Fires in the operating room

by Yale D. Podnos, Irvine, CA, and Russell A. Williams, MD, FACS, Orange, CA

Each year there are an estimated 27 million surgical operations in the United States alone.1 Despite the many precautions taken in the operating room, there are substantial risks of injury to the patient and health care provider. These hazards include exposure to a patient's infectious bodily fluids, low back injury, harm from tools (manual and power), and burns from electrocautery and other electrical equipment. However, few situations in the operating room are more terrifying for the patient and surgical staff than an unexpected fire.

In the United States, there are approximately 2,260 reported hospital fires per year, resulting in about one death and 130 injuries.2 Of these, between 20 and 30 occur in the operating room.3 Historically these figures were much higher. The incidence of fires in the operating room has substantially decreased over the past 40 years, as flammable anesthetic use has diminished and the awareness of situations predisposing to fires starting has increased.

Fire causes

For any fire to occur, three factors must be present. These are an oxygen source, a fuel source, and an ignition mechanism. In the operating room these are all abundantly available.

The use of additional oxygen in the operating room makes it an oxygen-rich environment, priming the arena to fires of greater intensity than those without oxygen supplementation.4 The additional sources of oxygen can include that from nasal cannulae, nebulizers, and oxygen cylinders. To diminish the possibilities of a fire in the operating room, extreme care must be used to contain any oxygen source and keep it from an ignition source.

The use of the lowest possible inspired oxygen concentration that still ensures adequate oxygen saturation is an effective means of controlling excess oxygen accumulation. Another effective means is administering oxygen along with a nonflammable gas such as helium or nitrogen. Nitrous oxide, historically used by anesthesiologists, should not be used to dilute oxygen because it does not improve the safety of delivered oxygen. It too can serve as an oxidizing agent, further propagating fires.

There are a variety of possible sources that can serve as fuel for fires in the operating room, some relatively obvious and others more obscure. More obvious sources include paper and cloth drapes, antiseptic skin agents, endotracheal tubes, and other breathing apparatuses such as nasal cannulae and plastic masks. Cloth and paper drapes are by far the most implicated fuel for fires and have been shown to be ignitable by such common operating room utensils as electrocautery.5

This hazard has been heightened by the increased use of disposable drapes. While less expensive and more water-resistant than traditional draping, disposable drapes burn more readily. Although often treated with flame retardant materials, once ignited the flames spread with alarming speed.4 In 1983, a case was described in which disposable paper drapes treated with flame retardant chemicals were ignited by a defective electrocautery device during a laparoscopic operation. After failing to extinguish the fire, the surgical staff removed the drapes from the patient. The drapes became totally engulfed by fire within two minutes, filling the operating room with smoke and forcing its evacuation. The procedure was quickly moved to another theater and completed. However, the patient suffered second-degree burns of the hand and third-degree burns of the thigh.6

Antiseptic skin agents, particularly those with alcohol bases, are also flammable. Studies have shown that solutions in 70 percent alcohol will ignite in temperatures of 900[deg] C and only become nonflammable in concentrations less than 20 percent. Those in aqueous solution will ignite at temperatures above 1000[deg] C.7 These temperatures are often reached with lasers and with some electrocautery devices. Betadine solution (10% povidone-iodine) also is flammable and is not recommended for the cleaning of skin in the presence of an ignition source.4 Solutions containing iodine have been shown to explode in the presence of high oxygen or nitrous oxygen concentrations.7

Endotracheal tubes can also serve as a source of fuel to a potentially devastating fire. They can be made of silicone, plastic, red rubber, and metal. Only those of metal are nonflammable. What makes endotracheal tubes so dangerous is the close proximity the tubing inherently has to high concentrations of oxygen. This particular hazard is illustrated by a 1991 case in which a fire occurred during a tracheotomy after the patient was intubated and the lungs were ventilated with 100 percent oxygen. The surgeon used electrocautery for coagulation while entering the trachea. The tracheal tube ignited with an explosion. Oxygen delivery was discontinued and the tube pulled. The tube was melted and perforated. Bronchoscopy revealed charring of the trachea near the site of explosion but little other damage to the airway.8

Whereas the majority of the fires occurring in the operating room have involved the aforementioned fuels, there are a variety of less obvious substances that can ignite and become equally as catastrophic. These include dermatome glue used in the harvesting of skin grafts, lanugo, and gastrointestinal gases.9 Lanugo, the fine hair that covers most bodily surfaces and is found predominately on the face, is easily ignitable. Once burning, the fire can propagate at speeds between two and 10 feet per second. Covering these hairs with a water soluble lubricant can prevent these fires.10

Hydrogen and methane are extremely flammable gases produced by bacteria in the gastrointestinal tract in quantities of up to 200 ml per day.4 Forty percent of these gases are contained in the large bowel. Human flatus contains approximately 44 percent hydrogen and 30 percent methane.11 If in an environment of at least 5 percent oxygen, hydrogen can explode at concentrations of between 4 percent and 72 percent, while methane can explode at concentrations of between 5 percent and 15 percent. In the colon the concentration of oxygen is approximately 5 percent, but this level is increased when oxygen or nitrous oxide is administered during anesthesia.12 The use of mannitol to cleanse the bowel has also been shown to markedly increase the concentration of hydrogen in the colon.13 In addition, patients with medical conditions often requiring an operation, such as pyloric stenosis or intestinal obstruction, commonly have large amounts of gastrointestinal gas in their intestines as a result of stasis and bacterial overgrowth.14 These gases may be liberated during abdominal operations due to accidental perforation of bowel and can become the fuel source for intra-abdominal ignition.

Of course, for a fire to start there must be an ignition mechanism. There are many such potentials in the operating room. As mentioned previously, electrocautery (monopolar, bipolar, and battery-operated) units are renowned culprits. The temperature at the tip of the cautery unit can reach several hundred degrees, easily enough heat to start a fire.15 Other sources include lasers, overhead and fiberoptic light sources,16 drills, and burrs.15 The temperature at the distal end of a fiberoptic light source can reach levels well above the ignition temperature of most surgical drapes.17

Lasers are a particularly potent ignition mechanism for operating room fires. They create small areas of intense heat that can burn through anything in their path. Lasers have been reported to ignite throat packs, swabs, tracheal and tracheotomy tubes, clothing, and patient hair.18 The laser may also be reflected by surgical equipment such as forceps or other metallic instruments, creating fire hazards in many more unexpected places in the operating theater.

Safety in the OR

With all of the ways a fire can start in the operating room, meticulous care must be taken to ensure safety. It is the primary responsibility of the surgeon and anesthesiology staff to coordinate and control any possible hazards. However, all surgical staff must be trained in fire prevention and extinguishing.

All of the safety methods aim at keeping the fuel source, ignition mechanism, and oxygen separate. The best method of fire prevention is to trust one's own intuition. However, certain guidelines have been put forth.17 These include:

• Keep the electrocautery tip in the holster when it is not being used.
• Have power going to high-intensity light sources only when they are being used.
• Use only appropriately protected endotracheal tubes when operating near the trachea.
• Use air or air and oxygen mixtures in anesthetic gases.
• Avoid tenting of surgical drapes in a fashion that allows accumulation of oxygen or other flammable gases.
• Use water-soluble rather than oil-based substances to cover lanugo and other flammable parts on the body.
• Use fire-retardant surgical drapes.

In case of a fire, all persons in the operating room should know the location of fire extinguishers and how to use them. Fire alarm pull stations and emergency exits should be conveniently situated to facilitate orderly evacuation and extinguishing. Every attempt should be made to disrupt either the oxygen or fuel source. The anesthesiologist should turn off any supplemental oxygen or nitrous oxide, ventilate the patient with room air, and use intravenous agentsto maintain anesthesia.

Conclusion

With adequate knowledge of the factors precipitating operating room fires and sound plans regarding evacuation and extinguishing, injuries from these situations can be avoided. Fire safety translates into decreased morbidity and mortality for patients and staff. Inaddition, fewer hours of labor and operating room time will be lost, leading to better operating room productivity and efficiency.

References

1. Duensing RA, Mueller GP, Williams RA: Hazards in the operating room. In: Critical Issues in Operating Room Management. Lippincott-Raven Publishers: Philadelphia, PA, 1997.

2. Federal Emergency Management Agency, United States Fire Administration: NFIRS Data. FEMA, USFA: Emmitsburg, MD, 1993.

3. Eade GG: Hazard of nasal oxygen during aesthetic facial operations [letter]. Plast Reconstr Surg, 78:539, 1986.

4. MacDonald AG: A brief historical review of nonanaesthetic causes of fires and explosions in the operating room. Brit J Anaesth, 73:847-856, 1994.

5. Milliken RA, Bizzarri DV: Flammable surgical drapes: A patient and personnel hazard. Anesth Analgesia, 64:54-57, 1985.

6. Ott AE: Disposable surgical drapes: A potential hazard. Obst Gyn, 61:667-668, 1983.

7. Briscoe CE, Hill DW, Payne JP: Inflammable antiseptics and theatre fires. Brit J Surg, 63:981-983, 1976.

8. Aly A, McIlwain M, Duncavage JA: Electrosurgery induced endotracheal tube ignition during tracheotomy. Ann Otol, Rhinol, Laryngol, 100:31-33, 1991.

9. Demos JE: Fire in the operating room. Plast Recon Surg, 95:419-420, 1995.

10. Emergency Care Research Institute: The patient is on fire: A surgical fires primer. Hlth Devices, 21:19, 1992.

11. Kirk E: The quantity and quality of human colonic flatus. Gastroenterology, 12:782-794, 1949.

12. Bonnet YY, Haberer JP, Schutz R, et al: Explosion des gas intestinaux en cours d'operation. Ann Francaises D'Anesthesiologie et de Reanimation, 2:431-435, 1983.

13. Avgerinos A, Kalantzis N, Rekoumis G, et al: Preparation and the risk of explosion during colonoscopic polypectomy. Gut, 25:361-364, 1984.

14. Galley AH: Combustible gases generated in the alimentary tract and other hollow viscera, and their relationship to explosions occurring during anaesthesia. Brit Med J, 26:189-193, 1954.

15. Chang BW, Petty P, Manson PN: Patient fire safety in the operating room. Plast Reconstr Surg, 93:519-521, 1994.

16. Eisenbaum SL: Facial burns as a complication of office surgery lighting. Plast Reconstr Surg, 83:155, 1989.

17. Norris JL: Fire safety in the operating room. J Am Assoc Nurse Anesth, 62:342-345, 1994.

18. Sosis MB: Anaesthesia for laser. Int Anesthes Clin, 28:119-131, 1990.

Mr. Podnos is a medical student at the University of California College of Medicine, Irvine.
Dr. Williams is professor of surgery, University of California at Irvine Medical Center, Orange, CA. He is also a member of the ACS Committee on the Operating Room Environment.

__________

Reprinted from the Bulletin of the American College of Surgeons
Vol. 82, Number 8
August 1997

Readings on Perioperative Care Issues

Committee on Perioperative Care