Seven of 10 OR fires occur at the head, neck or upper chest during cases involving oxygen delivery under monitored anesthesia care. Eliminating oxygen-enriched atmospheres — which increase the flammability of drapes, plastics and hair — is a great way to prevent surgical fires. Let's review the risks of each of the fire triangle's components: oxidizers, fuels and ignition sources.

Oxidizers
Oxygen-enriched atmospheres (when oxygen concentration exceeds 21% by volume) created during procedures drop the temperature at which fuels will ignite and increase the intensity and speed of a fire; higher oxygen concentrations typically coincide with higher fire risks. When performing surgeries around the head, neck and upper chest, keep the following safety precautions in mind:

• Discontinue the traditional practice of open delivery of 100% oxygen. Use only ambient air for open delivery to the face if spontaneously sedated patients can maintain their oxygen saturation levels without extra oxygen.
• If patients can't maintain safe blood oxygen saturation without supplemental oxygen, secure the airway using a laryngeal mask airway or tracheal tube so that oxygen-enriched gases do not vent under the drapes.

There are exceptions to these recommendations, however: When open delivery of 100% oxygen is required — such as when the patient's verbal responses are necessary during some vascular or neurosurgical procedures — deliver a combination of air and oxygen and consider the following options to minimize the risk of a fire:

• Always deliver the minimum oxygen concentration for adequate oxygenation. Begin cases with 30% concentration and increase as needed.
• Deliver 5L to 10L/min of air under drapes to flush out excess oxygen.
• Stop supplemental oxygen at least 1 minute before using electrosurgery, electrocautery or laser devices.
• Use an incise drape to isolate incisions from oxygen-enriched atmospheres and vapors under the surgical drapes. Arrange surgical drapes to help avoid the build-up of oxygen.
• Keep towels placed around the drape's fenestration as far away from the incision as possible to prevent them from accidentally igniting.
• Whenever possible, opt for bipolar electrosurgery over monopolar electrosurgery.
• Coat exposed facial hair with water-soluble lubricating jelly.

Ignition sources
These provide the heat energy that combines with fuel sources to spark flames.

• Keep electrosurgery handpieces in holsters or secure locations off of patients when not in active use.
• The surgeon who uses the handpiece should be the only one to activate it, and he should do so only when its tip is in his direct line of sight.
• Always use active electrode tips with sufficient insulation that are manufactured and designed specifically for that purpose.
• Disconnect contaminated active electrodes and remove them from the surgical field.
• Keep only needed footswitches within the surgical field so you don't accidentally activate unneeded devices.
• Fiber-optic light sources can also cause fires. Keep them in standby mode or turn off the light source when disconnecting cables. Never place the cables on drapes or other flammable materials.

Fuels
Such common surgical supplies as dressings and ointments can burn easily in oxygen-enriched environments. Prepping solutions are well-known culprits, although the sloppy application of alcohol-based skin preps — which results in pooling of the prep on or below the patient — causes only about 4% of fires. Always soak up and remove excess solution from the patient, remember to remove the towels you used for the clean-up and let preps dry fully before applying drapes.

It's no surprise that surgical linens — both disposable and reusable — are combustible materials. What you may not know is that flames can race across the fine nap fibers on cotton towels, reusable drapes and sheets when oxygen concentrations exceed 50%, a phenomenon called surface-fiber flame propagation.

Fanning the flames
I've been asked to investigate hundreds of surgical fires and have commented on hundreds more. Surgical professionals well versed in fire prevention express shock when sparks fly in their ORs. "I've done this procedure 5,000 times," they tell me. "Why did it happen this time?" It happened because surgery became routine, because they didn't pay attention to the small risks and warning signs they might have noticed on another day. Do you fall into that trap? Don't. Ignoring fire prevention practices, even for a second, can have devastating consequences.