Risks
The risk of intraoperative fires is notably higher in specific "high-risk" procedures where an ignition source is brought close to an oxygen-enriched environment. Closed claims cases have demonstrated that such fires most frequently occur during surgeries involving the mouth, throat, tracheostomy, eyes, or surgeries conducted around the head, neck, chest, or face, including cranial burr hole operations. Procedures during which oxygen is administered through an open system, such as a face mask or nasal cannula, are classified as high-risk. It's crucial for the safety of surgical patients that monitoring of the inspired, exhaled, and/or delivered oxygen concentration is maintained throughout the procedure.
The majority of burn claims in the operating room are attributed to fires caused by the surgeon's use of cautery or laser. From a broader perspective, surgeons contribute the ignition or heat source through tools like electrocautery and lasers, but other devices such as defibrillator pads, coagulators, fiberoptic light cables, and heated probes also present risks. Nurses add to the potential fuel source with surgical preparations and drapes, and other combustible materials may include the patient's hair, dressings, gastrointestinal tract gases, blankets, gloves, etc. Anesthesia's role in increasing fire risk comes from providing an oxidizer source; any fractional inspired oxygen (FiO2) over 30% is considered supplemental, and the use of nitrous oxide also contributes to this risk. The manner in which oxygen or any oxidizer is delivered—especially via an open system—and the failure to document preventive measures for burns significantly heighten the liability on the part of anesthesia. Both oxygen and nitrous oxide act as oxidizers and accelerants, significantly increasing the likelihood of combustion and necessitating stringent safety measures to mitigate the risk of intraoperative fires.
Prevention and Management
Prior to embarking on high-risk surgical procedures, it's imperative for the surgical team to engage in a comprehensive discussion regarding strategies to prevent and manage potential fires, maintaining continuous communication throughout the procedure. Strategies include minimizing, managing, or avoiding an oxidizer-enriched atmosphere near the surgical site, ignition sources, and fuels. Specifically, for airway surgeries, opting for a cuffed tracheal tube over an uncuffed one can help maintain supplemental oxygen below the cuff level. In the case of laser surgeries, employing a laser-resistant tracheal tube and filling the tracheal cuff with methylene blue-tinted saline can aid in identifying cuff punctures. Additionally, placing moistened sponges or gauze near potential ignition sources and reducing the fractional inspired oxygen (FiO2) as much as possible during the use of lasers or cautery are prudent measures. Utilizing suction techniques, such as a suction catheter or Yankauer suction piece, can help divert gases away from the airway.
During surgeries involving the head, face, and neck, assessing the need for sedation and oxygen while ensuring effective communication with the surgeon is crucial, especially if a face mask or nasal cannula is utilized. It's important to halt any oxidizer delivery and wait a few moments before permitting ignition source activation. Surgical drapes should be arranged to prevent oxygen entrapment and the use of nitrous oxide should be avoided.
In the event of a fire, having several containers of sterile saline and a carbon dioxide extinguisher immediately available is crucial, as is promptly calling for help. The first steps involve removing the heat source, stopping the flow of all airway gases, and assessing for an airway fire. Any flammable or burning materials should be removed and extinguished. If the fire is within the airway or breathing circuit, removing the endotracheal tube might be necessary, followed by stopping all airway gases, pouring sterile saline into the airway, and reestablishing ventilation without supplemental oxygen or nitrous oxide when possible. Examination of the tracheal tube for integrity and potentially conducting a bronchoscopy to remove any debris and assess injury are critical steps.
For fires occurring elsewhere on the patient, the protocol involves stopping all airway gases, removing and extinguishing flammable materials, and assessing for smoke inhalation injury, potentially using a fiberoptic scope. In cases of burns to the face, intubation may be necessary.
Following patient stabilization, conducting a chest X-ray (CXR), arterial blood gases (ABGs) analysis, and measuring the carboxyhemoglobin level are essential steps in the ongoing care and assessment of the patient. This comprehensive approach underscores the importance of preparation, immediate action, and post-incident care in managing intraoperative fires.
| Step | Fire in the airway or breathing circuit | Fire elsewhere on the patient |
|---|---|---|
| First actions | Remove the heat source and stop the flow of all airway gases | Stop all airway gases |
| Burning material | Remove and extinguish any flammable or burning material | Remove and extinguish flammable materials |
| Tracheal tube | Removing the endotracheal tube may be necessary | — |
| Airway measure | Pour sterile saline into the airway | — |
| Ventilation | Reestablish ventilation without supplemental oxygen or nitrous oxide when possible | — |
| Injury assessment | Examine the tracheal tube for integrity; bronchoscopy to remove debris and assess injury | Assess for smoke inhalation injury, potentially with a fiberoptic scope; intubation may be needed for facial burns |
| After stabilization | Chest X-ray, arterial blood gases, carboxyhemoglobin level | Chest X-ray, arterial blood gases, carboxyhemoglobin level |
