Surgical fire: principles, risk factors, and prevention

Abstract

A surgical fire is potentially devastating for a patient and the best way to avoid its complications is through prevention. Although fires in the operating rooms (ORs) are rare events, they can quickly cause serious injury, disfigurement, and be fatal [1–4]. According to the Emergency Care Research Institute (ECRI), facial surgery is the second most common site of fire (tonsil is the first), and facial surgeons should be aware of potential risks of fire and explosions and how to manage injuries caused by them [5, 6]. This problem is of a similar order of magnitude as wrongsite surgery [7], and it is estimated that patients are harmed by 20% of the 550 to 700 operating room fires that are reported each year with more than 500 cases unreported or near misses [8–15], ranking as number 3 on the list of technology-related hazards in the hospital [16–18]. A US study found 17 to 20% of anesthetic malpractice claims are related to burns from surgical fires [19, 20]. Many will be minor fires causing no harm, but some may include major burns, inhalation injuries, infection, and others. It is estimated that of the surgical fires that occur, 20–30 patients are disabling or disfiguring each year in the USA and 1 or 2 are fatal [21–27]. Related adverse outcomes may include psychological trauma, prolonged hospitalization, delay or cancellation of surgery, additional hospital resource utilization, and liability [28–32]. The fire triangle (or Bfire triad^) has become the standard for diagramming the three necessary components for combustion. The triangle includes a heat or ignition source an oxidizer, and a fuel source [33–36] (Fig. 1). The surgeon’s, anesthesiologist’s, and nurse’s knowledge of the fire triad is the most important part of burns prevention in every surgical procedure [3, 4, 7, 10, 13, 22, 36–41]. As a heat or ignition source, an electrosurgical unit provides the ignition required for the fire to start in 70 to 90% of all surgical fires [42–46]. The surgeon should use the lowest possible power and there should be a safe distance from the heat and oxygen source [46]. Each element of the Bfire triad^ is essential for a fire to occur but the concentration of the oxidizer (oxygen or nitrous oxide) can also have a great importance on the fuel component of the triad [13, 19, 37]. It is unusual for a surgical fire to occur in the absence of an oxygen enriched environment [47–50]. It can happen within closed or semi-closed breathing systems, including an open oxygen sources (e.g., masks, nasal cannula) [48–51]. Oxygen supplementation via nasal cannula or oxygen mask works like the oxidizer in this exothermic reaction, which was responsible for a high oxygen concentration in the microenvironment beneath the drape’s Btent^ over the patient’s nose [52–57]. Another way to reduce this concentration is to reduce the oxygen supply from 100 to 24% and O2 supply beneath 3 l/min as a way to establish an environmental concentration (FIO2) below 30% or less, a concentration where there are no reports of this issue [38, 58]. * Paulo Renato de Paula [email protected]