,” which means it is a complication that should theoretically never happen. Besides the threat of a potential malpractice claim, the involved hospital, surgeon, and anesthesiologist may not receive any reimbursement from Medicare/Medicaid or some private insurance carriers for the surgical procedure or for any subsequent procedures the patient might need as a result of the complication.

Prevention strategies for operating room (OR) fires have been repeatedly described in medical literature3 and discussed in CME settings, such as the American Society of Anesthesiologists Refresher Course Lectures at the ASA annual meetings.4 The Anesthesia Patient Safety Foundation (APSF) recently reissued an updated free DVD titled “Prevention and Management of Operating Room Fires,” available at Two new fire safety posters were released by the ECRI Institute and the Anesthesia Patient Safety Foundation and are available at

The Fire Triangle
In order for a fire to occur, all three of the “fire triangle” elements must be present: (1) a heat/spark source, (2) combustible material, and (3) an oxidizer. The surgeon usually provides the ignition source. The anesthesiologist supplies the oxygen-enriched atmosphere and the combustible plastics of nasal prongs/masks/airway circuits. OR nurses apply the preparation solutions containing flammable vapors and may be responsible for overflow pools of such fluids.

Care Planning 
The planning for anesthesia care should take into account the fire hazard presented by every procedure, especially those procedures in which the surgeon might use electrocautery in close proximity to an oxygen source. Many fires that involve patient injury occur on the patient’s head, face, and upper torso. These areas are close to the patient’s airway, where an open source of supplemental oxygen may be used. Oxygen and nitrous oxide can pool in or under drapes. The anesthesiologist, the surgeon, and the facility all share the responsibility if they fail to consider the fire hazard presented by the planned surgery and a patient is injured.

Some hospitals and surgical centers have replaced alcohol-based preps with newer nonflammable solutions. If alcohol-based preps are used, it is crucial to allow sufficient time for the prep to dry fully and for vapors to be carried away from the operative site before starting the procedure.

Anesthesiologists can make a major contribution in reducing the risk of surgical fires. When deciding to use oxygen supplementation by an open source, such as nasal prongs or a face mask, the anesthesiologist should consider whether he or she can use low flows and less than 30 percent supplemental oxygen.6 Fires are much less likely to start in the presence of less than 30 percent oxygen. Even for patients who need a higher percentage of oxygen, reducing the flow rate and the FiO2 prior to the use of electrocautery devices can significantly reduce the risk of fire. Alternately, anesthesiologists could choose to discontinue oxygen completely unless there is a real need for continuing deep sedation.

The use of drapes can trap oxygen and nitrous oxide. Special precautions to vent the gases may be needed. If possible, drapes should be widely open to circulating room air to reduce accumulations of oxygen or nitrous oxide.

It would be optimal if, prior to using an ignition source, the surgeon would give the anesthesiologist adequate warning. The anesthesiologist could then reduce the oxygen concentration to the minimum required, stop the use of nitrous oxide, and wait a few minutes before agreeing to the activation of a Bovie or laser.7

In the past, devastating fires have occurred when surgery involved the use of combustible airway devices and 100 percent oxygen and/or nitrous oxide. Prior to activating an ignition source inside the airway, oxygen concentration should be reduced, and nitrous oxide should be discontinued. If necessary, scavenging the area with suction or flooding the area with air may be used to reduce the oxygen level near or within the airway or chest cavity.

Fire drills in surgery should be performed each year so that the surgical team members can quickly respond in the event of a fire. If there is a fire hazard, the surgical set should usually include a basin of saline. Fires on the surface of a patient should almost always be controlled by removing combustible material and flooding the area with saline. Chemical fire extinguishers may be needed to suppress burning materials that have been removed from the patient.

Special procedures are needed for extinguishing airway fires. The tracheal tube should be promptly removed along with any segments of a burned tube that remain in the airway. All gases to the airway should be stopped and a brief saline lavage performed. Ventilation should then be reestablished in the airway with air. Once it is confirmed there is nothing burning in the airway, a higher percentage of oxygen can be provided.

After a surgical fire, all materials and devices involved in the fire should be saved for later investigation.

Tips for Enhancing Patient Safety

  1. Evaluate even minor procedures for fire hazards:
    1. Is oxygen going to be used from an open source?
    2. Is the surgeon going to use an ignition device such as a Bovie, a laser, or a high-speed drill?
  2. Identify high-risk procedures, and discuss these cases with the surgeon and the OR team. Have saline open and on the back table during any high-risk procedure. High-risk procedures include:
    1. procedures involving the airway;
    2. procedures near the airway;
    3. procedures on the patient’s face, head, neck, or upper torso; and
    4. intracavitary procedures with the potential for release of flammable gas (bowel contents).
  3. Consider oxygen to be a drug with its own risks and benefits; use oxygen only when needed. If a patient requires oxygen, the anesthesiologist should consider delivering it in a closed system, such as through a cuffed endotracheal tube into a closed airway circuit. When oxygen must be used in an open system, use low-flow oxygen, or deliver oxygen mixed with air to achieve an FiO2 < 30 percent when possible.
  4. Add “fire risk” to the safety checklist that is discussed by the OR team before every surgery.

Besides conducting annual fire drills that include what to do if a fire occurs on a patient, it is also wise to review fire risks in high-risk procedures prior to the start of the surgical procedure. Even apparently “minor” procedures may pose a fire hazard, especially if oxygen will be used from an open source.


  1. ECRI Institute. Surgical Fires. Healthcare Risk Control Risk Analysis. Safety and Security. July 2010;3:13.1.
  2. Bhananker SM, Posner KL, Cheney FW, Caplan RA, Lee LA, Domino KB. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology. 2006;104(2):228-34.
  3. Ibid.
  4. Caplan RA, Barker SJ, Connis RT, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008;108(5):786-801.
  5. ECRI Institute. New Clinical Guide to Surgical Fire Prevention. Health Devices. 2009;38(10):330.
  6. Lampotang S, Gravenstein N, Paulus DA, Gravenstein D. Reducing the incidence of surgical fires: supplying nasal cannulae with sub-100% O2 gas mixtures from anesthesia machines. Anesth Analg. 2005;101(5):1407-12.
  7. Caplan RA, Barker SJ, Connis RT, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008;108(5):786-801.

This article originally appeared in The Doctor’s Advocate, fourth quarter 2010,

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

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