Operating room (OR) fires pose a significant risk during surgeries, often overlooked. Common causes include oxygen leakage, flammable substances, and ignition sources. Proper precautions, like assessing fire risk factors, mindful oxygen use, and ensuring flammable materials are dry, can prevent fires. Awareness and readiness are crucial to safeguard patients and staff. You must always be prepared.

Case #1:

My colleague was anesthetizing a 55-year-old woman having a breast biopsy, using local plus deep propofol sedation. Although breathing spontaneously, the patient was essentially unresponsive. She received 6-L flows of supplemental oxygen through a green mask.

Although she was covered by a surgical drape, oxygen was able to leak onto the surgical field through gaps in the drape where it crossed her neck.

A spark from the surgeon’s cautery lit the paper surgical drape on fire. The alert surgical tech immediately pulled the drape off the patient and extinguished the drape fire. What no one noticed in the resulting chaos was that the ChloraPrep (BD), which had dripped off the patient’s shoulder and breast onto the sheets underneath her—and was still wet—had caught fire. Alcohol flames are nearly invisible, especially in the very bright lighting of the OR. By the time they noticed this second fire, the patient’s shoulder and back had suffered third-degree burns. She required skin grafting.

Mistakes included:

• allowing an alcohol based prep to soak the sheets under the patient
• allowing oxygen to flow into an area with an ignition source and fuel,
• failing to recognize an alcohol fire in the sheets under the patient

Case #2:

My patient was undergoing a low-risk knee arthroscopy, under general anesthesia and an LM airway. The fiber-optic light source was detached and placed on top of the paper drape, still illuminated. Prolonged exposure to high heat caused the drape to smoke and then blacken. The ortho tech alerted the team and immediately bathed the area with saline from his Mayo stand. I dialed my FiO₂ to room air (21%) through the patient’s LM airway as a precaution. We covered the wound, removed the drapes, checked the patient and underlying sheets for hidden fire, and then re-prepped and re-draped the patient. Surgery proceeded uneventfully after the close call. This patient suffered no harm because the ortho tech was alert, had saline prepared on his mayo stand, and used it without hesitation.

Mistake: incautious use of the fiber optic light source, the ignition source, next to fuel

Incidence of OR Fire

Estimates suggest there are 500 to 700 OR fires each year, with more than 500 incidents that are unreported or near misses. [1,2] Fire requires three things: fuel, an ignition source and an oxidizer—three things that are abundant in our OR environment.

Most closed claims involve OR fires that:

• occur in an outpatient setting (76%),
• involve the upper body (85%), and
• are cases managed with monitored anesthesia care (81%). [3]

Testing of draping materials shows that in an oxygen-rich environment, ignition and burn times are so fast (fractions of seconds) that the ability to protect the patient from burn injury in a high percentage of inspired oxygen (FiO₂) setting is close to impossible. Therefore, prevention of OR fires is paramount.

I thankfully have not seen an airway fire myself, but I have seen sparking in the airway due to cautery use.

Early in my career, in 1989, I was doing anesthesia for cleft palate repairs on a plastic surgery mission to Vietnam. The only carrier gas we had was oxygen; there was no air available on our machines. The surgeons were using open cautery. We were using uncuffed tubes in children, sealing the lower pharynx with a moist gauze pad. I suppose I am lucky that not only did we not get a major airway fire, I was too naive at the time to be alarmed by the “pretty” sparks I was seeing. Endotracheal tubes (ETTs) will burn like a torch, especially in an oxygen-rich atmosphere.

OR Fire Prevention

Identify Patients at Risk

Identify patients at risk. In the OR, the three factors that greatly increase fire risk are:

• surgical site or incision above the xiphoid,
• open oxygen source (i.e., patient is receiving supplemental oxygen via face mask or nasal cannula),
• available ignition source (i.e., electrosurgery unit, laser or fiber-optic light source).

Many hospitals require the surgical team to identify any of the three key elements that are necessary for a fire to start before beginning any case during “time-out”. This discussion alerts the team and prompts them to take appropriate precautions.

• Red risk 3 = High risk. All three components of the fire triangle are present.
• Red risk 2 = Low risk with potential to convert to high risk. This score is given when the procedure is in the thoracic cavity, the ignition source is remote from an open oxygen source, the ignition source is close to a closed oxygen source, or no supplemental oxygen is used.
• Red risk 1 = Low risk. Only supplemental oxygen is being used.

Airway fires are more common in head/neck procedures including, but not limited to, tracheotomy, adenoidectomy, tonsillectomy, skin surgery, breast surgeries, and eye surgery. Any surgery above the xiphoid, such as the breast biopsy described above, presents higher risk. However, OR fire can potentially occur in any case at any time.

Be Selective with Oxygen Supplementation

Closed claims show that even patients receiving monitored anesthesia care for upper body surgery are at higher risk of fire injury. In today’s OR settings, conscious sedation can often mean caring for a fairly unresponsive, oblivious, patient. Such a patient will not be able to alert you to problems.

Not every patient receiving sedation requires oxygen. If they do, providing low-dose oxygen by using an oxygen blender reduces the risk. If higher oxygen concentrations are needed for surgery above the xiphoid, consider general anesthesia with either an LM airway or a cuffed endotracheal tube (ETT).

Nitrous Oxide Supports Combustion

During airway surgery, anesthesia providers often decrease FiO₂ by diluting the oxygen flow with air in order to minimize fire risk. It’s important to know that dilution with N20 (nitrous oxide) does NOT decrease fire risk at all. While not flammable itself, N20 fully supports combustion.

Nitrous oxide is a potent oxidizer. Race car drivers sometimes use it to increase fuel combustion and power to their engines. Never use nitrous oxide to try to lower the FiO₂ of your gas mixture during a case at risk for fire.

Be Careful with Alcohol Prep Solutions

ChloraPrep and DuraPrep are flammable, alcohol-based, antiseptic solutions. Drying time on skin is three minutes. Drying time on cloth or hair can take an hour. Prep solutions can easily spread beyond the area of the surgical field during the prep. This can occur for both the actual surgical prep, as well as the prep of any area where we perform a regional anesthetic block or central line placement.

During a block or line placement, I usually place (as appropriate) either a sterile blue OR towel, or an absorbent paper underpad such as a Chux under the field. This prevents the underlying sheets, or the patient’s hair, from becoming saturated with flammable liquid.

As case #1 above shows, never ignore sheets that are wet with alcohol prep underlying your patient. Let it dry or swap them out.

Volunteer Missions Have a High Risk of OR Fire

Medical Missions to disaster zones and developing countries are at especially high risk of OR fire. Frayed electrical cords and broken or poorly maintained equipment raises the risks of sparks and microshocks. there may be active fire in a disaster zone. Be especially vigilant. For more information on equipment hazards in volunteer settings see:

• Equipment—Avert Volunteer Anesthesia Mishaps 2

Be Prepared: Have a Plan for OR Fire

Fire can occur at any time with any surgery. The most feared OR fire is an airway fire. Airway fires are different from other fires in an operating room and can easily be fatal. Surgeries on the pharynx, larynx, and trachea are the most at risk for airway fires.

If an airway fire starts, immediately: 

• Stop ventilation 
• Notify the surgical team
• Call for help 
• Remove fuel source: Remove the endotracheal tube (ETT) and any other burning fragments 
• Remove ignition source: Turn off the laser or cautery
• Remove oxidizer flow: Disconnect the circuit and stop the delivery of gasses 
• Put out the fire: Pour water or saline into the airway to put out any remaining flames 
• Reestablish an airway: Reintubate or place a laryngeal mask 
• Ventilate the patient: Use medical air until there are no more smoldering materials, then switch to 100% oxygen 
• Assess the damage: Perform a direct or video laryngoscopy or bronchoscopy to evaluate the damage and remove debris 
• Monitor for worsening airway edema if not intubated
• Consider ICU admission
• Report the event to your risk management office and/or liability insurance carrier(s) 

General Guidelines for Any OR Fire

• Be alert to OR fire
• Have a means to extinguish fire on the field, such as saline on the mayo stand
  • don’t forget you have IV bags available
• Remove and only replace the drapes after ensuring there is no fire on or under the patient
• Have a plan for what to do with burning drapes
• Know where the fire extinguishers are in your OR/periop area area
• Know how to use the fire extinguishers.
• Be suspicious that the obvious fire you see is not the only fire. Check UNDER the drapes and UNDER the patient.

The American Society of Anesthesiologists’ algorithm for Operating Room Fire can be found here. [4]

Practice for OR Fire

Practice fire drills with the anesthesia/OR/perioperative staff. Include fire training with simulator practice. Send staff on scavenger hunts to find the fire extinguishers. Don’t wait for the fire emergency to figure it out. I have seen trainees in drills remove the practice burning drapes and throw them into the corner waste bin, where they could easily continue to burn and ignite the room. Make those sorts of mistakes in practice to avoid them in real life.

OR fire can happen in an instant, with devastating consequences for the patient and the staff caring for her/him. We must be vigilant and prepared. For a discussion of other anesthetic airway complications see:

• Boredom Interrupted: 10 Causes of Airway Complications and How To Avoid Them

May The Force Be With You

Christine E Whitten MD, author
Anyone Can Intubate: A Step-By-Step Guide
and
Pediatric Airway Management: A Step-By-StepGuide

References

1. Culp WC Jr, Kimbrough BA, Luna S. Flammability of surgical drapes and materials in varying concentrations of oxygen. Anesthesiology. 2013;119:770-776.
2. Akhtar N, Ansar F, Baig M, et al. Airway fires during surgery: management and prevention. J Anaesthesiol Clin Pharmacol. 2016;32(1):109-111.
3. Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires: a closed claims analysis. Anesthesiology. 2013;118:1133.
4. American Society of Anesthesiologists Task Force on Operating Room Fires. Practice advisory for the prevention and management of operating room fires. Anesthesiology. 2008;108:786-801.