Overview
Definition:
An operating room fire is an uncontrolled combustion event occurring in the surgical environment, posing significant risks to patients, staff, and equipment.
Epidemiology:
Estimated incidence ranges from 1-2 per 1,000 surgical procedures in the US, with an increasing trend
Most fires occur in the head, neck, and upper chest
Patient injury rates vary but can be severe, including burns, respiratory damage, and psychological trauma.
Clinical Significance:
Operating room fires are preventable but potentially catastrophic events
Understanding the fire triangle (oxygen, ignition source, fuel) and implementing stringent preventive measures is paramount to patient safety and successful surgical outcomes
This topic is crucial for all surgical trainees and attending physicians.
Fire Triangle Components
Oxygen Enrichment:
Elevated oxygen concentration above room air (21%) significantly increases flammability
Sources include supplemental oxygen delivery, use of nitrous oxide, and leaks from anesthetic circuits
High-flow oxygen delivery or prolonged application can lead to pocketing of oxygen under drapes.
Ignition Sources:
Common ignition sources in the OR include electrocautery devices, laser beams, unipolar/bipolar electrosurgical units, fiberoptic light sources, electrical equipment malfunctions, and static electricity discharge
The spark from an electrocautery tip is a frequent culprit.
Fuel Sources:
Surgical drapes (particularly synthetic ones), patient skin preparation solutions (e.g., alcohol-based tinctures), surgical sponges, endotracheal tubes, dressings, and combustible materials are common fuels
Alcohol-based prep solutions are highly flammable and require adequate drying time.
Prevention Strategies
Preoperative Assessment:
Identify patients at high risk (e.g., those with prolonged oxygen therapy, scheduled for head/neck surgery)
Assess the surgical site and procedure for potential fire hazards
Review patient medications and skin preparation protocols.
Oxygen Management:
Use the lowest effective fraction of inspired oxygen (FiO2)
If supplemental oxygen is used, ensure it is delivered cautiously and is not allowed to accumulate under surgical drapes
Consider using air instead of pure oxygen when possible for non-anesthetic gas procedures.
Anesthesia Considerations:
Carefully monitor anesthetic gas mixtures
Avoid nitrous oxide in combination with high oxygen concentrations if possible
Ensure anesthetic circuits are leak-free and that oxygen delivery systems are functioning correctly
Document oxygen delivery parameters.
Electrosurgical Safety:
Use the lowest effective power setting for electrocautery
Engage the device only when necessary and when in direct contact with tissue
Employ a return electrode monitoring system
Ensure proper placement and good contact of the patient return electrode
Use blades/tips that are not frayed or damaged.
Laser Safety:
Use appropriate laser safety goggles for the specific wavelength
Ensure laser fibers are intact and connections are secure
Employ a wet surgical sponge to absorb stray laser light
Cover any exposed endotracheal tubes with a fire-resistant material.
Draping And Fuel Management:
Use flame-retardant drapes
Ensure drapes are applied correctly to prevent oxygen pooling
Remove any excess prep solutions
Keep flammable materials away from potential ignition sources
Have sterile water or saline readily available to extinguish small fires.
Equipment Maintenance:
Regularly inspect and maintain all electrical equipment, including electrocautery units, lasers, and monitoring devices, to prevent malfunctions and sparks
Ensure proper grounding of electrical equipment.
Management Of An Or Fire
Stop Oxygen Administration:
Immediately turn off supplemental oxygen or anesthetic gas flow
This is the most critical first step to starve the fire.
Extinguish The Fire:
Use sterile saline or water to douse the flames
Small fires can be smothered with wet sponges or saline-soaked gauzes
Do not use dry chemical extinguishers near the patient due to risk of aspiration and tissue damage.
Assess Patient:
Once the fire is out, immediately assess the patient for burns and airway injury
Document the extent and depth of any burns
Ensure the patient is stable and adequately oxygenated.
Document And Report:
Thoroughly document the incident, including the timeline, contributing factors, interventions, patient assessment, and any injuries
Report the event according to institutional policy for quality improvement and to prevent recurrence.
Complications
Burns:
Patient burns can range from superficial partial-thickness to full-thickness injuries, often occurring on the face, neck, chest, or extremities
Tissue damage can be extensive and lead to disfigurement and functional impairment.
Airway Injury:
Inhalation of hot gases and smoke can cause thermal injury to the upper and lower airways, leading to edema, obstruction, and respiratory distress
This can be life-threatening.
Equipment Damage:
Fire can damage critical surgical and anesthetic equipment, leading to procedural delays and significant financial costs for replacement.
Psychological Trauma:
Both patients and staff can experience significant psychological distress, including post-traumatic stress disorder (PTSD), anxiety, and fear, following an OR fire incident.
Delayed Procedure:
The fire event necessitates immediate cessation of the surgery, leading to significant delays, potential re-scheduling, and increased healthcare costs.
Key Points
Exam Focus:
Understand the three components of the fire triangle in the OR: oxygen, ignition source, and fuel
Know the common ignition sources (electrocautery, laser) and fuels (drapes, prep solutions)
Remember the mnemonic "Stop, Douse, Assess" for immediate fire management.
Clinical Pearls:
Always ensure alcohol-based prep solutions are completely dry before using electrocautery or laser
Keep the surgical field clear of unnecessary flammable materials
Have sterile saline or water readily accessible at all times during procedures where fire risk is elevated.
Common Mistakes:
Failure to turn off oxygen immediately
Using the wrong extinguishing agent
Inadequate assessment of burn severity and airway injury
Insufficient documentation and reporting of the incident.