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Surgical fires, a clear and present danger
the surgeon 8 (2010) 87–92
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
Surgical fires, a clear and present danger I.E. Yardley, L.J. Donaldson* Department of Health, 79 Whitehall, Richmond House, London SW1A 2NS, United Kingdom
article info
abstract
Article history:
Background: A surgical fire is potentially devastating for a patient. Fire has been recognised
Received 19 January 2010
as a potential complication of surgery for many years. Surgical fires continue to happen
Accepted 19 January 2010
with alarming frequency. We present a review of the literature and an examination of possible solutions to this problem.
Keywords:
Methods: The PubMed and Medline databases from 1948 onwards were searched using the
Surgical fires
subject headings ‘‘operating rooms’’, ‘‘fire’’, ‘‘safety’’ and ‘‘safety management’’. ‘‘Surgical
Patient safety
fire’’ was also searched as a keyword. Relevant references from articles were obtained.
Operating room
Results: Fire occurs when the three elements of the fire triad, fuel, oxidiser and ignition
Safety management
coincide. Surgical fires are unusual in the absence of an oxygen-enriched atmosphere. The
Communication
ignition source is most commonly diathermy but lasers carry a relatively greater risk. The majority of fires occur during head and neck surgery. This is due to the presence of oxygen and the extensive use of lasers. The risk of fire can be reduced with an awareness of the risk and good communication. Conclusions: Surgery will always carry a risk of fire. Reducing this risk requires a concerted effort from all team members. ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Of all the potential complications of surgery, a surgical fire is perhaps the most extraordinary. That patients who entrust themselves to medical care are actually set alight when at their most vulnerable seems almost unbelievable.1 Yet it happens, with alarming frequency and potentially devastating consequences. Exact numbers are difficult to ascertain due to the absence of a standard reporting system and confidentiality clauses in many malpractice settlements2, but it does remain a relatively rare event.3 Estimates from the USA put the incidence at anything from 204,5 to 6506–8 surgical fires
each year. This makes the problem of a similar order of magnitude to wrong site surgery, a topic that has received far more attention in recent times.9 Three instances of surgical fires were reported to the National Reporting and Learning System in the UK between 2006 and 2009 (NPSA, personal communication). A US study found 17% of anaesthetic malpractice claims related to burns from surgical fires.10 Many will be minor fires causing no harm, but it is estimated that of the surgical fires that occur in the USA each year 20–30 are disabling or disfiguring and one or two are fatal.8 Airway injuries can necessitate prolonged intensive care with its accompanying morbidity.11
* Corresponding author. Tel.: þ44 (0)2072105139; fax: þ44 (0)2072105919. E-mail address: [email protected] (L.J. Donaldson). 1479-666X/$ – see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.01.005
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Table 1 – Actions to prevent surgical fires. Team member Nursing staff
Surgeon
Anaesthetist
All staff
Recommendation Moisten all swabs and sponges before passing them to surgeon Do not use alcoholic skin preparation solution Label all solutions in the sterile field Wet patient’s hair with aqueous gel Let preparation solution dry completely before draping Use diathermy and laser sparingly Holster the diathermy when not in use Keep the diathermy tip as clean as possible Open all lumens using cold cutting Use minimal oxygen concentrations Avoid air leaks from the anaesthetic circuit Do not allow oxygen to collect beneath drapes Use protected tracheal tubes for laser surgery Use dyed saline to inflate tracheal tube cuffs for laser surgery Maintain awareness of the risks of surgical fires Use dedicated theatre teams for high-risk head and neck surgery Ensure excellent pre- and intra-operative communication
We present a review of the published literature on surgical fires and an examination of possible solutions to this problem.
Methods The PubMed and Medline databases were searched using the subject headings ‘‘operating rooms’’, ‘‘fire’’, ‘‘safety’’ and ‘‘safety management’’. ‘‘Surgical fire’’ was also searched as a keyword. The date range used was from 1948 onwards. Relevant references from articles were obtained. Relevant websites were identified using the Google internet search tool. Established patient safety organisations’ websites were accessed for alerts and advisories relating to surgical fires.
Several devastating operating theatre explosions have occurred in history. In 1964 an operating room explosion and subsequent fire in the USA killed two patients, two surgeons and two nurses, it also led to three traumatic amputations.14 In 1979 an explosion in Italy involving an oxygen cylinder and flammable substances killed 21 people.15 Not all fires are so dramatic. Many are mere flashes, for example prep solution igniting, and cause no harm.16,17
Changes over time In 1941 the American Association of Anesthesiologists reported a large series of 230 anaesthetic associated fires and explosions.18 Typically for this era, they all involved volatile anaesthetic agents such as ether and cyclopropane. Their use meant that fire was considered an unavoidable risk to surgery. Its prevention was largely the responsibility of anesthesiologists.19 During the late 1960s and 1970s newer, less volatile agents largely superseded these flammable anaesthetics3 although a fatality from ether ignition in the UK occurred as late as 1985.20,21 The legacy of this era of explosive anaesthetics remains in the anti-static floors still installed in operating theatres and the anti-static clogs theatre personnel wear. Replacing explosive anaesthetic agents certainly made surgery safer but has also reduced the awareness of the potential risk of surgical fires.22,23 The risk of surgical fires remains today.24 Other potential fuels are bowel gas,25,26 skin disinfecting agents,27,28 drapes,29 swabs,30 suture packets31 and even a patient’s own tissues or hair.32,33 Advances in surgical practice in the past few decades have introduced new fire risks. These include laparoscopy, where the pneumoperitoneum is a potential hazard,34,35 as are the light sources used,36 endoscopic and transurethral surgery37,38 and the use of lasers39 and diathermy40,41 to cut and coagulate tissue. The vast majority of surgical fires, however, occur during head and neck (including plastic and neurosurgery),42–46 particularly airway,7,8,47,48 surgery.
Head and neck surgery
Results Over 400 relevant citations were identified. Many of these were case reports of specific fires. Some of these case reports also included a review of the literature as it was at the time. Other papers were non-clinical experiments exploring the conditions required for ignition, others still were intended to provide advice to clinicians in order to prevent further fires.
Sources of fire in the operating theatre For a fire to occur, the three elements of a fire triangle are needed: fuel, oxygen (or some oxidising agent) and an ignition source.12 All three are in plentiful supply in the operating theatre environment. A different member of the team supplies each. The nursing staff deliver fuel in the form of prepping agents, swabs and drapes. The anaesthetist provides oxygen and nitrous oxide as the oxidiser. Ignition is triggered by the surgeon, with the use of diathermy or lasers.13 This makes the operating theatre an inherently dangerous place in terms of fire safety.
There are two key reasons for this increased risk in head and neck surgery. Most obvious is the routine administration of oxygen during anaesthesia and sedation, meaning that head and neck surgery is performed in an oxygen enriched environment.49 Head and neck surgeons also make frequent use of incendiary operating tools, including diathermy16 and lasers.50 Each element of the fire triad is essential for a fire to occur but the concentration of the oxidiser can also have a major effect on the fuel component of the triad. Oxygen can support combustion so effectively that objects that do not support a flame in air will burn readily and vigorously in higher concentrations of oxygen.51 In an oxygen enriched atmosphere, endotracheal tubes52,53 and plastic facemasks54 can ignite, antiseptic solutions become explosive44 and swabs24 and drapes55 catch light. The oxidiser element of the fire triad is so important that is unusual for a surgical fire to occur in the absence of oxygen enrichment.17 Even fires occurring away from the head and neck area are commonly associated with an increased oxygen concentration.24,56 It should be remembered that nitrous oxide is also an oxidiser and will
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support combustion. Reducing the oxygen flow and replacing it with nitrous oxide does not remove the risk of fire.57 In 70% of surgical fires, electrosurgical equipment provides the ignition required for the fire to start,8 lasers are responsible in a further 10%. Both these modalities deliver focused energy to either cut or coagulate tissue, creating intense heat and generating temperatures well above those needed to start a fire.58,59 When the almost ubiquitous nature of electrosurgery in modern surgical practice and the comparatively sparse use of lasers are considered, it is clear that lasers present a far greater individual risk. Lasers are used more extensively in head and neck surgery than any other branch of surgery. They have a number of applications from tumour ablation60 to palatoplasty.61 As already discussed this requires their use in a potentially oxygen rich environment. Accidental contact of the laser beam with a variety of items that enter the surgical field in the presence of oxygen can be enough to cause a fire. These items include endotracheal tubes, surgical swabs, and surgical drapes. In the early days of laser surgery, endotracheal tube ignition was reported in as many as 1.5% of patients undergoing laryngeal laser surgery.62–64 Tubes are manufactured from a variety of materials with varying potential to ignite.65 Polyvinyl chloride tubes are probably least safe, they are readily penetrated by a laser to release the oxygen within the lumen and burn in oxygen concentrations as low as 25%.66 There are a variety of endotracheal tubes designed to be laser-proof for ‘‘shared-airway’’ laser surgery.58 A standard tube can be prepared for laser safety by wrapping in foil tape67 although this does introduce its own risks such as mucosal damage68 and detachment of the foil tape.69 Altering the gas mixture administered during surgery can also improve safety of airway laser surgery. Replacing the nitrogen with helium reduces the time to ignition with the carbon dioxide laser.70 Interestingly however, this is not the case with the other laser commonly used in airway surgery, the potassium titanyl phosphate laser, which remains a hazard in a helium and oxygen mixture.71
Conditions predisposing to fire Several non-clinical studies have been published examining the conditions that predispose to surgical fires. One tested the ignition of various surgical drape materials in air and 50% and 95% oxygen.55 It found that the laser would ignite any material commonly used as surgical drape in oxygen enriched circumstances, even those that did not burn at all in air. Similarly, another found that surgical cotton patties ignited much more rapidly in higher concentrations of oxygen.72 Unsurprisingly this study also found that soaking the patties in saline solution significantly increased the time to ignition, requiring over 15 s of continuous firing of the laser beam to create a flame, unlikely to occur in surgical practice.
Recommendations to prevent fires The accumulated experience of surgical fires and the conditions that predispose to them has lead to many sets of guidelines and recommendations to avoid them. Several lay the responsibility for fire prevention with the anaesthetist.2,73 There are several reasons for this, firstly the historical
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perspective of a time when anaesthetic gases were explosive,1 secondly the importance of oxidisers on the risks of fire2,74 and also simply that the majority of advisories are published in anaesthetic journals and hence targeted at anaesthetists.73 Other advisories take a broader view of the issue and address each of the theatre team members in turn and the elements of the fire triad they can control (Table 1).4,75–77 Nursing staff are primarily responsible for providing the fuel for surgical fires and recommendations directed to them include using fire retardant drapes,55,78 minimising the use of alcoholic skin preparation solutions,44,79 dampening swabs and sponges,17,80 and labelling any liquids on the surgical tray so that flammable liquids are not used inadvertently.81 The advice and recommendations given to surgeons also relate to the presence of potential fuels, avoiding alcoholic preparation solutions where possible and ensuring they dry adequately if they are needed.33,82 The patient’s hair should be wetted, ideally with an aqueous gel, to reduce its flammability.8,76 The key involvement a surgeon has is ignition however and the use of diathermy or laser should be kept to a minimum, with the diathermy tip kept clean to reduce sparking. The airway or other cavity containing potentially explosive mixtures such as intestine should be opened using a ‘‘cold’’ instrument such as scalpel or scissors.23,83,84,95 The use of non-incendiary, haemostatic operating tools such as the harmonic scalpel is also recommended where possible.85 The anaesthetist’s role is to keep oxidiser concentrations to a minimum. This is achieved in several ways: by using the lowest oxygen flow feasible and no supplementary oxygen where possible,86 ensuring there are no leaks in the circuit (for example around the endotracheal tube). Anaesthetists should also ensure that oxygen does not collect under the drapes,87 using a secured airway if necessary.73 When anaesthetising for high-risk head and neck surgery using lasers, a double-cuffed tube has been recommended, filling the cuffs with dyed saline so that perforation is immediately obvious.39,73 Many published papers on surgical fires advocate education as the key to reducing the risk of surgical fires.44,54,75,88–90 The findings that both nursing and medical staff are unaware that commonly used solutions are highly flammable,27 that nearly two in three newly qualified doctors had never heard of surgical fires75 and that even amongst experienced surgeons awareness was far from universal91 would support this. However, when surgical fires are reviewed, it is apparent that knowledge of the risks is not enough. Almost all fires, both historical and current, are preventable by the use of measures that are well known.92,93 It only takes a momentary lapse by one individual to cause a fire.94 For this reason, maintaining awareness, for example with posters in the operating room, is encouraged by several organisations.8,95 Excellent communication between team members is essential to improving operating theatre safety generally and is also relevant to reducing fire risks.3,80,96–99 Communication can be structured by the use of a checklist96,98 at the beginning of surgery. A discussion about the risk of fire can be incorporated into these checklists for high-risk surgery. Further formalising of communication has been suggested using a scoring system to assess the risk of surgical fire.100 This scoring system sets out a simple three point score for the risk of fire. Each of the following score one point, surgical site above the xiphoid,
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open oxygen source and a source of ignition. If the score is 2 or 3, then specific protocols are followed to reduce the risk of fire.
of the fire triad from each other. This requires ongoing awareness of the threat and a concerted effort from all members of the operating theatre team.
Action to take in the event of fire If a fire does occur, prompt action can mitigate the harm caused. The first step is to recognise that a fire has occurred. This is usually obvious with the presence of flames or smoke28 but a fire can also be first noticed by an unusual noise,26 smell54 or feeling of warmth.71 The next step is to remove the fire from the patient. This is done by simultaneously removing the burning material from the patient and cutting off the flow of gas to the field.101 Stopping the flow of oxygen will often put out the fire as many materials only burn in oxygen enriched atmospheres and all materials will burn less fiercely if the oxygen concentration is reduced.8 In the case of an airway fire with a burning endotracheal or tracheostomy tube the advice is almost universally to remove the tube.8,73,95,102 This is to prevent ongoing damage to the trachea, damage to the more distal airways and to reduce the inhalation of toxic material from the fire.103,104 However, one paper does advise caution in this and recommends that if a patient was difficult to intubate then consideration should be given to leaving the tube in situ.105 Burning material may include swabs, drapes and other items in the surgical field. These should be removed, even if doing so compromises the sterility of the surgical field.101 These steps will almost always be enough to put out the fire. Any residual burning should be extinguished as quickly as possible. Pouring water or saline into the fire is usually the preferred means as it has the advantages of being quick and also acting as a heat sink to cool the field and stop further damage.8,73 If a fire is large then a fire extinguisher should be used, a carbon dioxide type being preferred.32,77 A fire blanket should never be used as this will contain the fire on the patient, including potentially hot material, and fires may continue unnoticed beneath the blanket if the oxygen supply is maintained.8 Any scorched material should be removed, as it may be hot even after the fire is out or reignite on the reintroduction of oxygen.77,95 Once the fire is out then attention should be rapidly turned to caring for the patient who may be bleeding, without an airway or otherwise in danger.8 A secure airway should be reestablished and the patient ventilated with room air until it is absolutely certain that the fire is out.95 Only then should oxygen be reintroduced to the breathing circuit. In the case of an airway fire, bronchoscopy, preferably rigid, should be performed to assess the extent of injury to the airway and perform lavage as appropriate73,95 A tracheostomy may be required.19,95 Some authors recommend administering steroids and prophylactic antibiotics23,106 There is little evidence for this practice but it makes good clinical sense to attempt reduce the airway oedema and prevent secondary pneumonia following thermal alveolar damage.
Conclusions Surgical fire will always be a risk in the operating room. The danger is highest in head and neck surgery and where lasers are used. The risk can be mitigated by separating the elements
Financial support None.
references
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75. Lypson ML, Stephens S, Colletti L. Preventing surgical fires: who needs to be educated? Jt Comm J Qual Patient Saf 2005;31:522–7. 76. Lowry RK, Noone RB. Fires and burns during plastic surgery. Ann Plast Surg 2001;46:72–6. 77. ECRI. A Clinician’s guide to surgical fires. Health Devices 2003; 32:5–24. 78. Patterson P. Fire dept makes recommendation for class I drapes. OR Manager 1990;6:1–5. 79. Fire marshal bans alcohol-based preps. OR Manager 2005;21: 5–7. 80. Sosis MB. Anesthesiologists must inform their surgical colleagues when there is a risk of an operating room fire. Anesth Analg 2005;101:1564. 81. Pennsylvania Patient Safety Authority. Dangers associated with unlabeled basins, bowls and cups. PA-PSRS Patient Safety Advisory 2005;2:1–3. 82. Briscoe CE, Hill DW, Payne JP. Inflammable antiseptics and theatre fires. Br J Surg 1976;63:981–3. 83. Joyce FS, Rasmussen TN. Gas explosion during diathermy gastrostomy. Gastroenterology 1989;96:530–1. 84. Branday JM. Jejunal gas explosion resulting from the use of diathermy. Br J Surg 1982;69:728. 85. Coulson AS, Bakhshay SA. Harmonic scalpel prevents tracheotomy fires. Chest 1998;114:349–50. 86. Lampotang S, Gravenstein N, Paulus DA, Gravenstein D. Reducing the incidence of surgical fires: supplying nasal cannulae with sub-100% O2 gas mixtures from anaesthetic machines. Anesth Analg 2005;101:1407–12. 87. Barnes AM, Frantz RA. Do oxygen-enriched atmospheres exist beneath surgical drapes and contribute to fire hazard potential in the operating room? AANA J 2000;68:153–61. 88. Salmon L. Fire in the OR: prevention and preparedness. AORN J 2004;80:41–54. 89. Smith C. Surgical fires: learn not to burn. AORN J 2004;80:24–40. 90. Prasad R, Quezado Z, St Andre A. Fires in the operating room and intensive care unit: awareness is the key to prevention. Anesth Analg 2006;102:172–4. 91. Sudhindra TV, Joseph A, Hacking CJ, Haray PN. Are surgeons aware of the dangers of diathermy? Ann R Coll Surg Engl 2000; 82:31–2.
92. Nicholson MJ. Comment on: ‘‘nonflammable’’ fires in the operating room. Anesth Analg 1975;54:152. 93. Prado A, Andrades P, Fuentes P. Fire in the operating room after reading a CME. Plast Reconstr Surg 2007;119:770–3. 94. Walter CW. Anesthetic explosions: a continuing threat. Anesthesiology 1964;25:505–14. 95. Pennsylvania Patient Safety Authority. Airways fires during surgery. PA-PSRS Patient Safety Advisory:1–6, http:// patientsafetyauthority.org/EducationalTools/ PatientSafetyTools/airway_fires/Documents/airwayfires_ poster.pdf, 2007;4. 96. Rosenfield LK, Chang DS. The error of omission: a simple checklist approach for improving operating room safety. Plast Reconstr Surg 2008;123:399–402. 97. Paige JT, Aaron DL, Yang T, Howell DS, Chauvin SW. Improved operating room teamwork via SAFETY prep: a rural community hospital’s experience. World J Surg 2009;33:1181–7. 98. Pollock GS. Eliminating surgical fires: a team approach. AANA J 2004;72:293–8. 99. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491–9. 100. Salmon L. Scoring fire risk for surgical patients. OR Manager 2006;22:19–20. 101. ECRI. When a fire occurs. Health Devices 2006;35:58–63. 102. Wolf GL, Sidebotham GW. Endotracheal tube fire: comments on the advisability of not extubating. Anesthesiology 1999;91: 888–9. 103. Aly A, McIlwain M, Duncavage JA. Electrosurgery-induced endotracheal tube ignition during tracheostomy. Ann Otol Rhinol Laryngol 1991;100:31–3. 104. Schramm VL, Matoox DE, Stool SE. Acute management of laser-ignited intratracheal explosion. Laryngoscope 1981;91: 1417–26. 105. Chee MW, Benumof JL. Airway fire during tracheostomy: extubation may be contraindicated. Anesthesiology 1998;89: 1576–8. 106. Le-Clair. Endotracheal tube cuff ignition by electrocautery. JAMA 1990;58:259–61.
available at www.sciencedirect.com
The Surgeon, Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland www.thesurgeon.net
Review
Surgical fires, a clear and present danger I.E. Yardley, L.J. Donaldson* Department of Health, 79 Whitehall, Richmond House, London SW1A 2NS, United Kingdom
article info
abstract
Article history:
Background: A surgical fire is potentially devastating for a patient. Fire has been recognised
Received 19 January 2010
as a potential complication of surgery for many years. Surgical fires continue to happen
Accepted 19 January 2010
with alarming frequency. We present a review of the literature and an examination of possible solutions to this problem.
Keywords:
Methods: The PubMed and Medline databases from 1948 onwards were searched using the
Surgical fires
subject headings ‘‘operating rooms’’, ‘‘fire’’, ‘‘safety’’ and ‘‘safety management’’. ‘‘Surgical
Patient safety
fire’’ was also searched as a keyword. Relevant references from articles were obtained.
Operating room
Results: Fire occurs when the three elements of the fire triad, fuel, oxidiser and ignition
Safety management
coincide. Surgical fires are unusual in the absence of an oxygen-enriched atmosphere. The
Communication
ignition source is most commonly diathermy but lasers carry a relatively greater risk. The majority of fires occur during head and neck surgery. This is due to the presence of oxygen and the extensive use of lasers. The risk of fire can be reduced with an awareness of the risk and good communication. Conclusions: Surgery will always carry a risk of fire. Reducing this risk requires a concerted effort from all team members. ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.
Introduction Of all the potential complications of surgery, a surgical fire is perhaps the most extraordinary. That patients who entrust themselves to medical care are actually set alight when at their most vulnerable seems almost unbelievable.1 Yet it happens, with alarming frequency and potentially devastating consequences. Exact numbers are difficult to ascertain due to the absence of a standard reporting system and confidentiality clauses in many malpractice settlements2, but it does remain a relatively rare event.3 Estimates from the USA put the incidence at anything from 204,5 to 6506–8 surgical fires
each year. This makes the problem of a similar order of magnitude to wrong site surgery, a topic that has received far more attention in recent times.9 Three instances of surgical fires were reported to the National Reporting and Learning System in the UK between 2006 and 2009 (NPSA, personal communication). A US study found 17% of anaesthetic malpractice claims related to burns from surgical fires.10 Many will be minor fires causing no harm, but it is estimated that of the surgical fires that occur in the USA each year 20–30 are disabling or disfiguring and one or two are fatal.8 Airway injuries can necessitate prolonged intensive care with its accompanying morbidity.11
* Corresponding author. Tel.: þ44 (0)2072105139; fax: þ44 (0)2072105919. E-mail address: [email protected] (L.J. Donaldson). 1479-666X/$ – see front matter ª 2010 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.surge.2010.01.005
88
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Table 1 – Actions to prevent surgical fires. Team member Nursing staff
Surgeon
Anaesthetist
All staff
Recommendation Moisten all swabs and sponges before passing them to surgeon Do not use alcoholic skin preparation solution Label all solutions in the sterile field Wet patient’s hair with aqueous gel Let preparation solution dry completely before draping Use diathermy and laser sparingly Holster the diathermy when not in use Keep the diathermy tip as clean as possible Open all lumens using cold cutting Use minimal oxygen concentrations Avoid air leaks from the anaesthetic circuit Do not allow oxygen to collect beneath drapes Use protected tracheal tubes for laser surgery Use dyed saline to inflate tracheal tube cuffs for laser surgery Maintain awareness of the risks of surgical fires Use dedicated theatre teams for high-risk head and neck surgery Ensure excellent pre- and intra-operative communication
We present a review of the published literature on surgical fires and an examination of possible solutions to this problem.
Methods The PubMed and Medline databases were searched using the subject headings ‘‘operating rooms’’, ‘‘fire’’, ‘‘safety’’ and ‘‘safety management’’. ‘‘Surgical fire’’ was also searched as a keyword. The date range used was from 1948 onwards. Relevant references from articles were obtained. Relevant websites were identified using the Google internet search tool. Established patient safety organisations’ websites were accessed for alerts and advisories relating to surgical fires.
Several devastating operating theatre explosions have occurred in history. In 1964 an operating room explosion and subsequent fire in the USA killed two patients, two surgeons and two nurses, it also led to three traumatic amputations.14 In 1979 an explosion in Italy involving an oxygen cylinder and flammable substances killed 21 people.15 Not all fires are so dramatic. Many are mere flashes, for example prep solution igniting, and cause no harm.16,17
Changes over time In 1941 the American Association of Anesthesiologists reported a large series of 230 anaesthetic associated fires and explosions.18 Typically for this era, they all involved volatile anaesthetic agents such as ether and cyclopropane. Their use meant that fire was considered an unavoidable risk to surgery. Its prevention was largely the responsibility of anesthesiologists.19 During the late 1960s and 1970s newer, less volatile agents largely superseded these flammable anaesthetics3 although a fatality from ether ignition in the UK occurred as late as 1985.20,21 The legacy of this era of explosive anaesthetics remains in the anti-static floors still installed in operating theatres and the anti-static clogs theatre personnel wear. Replacing explosive anaesthetic agents certainly made surgery safer but has also reduced the awareness of the potential risk of surgical fires.22,23 The risk of surgical fires remains today.24 Other potential fuels are bowel gas,25,26 skin disinfecting agents,27,28 drapes,29 swabs,30 suture packets31 and even a patient’s own tissues or hair.32,33 Advances in surgical practice in the past few decades have introduced new fire risks. These include laparoscopy, where the pneumoperitoneum is a potential hazard,34,35 as are the light sources used,36 endoscopic and transurethral surgery37,38 and the use of lasers39 and diathermy40,41 to cut and coagulate tissue. The vast majority of surgical fires, however, occur during head and neck (including plastic and neurosurgery),42–46 particularly airway,7,8,47,48 surgery.
Head and neck surgery
Results Over 400 relevant citations were identified. Many of these were case reports of specific fires. Some of these case reports also included a review of the literature as it was at the time. Other papers were non-clinical experiments exploring the conditions required for ignition, others still were intended to provide advice to clinicians in order to prevent further fires.
Sources of fire in the operating theatre For a fire to occur, the three elements of a fire triangle are needed: fuel, oxygen (or some oxidising agent) and an ignition source.12 All three are in plentiful supply in the operating theatre environment. A different member of the team supplies each. The nursing staff deliver fuel in the form of prepping agents, swabs and drapes. The anaesthetist provides oxygen and nitrous oxide as the oxidiser. Ignition is triggered by the surgeon, with the use of diathermy or lasers.13 This makes the operating theatre an inherently dangerous place in terms of fire safety.
There are two key reasons for this increased risk in head and neck surgery. Most obvious is the routine administration of oxygen during anaesthesia and sedation, meaning that head and neck surgery is performed in an oxygen enriched environment.49 Head and neck surgeons also make frequent use of incendiary operating tools, including diathermy16 and lasers.50 Each element of the fire triad is essential for a fire to occur but the concentration of the oxidiser can also have a major effect on the fuel component of the triad. Oxygen can support combustion so effectively that objects that do not support a flame in air will burn readily and vigorously in higher concentrations of oxygen.51 In an oxygen enriched atmosphere, endotracheal tubes52,53 and plastic facemasks54 can ignite, antiseptic solutions become explosive44 and swabs24 and drapes55 catch light. The oxidiser element of the fire triad is so important that is unusual for a surgical fire to occur in the absence of oxygen enrichment.17 Even fires occurring away from the head and neck area are commonly associated with an increased oxygen concentration.24,56 It should be remembered that nitrous oxide is also an oxidiser and will
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support combustion. Reducing the oxygen flow and replacing it with nitrous oxide does not remove the risk of fire.57 In 70% of surgical fires, electrosurgical equipment provides the ignition required for the fire to start,8 lasers are responsible in a further 10%. Both these modalities deliver focused energy to either cut or coagulate tissue, creating intense heat and generating temperatures well above those needed to start a fire.58,59 When the almost ubiquitous nature of electrosurgery in modern surgical practice and the comparatively sparse use of lasers are considered, it is clear that lasers present a far greater individual risk. Lasers are used more extensively in head and neck surgery than any other branch of surgery. They have a number of applications from tumour ablation60 to palatoplasty.61 As already discussed this requires their use in a potentially oxygen rich environment. Accidental contact of the laser beam with a variety of items that enter the surgical field in the presence of oxygen can be enough to cause a fire. These items include endotracheal tubes, surgical swabs, and surgical drapes. In the early days of laser surgery, endotracheal tube ignition was reported in as many as 1.5% of patients undergoing laryngeal laser surgery.62–64 Tubes are manufactured from a variety of materials with varying potential to ignite.65 Polyvinyl chloride tubes are probably least safe, they are readily penetrated by a laser to release the oxygen within the lumen and burn in oxygen concentrations as low as 25%.66 There are a variety of endotracheal tubes designed to be laser-proof for ‘‘shared-airway’’ laser surgery.58 A standard tube can be prepared for laser safety by wrapping in foil tape67 although this does introduce its own risks such as mucosal damage68 and detachment of the foil tape.69 Altering the gas mixture administered during surgery can also improve safety of airway laser surgery. Replacing the nitrogen with helium reduces the time to ignition with the carbon dioxide laser.70 Interestingly however, this is not the case with the other laser commonly used in airway surgery, the potassium titanyl phosphate laser, which remains a hazard in a helium and oxygen mixture.71
Conditions predisposing to fire Several non-clinical studies have been published examining the conditions that predispose to surgical fires. One tested the ignition of various surgical drape materials in air and 50% and 95% oxygen.55 It found that the laser would ignite any material commonly used as surgical drape in oxygen enriched circumstances, even those that did not burn at all in air. Similarly, another found that surgical cotton patties ignited much more rapidly in higher concentrations of oxygen.72 Unsurprisingly this study also found that soaking the patties in saline solution significantly increased the time to ignition, requiring over 15 s of continuous firing of the laser beam to create a flame, unlikely to occur in surgical practice.
Recommendations to prevent fires The accumulated experience of surgical fires and the conditions that predispose to them has lead to many sets of guidelines and recommendations to avoid them. Several lay the responsibility for fire prevention with the anaesthetist.2,73 There are several reasons for this, firstly the historical
89
perspective of a time when anaesthetic gases were explosive,1 secondly the importance of oxidisers on the risks of fire2,74 and also simply that the majority of advisories are published in anaesthetic journals and hence targeted at anaesthetists.73 Other advisories take a broader view of the issue and address each of the theatre team members in turn and the elements of the fire triad they can control (Table 1).4,75–77 Nursing staff are primarily responsible for providing the fuel for surgical fires and recommendations directed to them include using fire retardant drapes,55,78 minimising the use of alcoholic skin preparation solutions,44,79 dampening swabs and sponges,17,80 and labelling any liquids on the surgical tray so that flammable liquids are not used inadvertently.81 The advice and recommendations given to surgeons also relate to the presence of potential fuels, avoiding alcoholic preparation solutions where possible and ensuring they dry adequately if they are needed.33,82 The patient’s hair should be wetted, ideally with an aqueous gel, to reduce its flammability.8,76 The key involvement a surgeon has is ignition however and the use of diathermy or laser should be kept to a minimum, with the diathermy tip kept clean to reduce sparking. The airway or other cavity containing potentially explosive mixtures such as intestine should be opened using a ‘‘cold’’ instrument such as scalpel or scissors.23,83,84,95 The use of non-incendiary, haemostatic operating tools such as the harmonic scalpel is also recommended where possible.85 The anaesthetist’s role is to keep oxidiser concentrations to a minimum. This is achieved in several ways: by using the lowest oxygen flow feasible and no supplementary oxygen where possible,86 ensuring there are no leaks in the circuit (for example around the endotracheal tube). Anaesthetists should also ensure that oxygen does not collect under the drapes,87 using a secured airway if necessary.73 When anaesthetising for high-risk head and neck surgery using lasers, a double-cuffed tube has been recommended, filling the cuffs with dyed saline so that perforation is immediately obvious.39,73 Many published papers on surgical fires advocate education as the key to reducing the risk of surgical fires.44,54,75,88–90 The findings that both nursing and medical staff are unaware that commonly used solutions are highly flammable,27 that nearly two in three newly qualified doctors had never heard of surgical fires75 and that even amongst experienced surgeons awareness was far from universal91 would support this. However, when surgical fires are reviewed, it is apparent that knowledge of the risks is not enough. Almost all fires, both historical and current, are preventable by the use of measures that are well known.92,93 It only takes a momentary lapse by one individual to cause a fire.94 For this reason, maintaining awareness, for example with posters in the operating room, is encouraged by several organisations.8,95 Excellent communication between team members is essential to improving operating theatre safety generally and is also relevant to reducing fire risks.3,80,96–99 Communication can be structured by the use of a checklist96,98 at the beginning of surgery. A discussion about the risk of fire can be incorporated into these checklists for high-risk surgery. Further formalising of communication has been suggested using a scoring system to assess the risk of surgical fire.100 This scoring system sets out a simple three point score for the risk of fire. Each of the following score one point, surgical site above the xiphoid,
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open oxygen source and a source of ignition. If the score is 2 or 3, then specific protocols are followed to reduce the risk of fire.
of the fire triad from each other. This requires ongoing awareness of the threat and a concerted effort from all members of the operating theatre team.
Action to take in the event of fire If a fire does occur, prompt action can mitigate the harm caused. The first step is to recognise that a fire has occurred. This is usually obvious with the presence of flames or smoke28 but a fire can also be first noticed by an unusual noise,26 smell54 or feeling of warmth.71 The next step is to remove the fire from the patient. This is done by simultaneously removing the burning material from the patient and cutting off the flow of gas to the field.101 Stopping the flow of oxygen will often put out the fire as many materials only burn in oxygen enriched atmospheres and all materials will burn less fiercely if the oxygen concentration is reduced.8 In the case of an airway fire with a burning endotracheal or tracheostomy tube the advice is almost universally to remove the tube.8,73,95,102 This is to prevent ongoing damage to the trachea, damage to the more distal airways and to reduce the inhalation of toxic material from the fire.103,104 However, one paper does advise caution in this and recommends that if a patient was difficult to intubate then consideration should be given to leaving the tube in situ.105 Burning material may include swabs, drapes and other items in the surgical field. These should be removed, even if doing so compromises the sterility of the surgical field.101 These steps will almost always be enough to put out the fire. Any residual burning should be extinguished as quickly as possible. Pouring water or saline into the fire is usually the preferred means as it has the advantages of being quick and also acting as a heat sink to cool the field and stop further damage.8,73 If a fire is large then a fire extinguisher should be used, a carbon dioxide type being preferred.32,77 A fire blanket should never be used as this will contain the fire on the patient, including potentially hot material, and fires may continue unnoticed beneath the blanket if the oxygen supply is maintained.8 Any scorched material should be removed, as it may be hot even after the fire is out or reignite on the reintroduction of oxygen.77,95 Once the fire is out then attention should be rapidly turned to caring for the patient who may be bleeding, without an airway or otherwise in danger.8 A secure airway should be reestablished and the patient ventilated with room air until it is absolutely certain that the fire is out.95 Only then should oxygen be reintroduced to the breathing circuit. In the case of an airway fire, bronchoscopy, preferably rigid, should be performed to assess the extent of injury to the airway and perform lavage as appropriate73,95 A tracheostomy may be required.19,95 Some authors recommend administering steroids and prophylactic antibiotics23,106 There is little evidence for this practice but it makes good clinical sense to attempt reduce the airway oedema and prevent secondary pneumonia following thermal alveolar damage.
Conclusions Surgical fire will always be a risk in the operating room. The danger is highest in head and neck surgery and where lasers are used. The risk can be mitigated by separating the elements
Financial support None.
references
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