Introduction
Surgical fires--fires that occur on or in a surgical patient--happen only rarely, but their consequences can be grave. They can kill or seriously injure patients, injure surgical staff, and damage critical equipment. The risk of surgical fires is present whenever and wherever surgery is performed, whether in an operating room (OR), a physician's office, or an outpatient clinic.
The Elements of Surgical Fires
The three basic elements of surgical fires constitute the traditional fire triangle. In the OR, these elements are present in the following forms:
- Ignition sources include electrosurgical equipment, surgical lasers, electrocautery equipment, fiberoptic light sources, and defibrillators.
- Oxidizers include oxygen-enriched atmospheres, nitrous oxide, medical air, and ambient air.
- Fuels include common OR material such as mattresses, sheets, gowns, towels, drapes, dressings, and sponges. Other fuels include volatile organic chemicals, body hair, intestinal gases, tracheal tubes, and body tissue.
Each member of the surgical team is associated with—and should be concerned with—one or more sides of the fire triangle. Surgeons are involved mainly with ignition sources, anesthesia providers mainly with oxidizers, and nurses mainly with fuels, although these areas frequently overlap. Each member of the surgical team should understand the various fire hazards presented by each side of the fire triangle and should make a point of communicating information on the risks to the other team members—intraoperatively or in seminars, for example.
Recommendations for Preventing Surgical Fires
The following items are examples of ways in which the risk of a surgical fire can be minimized. For a comprehensive list, see the original guideline document.
Minimizing Ignition Risks
During Electrosurgery
- Place the electrosurgical pencil in a holster when it is not in active use--that is, when it won't be needed within the next few moments.
- Activate the active electrode only when the tip is under the surgeon's direct vision.
- Allow the pencil to be activated only by the person wielding it.
- Deactivate the pencil before removing it from the surgical site.
- If open O2 sources are employed, use bipolar electrosurgery whenever possible and clinically appropriate (such as for cauterization during head and neck surgery). Bipolar electrosurgery creates little or no sparking or arcing.
- Never use insulating sleeves cut from catheters over electrosurgical active electrode tips.
- Never use electrosurgery to enter the trachea during tracheostomy.
During Laser Surgery
- Place the laser in standby mode whenever it is not in active use.
- Activate the laser only when the tip is under the surgeon's direct vision.
- Allow only the person using the laser to activate it.
- Deactivate the laser and place it in standby mode before removing it from the surgical site.
- When performing laser surgery through an endoscope, pass the laser fiber through the endoscope before introducing the scope into the patient. This will minimize the risk of damaging the fiber. Before inserting the scope in the patient, verify the fiber's functionality.
- During lower-airway surgery, keep the laser fiber tip in view and make sure it is clear of the end of the bronchoscope or tracheal tube before laser emission.
- Use appropriate laser-resistant tracheal tubes during upper-airway surgery. Follow the directions in the product literature and on the labels, which typically include information regarding the tube's laser resistance, use of dyes in the cuff to indicate a puncture, use of a saline fill to prevent cuff ignition, and immediate replacement of the tube if the cuff becomes punctured.
In General
- Remove unneeded footswitches so they are not accidentally activated. (Do this only after the attached device has been placed in standby mode.)
- Dispose of electrocautery pencils properly--for example, break off the cauterizing wire and cap the pencil.
- Be aware that fiberoptic light sources can start fires.
- Use a pulse oximeter to monitor the patient’s blood oxygen saturation and titrate the delivery of oxygen to the patient’s needs.
- Never place active fiberoptic cables on flammable materials.
- Place the fiberoptic light source in standby mode when disconnecting cables.
Minimizing Oxidizer Risks
During Oropharyngeal Surgery
- Use suction as near as possible to any potential breathing gas leak to scavenge the gases from the oropharynx of an intubated patient.
- Wet any gauze or sponges used with uncuffed tracheal tubes to minimize leakage of gases into the oropharynx, and keep them wet.
- Keep all moistened sponges, gauze, pledgets, and their strings moist throughout the procedure to render them ignition resistant.
In General
- Be aware of possible O2- and O2/N2O-enriched atmospheres near the surgical site under the drapes, especially during head and neck surgery.
- Question the need for 100% O2 for open delivery to the face (for example, when using a nasal cannula); if possible, use air or +30% O2 for open delivery, consistent with patient needs.
- If possible, stop supplemental O2 (if concentration is more than 30%) at least one minute before beginning the use of electrosurgery, electrocautery, or laser surgery on the head or neck.
- Minimize the buildup of O2 and N2O (such as from an uncuffed tracheal tube or a laryngeal mask airway) beneath the drapes.
- Use a properly applied incise drape, if possible, to help isolate head and neck incisions from O2-enriched atmospheres and from flammable vapors beneath the drapes. Proper application of an incise drape ensures that there are no gas communication channels from the under-drape space to the surgical site.
- Consider active gas scavenging of the space beneath drapes during open O2 delivery, or of the oropharynx of an intubated patient. When scavenging beneath drapes, exercise caution so that the space beneath the drapes does not collapse.
Minimizing Fuel Risks
During Preparation
- Avoid pooling or wicking of flammable liquid preps.
- Allow flammable liquid preps to dry fully before draping; pooled or wicked liquid will take longer to dry than will prep on the skin alone.
- Use a properly applied incise drape, if possible, to help isolate head and neck incisions from O2-enriched atmospheres and from flammable vapors beneath the drapes. Proper application of an incise drape ensures that there are no gas communication channels from the under-drape space to the surgical site.
In General
- Coat facial hair (including eyebrows, beard, and mustache) near the surgical site with water-soluble surgical lubricating jelly to make the hair nonflammable.
- Be aware of the flammability of tinctures, solutions, and dressings (such as benzoin, phenol, and collodion) used during surgery, and take steps to avoid igniting their vapors.
Recommendations for Responding to Surgical Fires
When a Fire Starts
First Response
Small fires on the patient (such as those caused when a hot electrosurgical pencil ignites drapes on a patient, or when an electrocautery pencil ignites a blotting sponge) can be extinguished by patting out the fire with a gloved hand or towel.
- Large fires on or in the patient require a more comprehensive response: Stop the flow of oxidizers to the patient. In many cases, this will cause the fire to go out or at least lessen in intensity.
- Remove the burning materials from the patient, and extinguish them. This is the only way to protect the patient from the heat of these materials.
- Care for the patient swiftly. Restore breathing if necessary (with air, never O2) and deal with any injuries.
(There is some debate over this sequence--specifically, the order in which the first two steps should be carried out. The guideline developers believe they should be performed simultaneously; others disagree. In any case, they should both be done as close to instantaneously as possible.)
If Evacuation is Necessary
In some very rare cases, extreme smoke and fire conditions may force the evacuation of the OR where the fire occurs. In such cases, the acronym RACE defines the actions that should take place: rescue the patient if possible, alert staff in nearby ORs and activate fire alarm systems, confine the smoke and fire by shutting all doors and closing off gas, vacuum, and power systems, and evacuate the OR and, if necessary, the surgical suite.
Putting Out the Fire
If the fire cannot be extinguished by the methods discussed under First Response in the original guideline document, then other means may be required.
Fire Extinguishers
Although they should not be the first resort when dealing with a surgical fire, fire extinguishers may be needed to deal with fires that engulf or that have migrated off the patient.
The correct procedure for using any fire extinguisher can be recalled by the acronym PASS: pull the pin, aim the horn or nozzle, squeeze the trigger, and sweep out the fire. The basic types of fire-extinguishing devices commonly available in ORs are water-based, CO2, and dry powder. Not all of these are equally safe or effective. Of them, the guideline developer prefers CO2 extinguishers, and recommends that a 5 lb CO2 extinguisher be mounted just inside the entrance of each OR in the hospital.
Other Ways to Put Out a Fire
Other, less common means of extinguishing surgical fires include halon, aqueous solutions found in the OR, fire blankets, sprinkler systems, and hoses. Again, these are not all equally safe or effective.
Halon is highly effective at putting out fires but has been banned from manufacture by international agreement because of its effect on atmospheric ozone.
Aqueous solutions include bottled saline solution, bottled water, and tap water.
Fire blankets--typically wool blankets treated with fire retardants that are placed over a fire to smother it--should never be located in an OR and should never be used for patient fires. Their use will likely cause more severe injuries to the patient. However, they can be placed outside it in case of a fire on a conscious person, such as a surgical team member. In such a fire, the person can actively use the blanket, is likely not O2-enriched, and can tell others where fire is still burning.
For more details on this subject, refer to the original guideline document.
Sprinkler systems are often found in the ORs of newer facilities. They may activate only in response to large fires. Like water from extinguishers, sprinkler system water is not sterile and could, under some circumstances, present an electric shock hazard.
Fire hoses are sometimes found in hallways and stairwells of older facilities. Water from hoses is not sterile. The water can also create an electric shock hazard. In addition, the water stream itself can deliver sufficient force to cause injury or mechanical damage and can make the hose difficult to hold onto. The guideline developers do not recommend the uses of fire hoses to extinguish surgical fires.
In the Aftermath
After the fire, the OR and all materials and devices involved in the fire should be secured until an investigation can be completed. Statements from the staff should be taken as soon as possible after the incident.
Fire Drills
Fire drills not only allow staff to practice for a fire but also help troubleshoot any difficulties that might occur. Some elements to consider in planning a fire drill are:
- The proper response of each surgical team member and the operating suite staff
- How the patient can easily and safely be moved to another OR
- How the spread of smoke should be prevented (for example, through the use of smoke doors and air duct dampers)
- The location and operation of fire extinguishers, fire alarm pull stations, and exits
- What the response of additional fire-fighting personnel (such as the fire response team and local fire department) should be
For a more comprehensive list, see the original guidance document.
