As anesthesiologist Carol A. Hirshman, MD, found out nearly 25 years ago, the risk of OR fires is present whenever and wherever surgery is performed. "One of the scariest things to happen to me in an OR," is how Dr. Hirshman describes the moment the cuff of the tube exploded and an airway fire broke out during a routine CO2 laser removal of papilloma lesions from a teenage boy's throat. "It was wrapped with foil, but somehow the inside of the tube caught fire and burned."

The boy would recover, but the incident still haunts Dr. Hirshman. "It was very fortunate that the child was all right. Awareness is the key. You have to make sure people understand that [surgical fires] are a possibility. Once you know, you can be more careful," she says.

Just last month, Abbott Laboratories sent 50,000 anesthetists a letter warning of possible fire or extreme heat in the respiratory circuit of anesthesia machines when Ultane (sevoflurane) is used with a desiccated CO2 absorbent (see "Fires Prompt Warning, Ultane Label Change" on page 12).

A hundred or so surgical fires occur annually, estimates ECRI, a health-services research agency in Plymouth Meeting, Pa. The most common ignition sources for surgical fires are electrosurgery (68 percent), cautery (hot wire), light sources and bur sparks(19 percent), and laser (13 percent). Surgical fires most often occur in the airway (34 percent) or in the face, head, neck and chest (28 percent). Thirty years ago, when such flammable anesthetic gases as ether or cyclopropane were used for surgery, fire precautions were commonplace. Prevention methods included maintaining proper humidity in the OR to prevent static buildup, and using anti-static surgical-table mat covers and anesthetic gas scavenging systems that trap and dispose of exhaled gases.

"Once we got rid of flammable anesthetics, there's nothing we can do technically," says Mark Bruley, ECRI's vice president of accident and forensic investigation. "We can't get rid of lasers, O2, N2O, fuels - and we can't make fuels non-flammable. Drape manufacturers simply can't make fireproof drapes."

The elimination of flammable anesthetic gases was a step toward preventing surgical fires. But the development of electrosurgical units, lasers and cautery units provides more potential ignition sources. In addition, tubes, drapes and gowns are flammable - they are fuel sources -in the often oxygen-enriched environment set up by outpatient surgery.

"Conscious sedation and local anesthesia are on the rise," says Mr. Bruley. "But when you're doing conscious sedation, the patient is breathing on his own, and usually there's the unquestioned application of 100 percent oxygen on the face, which sets up an environment ripe for fire."

The fire triangle
A confluence of three factors, the so-called fire triangle, is responsible for surgical fires:

• Oxygen. Consider that 74 percent of flash fires are related to an oxygen-enriched atmosphere and that flash fires only occur at about 50 percent oxygen concentration and above. "Eliminate oxygen-enriched fires, and you eliminate 75 percent of the problem," says Mr. Bruley, who suggests that you question the need for open-flow supplemental oxygen on a patient before the procedure and, if needed and consistent with patient needs, keep the open oxygen concentration delivered to a patient to 30 percent during a procedure.

  "CRNAs and anesthesiologists have been applying 100 percent oxygen without question," says Mr. Bruley. "If 100 percent oxygen is needed, then fine. But you should question whether it's necessary. If you can keep the patient's blood oxygenation at 97 or 98 percent while giving less than 100 percent oxygen or even with room air, then do it. You're providing the appropriate therapy and monitoring while minimizing the risk of fire."

• Fuel. Fuel for fire is ever-present in the OR. Just think of what you place on the patient - drapes, gowns and prepping agents. There's also the patient.

  "If there's a spark, each of the fine hairs on the nose and forehead can burst into flame and set the one next to it on fire," says Mr. Bruley. "It spreads like a ripple of flame and will ignite towels and drapes."

  While excess oxygen is responsible for 75 percent of surgical fires, alcohol-based prepping solutions are at fault for the other 25 percent, says Mr. Bruley. Taking care during the prepping process can reduce the risk of fire. "Sloppy prepping can wet hair, the pillow and the linens," he says. "Alcohol will continue to evaporate and result in an alcohol-vapor mix under the drapes, and it will spark if it wafts into the surgical site."

• Ignition sources. Electrosurgical units, lasers, cautery units, light sources and bur sparks ignite fuels in oxygen-enriched environments, so it's important for these instruments to be handled with extreme caution.

  ECRI recommends completing all cable connections before activating a fiberoptic light source and placing it in standby mode when disconnecting cables. During electrosurgery, electrocautery or laser surgery, ECRI recommends activating such units only when the active tip is in view (especially when using a microscope) and deactivating the unit before the tip leaves the surgical site. When not in active use, electrosurgical electrodes should be placed in a holster and lasers should be set to standby. In addition, use common sense. "For instance, don't cauterize without letting the alcohol prep dry first," says Mr. Bruley.

Pre-emptive solutions
According to ECRI statistics, 80 percent of fires are minor, with no patient injury. About 10 to 20 percent are serious, causing serious burns or disfigurement. Surgical fires cause one two deaths per year, almost exclusively the result of tracheal tubes igniting.

For an event that can have such serious consequences, then, "prevention is best," says Mr. Bruley.

• Education. At a 1991 ASA conference at Washington Medical Center, a committee of surgeons, nurses, anesthesiologists, biomedical engineers and manufacturers of surgical drapes was convened. The conclusion they came to: We can't fix this with devices. "Education was the only fix they could come up with," says Mr. Bruley. This starts with buy-in from those in charge, especially administration and the directors of surgery, anesthesia and nursing.

  Then, they must take charge to educate the facility's nurses, physicians, techs, anesthesiologists - everyone on the surgical team - with an active, ongoing program that takes clinical and risk-management factors into account.

  Mr. Bruley advocates educating new staff on surgical fires when they are oriented and putting the rest of the staff through refreshers annually. Lectures, videos and written materials are a start, but staff should also interact. Instead of training nurses and physicians separately, train them together and let them discuss the best strategies for surgical fire prevention. This can help you develop and update your facility's policies and protocol.

• Protocols/policies. Develop and document protocols and policies for prevention of surgical fires - and for handling them if a surgical fire were to break out. A poster on surgical fire prevention is available at ECRI's clinical free Web site, Medical Device Safety Reports, at www.mdsr.ecri.org.
• OR setup. "Some people advocate having a fire blanket, fire extinguisher and alarm in the OR in case of a surgical fire," says Mr. Bruley. "But you just won't have time for that, and some of it's just not appropriate." Mr. Bruley says a fire blanket should not be used in the event of a surgical fire. First of all, it, too, will burn if the oxygen is still flowing. Second, it may push a sharp instrument into the patient's body. And third, it may simply trap the fire next to the patient, causing more severe burns. Overall, says Mr. Bruley, fire blankets have no place in the OR setting and should not be in ORs.

  In addition, in some cases, a fire extinguisher may not be a good idea.

  "Once, during a full craniotomy, a patient caught fire due to a misfire of a laser," says Mr. Bruley. "They used a dry-chemical fire extinguisher and sprayed everything, including the brain, with chemical dust."

  Instead, ECRI recommends having a five-pound CO2 fire extinguisher - mounted just inside the OR door - because, if you do need to use an extinguisher, it won't leave unwanted residue in the wounds. "You might also want to have a basin of water with wet towels handy to use at the surgical site in case of a fire," says Mr. Bruley.

• Communication. The most important factor to surgical-fire prevention can also be the most difficult. "Underneath all the policies, procedures and systems is communication," says Mr. Bruley.

  Surgical fires cross the boundaries of three professional specialties: Generally speaking, the surgeon wields the ignition source, the anesthesiologist controls the oxygen and the nurses have some responsibility for the fuels, such as alcohol-based prepping agents and drapes. So who initiates communication in the OR?

  "The oxygen is administered by anesthesia, so it's not unreasonable to expect that the anesthesiologist should start the conversation if open oxygen is to be delivered," says Mr. Bruley. "Then again, the surgeon is the one wielding the ignition source, and he or she may see that open oxygen is in use on the face and raise appropriate fire-prevention questions. The nurse may realize the patient isn't draped properly or that a flammable prepping agent has run off and wetted surgical-table linens.

  "At this point, it's just splitting hairs to figure out who has the power to start the conversation. It just needs to be started."

  Mr. Bruley draws an analogy with another low-incident, high-adversity medical error: wrong-site surgery.

  "In the past if a nurse or anesthesiologist felt uncomfortable about what surgery was going to be done or where on the body it was going to take place, they may have felt intimidated to speak up, based on the dynamics of the OR," he says. "But with increased awareness, that dynamic has changed."

If the patient is on fire
In the event of a small fire on the patient, immediately pat out or smother small fires or remove burning material from the patient, recommends ECRI. In the event of a large fire on the patient, immediately:

1. stop the flow of breathing gasses to the patient;

2. remove the burning material from the patient;
? ? ?'' Have another team member extinguish the burning material.
? ? ?'' If needed, use a fire extinguisher to put out a fire involving the patient.

3. care for the patient;
? ? ?'' Resume patient ventilation.
? ? ?'' Control bleeding.
? ? ?'' Evacuate the patient if the room is dangerous from smoke or fire.
? ? ?'' Examine the patient for injuries and treat accordingly.

4. if not quickly under control, notify other OR staff and the fire department that a fire has occurred; and

5. isolate the room to contain smoke and fire.

Tracheal tube fires
At the first sign of a tracheal tube fire, immediately:

1. disconnect the breathing circuit from the tracheal tube;

2. remove the tracheal tube; and
? ? ?'' Have another team member extinguish it.
? ? ?'' Remove cuff-protective devices and any segments of burned tube that may remain smoldering in the airway.

3. care for the patient.
? ? ?'' Re-establish the airway and resume ventilating with air until certain that nothing is left burning in the airway; switch to 100 percent oxygen.
? ? ?'' Examine the airway for the extent of the damage and treat the patient accordingly.

One final note: Always save involved materials and devices for later investigation.

Future of surgical fires
JCAHO considered designating surgical-fire prevention a patient-safety goal, says Mr. Bruley, but opted this summer to add an infection-control goal to the 2004 list (bringing the total to six) and issue a sentinel event alert in June instead. Mr. Bruley and ECRI worked with JCAHO to craft the alert, which boils ECRI's fire-prevention poster down to three recommendations:

• Administration should inform staff about the importance of fire-safety practices in the OR and should establish guidelines for managing oxygen under the drapes. In addition, clinicians should manage fuels and ignition sources.
• Healthcare facilities should develop procedures to ensure proper education for staff in the OR.
• All incidents of surgical fires should be reported to JCAHO.

"No one has done a detailed data study," says Mr. Bruley. "But based on the general information about the number of fires and what's been published by JCAHO about the number of wrong-site surgeries, it's valid to suggest that the number of wrong-site surgeries is the same as the number of surgical fires. And surgical fires deserve no less attention. So [preventing surgical fires] isn't a patient-safety goal yet, but JCAHO has recognized it as a valid issue."