**3. Clinical vignette #2**

Although all ORFs should be potentially preventable, their rarity combined with relatively more focus on other OR complications contribute to knowledge gaps and inconsistent approaches to stop these "never events" [4, 5]. Institutions must overcome common misunderstandings about risk factors associated with ORFs including the misconceptions that fires are largely nonpreventable, staff is appropriately trained in fire safety and aware of critical actions required in an ignition event, and fires do not happen at institutions with well-devel-

The abovementioned fallacies must be actively countered at all levels of the establishment from the executive suite to the equipment maintenance staff. Continuous education, including didactic sessions, web-based self-assessment activities, multimedia materials, and readiness drills, form the foundation of organizational excellence that is based on the combination of high performing teams, well-designed safety protocols, and zero tolerance for complacency [6, 7]. When implementing and disseminating information about operating room fire safety, all stakeholders must be actively engaged, including nursing staff, surgical technologists, anesthesia professionals and surgeons. As with other forms of patient safety events, effective communication is essential in both prevention and management of ORFs [8]. It is also important to note that the healthcare environment is inherently more prone to fires than other nonindustrial workplace environments, primarily due to the coexisting use of flammable materials and surgical energy sources [8]. As such, other locations within hospitals may be at elevated risk of procedure-related fires, including the emergency department, labor and delivery, and endoscopy suites [9]. In this chapter, we present two realistic clinical vignettes describing ORFs. Detailed discussion of risk factors,

preventive strategies, fire preparedness, and post-event management then follows.

Mr. "A" is a 65-year-old male admitted to a local Ambulatory Surgery Center for a minor surgical procedure. He has cervical lymphadenopathy and is scheduled for excisional biopsy of a palpably enlarged right-sided cervical lymph node. After all preoperative medical and safety checks are completed, Mr. "A" is escorted into the OR and positioned supine. General anesthesia is induced after an uneventful endotracheal intubation. The surgical resident assisting with the procedure preps the patient's neck, shoulder and chest using alcohol-containing chlorhexidine solution. Soon after, the surgical site is draped with sterile surgical cotton drapes. An incision is made over the enlarged lymph node, and subcutaneous tissue is exposed. Electrocautery is then introduced into the field for hemostasis and surgical dissection around the enlarged lymph node. Immediately following electrode activation, a flame ignites and rapidly spreads over the surgical field prepped with chlorhexidine. The surgeon in charge immediately removes the drapes, the electrocautery is switched off, the fire is extinguished within seconds, and the lymph node biopsy procedure is aborted. The patient suffers from first degree burns over his neck and chest. His recovery is complete, although he requires another trip to the OR for completion of his

oped cultures of safety [2].

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**2. Clinical vignette #1**

lymph node biopsy.

Mrs. "W" is a 75-year-old female, admitted to the intensive care unit (ICU) for severe pneumonia. She subsequently developed respiratory failure and was unable to successfully wean from mechanical ventilatory support. Consequently, she was scheduled for a tracheostomy due to anticipated prolonged need for mechanical ventilation. On the morning of surgery, the patient was transferred directly from the ICU to the OR, with required preoperative safety checks performed at her bedside in the ICU.After the anesthesiologist administered total intravenous anesthesia, the surgical intern prepped and draped the patient's neck in the usual sterile fashion. The surgeon proceeded to perform a transverse incision above the suprasternal notch and dissected down to the trachea using a combination of sharp (scissors) and blunt techniques. The trachea was subsequently exposed and, with appropriate anesthesia (lowering of inspired oxygen concentration) and surgical team (abstinence from electrocautery) precautions, incised sharply. Without consulting the attending surgeon, the surgical intern suddenly noticed significant amount of bleeding in the area of the retracted strap muscles and proceeded to use coagulating diathermy to secure hemostasis. Immediately following the use of diathermy, a loud noise was heard and a large flame burst from the tracheal stoma. Ventilation was immediately stopped, the anesthesia circuit was disconnected from the tracheal tube, and the fire rapidly extinguished using normal saline administered through the endotracheal tube. Without delay, the surgeon gained access into the trachea with a tracheostomy cannula and once the positioning of the tracheostomy device was confirmed, the endotracheal tube was removed. The endotracheal tube was notably burned, with carbonized plastic material visible in the distal portion. The patient suffered superficial thickness burns around the stoma site. Fiberoptic bronchoscopy demonstrated minimal burn injury around the tracheostomy site and the proximal airway. Fortunately, the patient recovered without other major complications and was discharged from the hospital to rehabilitation facility after successful tracheostomy decannulation 2 weeks later.

#### **4. Risk factors for fire in the operating room**

Key risk factors for ORF should be well known to all OR team members, should be included as standard parts of staff educational curriculum, and should be readily identified whenever present (alone or in combination) [10, 11]. According to Apfelbaum *et al*., prevention of ORFs begins with minimizing patient exposure to the presence, alone or in combination, of "oxidizer-enriched atmosphere," potential ignition source(s)/surgical energy device(s), flammable liquids (e.g., alcohol-based surgical prep), and other potentially flammable materials (e.g., paper or plastic drapes) [12]. Mandych and his group reported an intraoperative fire that occurred during tracheostomy placement for a patient who had an unresectable lingual carcinoma [13]. When attempting to recreate the circumstances of the fire under laboratory conditions, they found that electrocautery did not ignite any towels, sponges, or other materials without the presence of oxygen. The authors concluded that an "ignition source," a "combustible agent," and oxygen were necessary for a fire to occur. Interestingly, they also cited the organic gases which emanated from the necrotic tumor to be a potential source of combustible

#### **Risk factors for operating room fires**

#### **Ignition sources**


#### **Fuel sources**


#### **Oxygen sources**


Risks are grouped by their primary category of "ignition source," "fuel source," and "oxygen source."

**Table 1.** Listing of major risk factors for operating room fire.

material [13]. Ladas and colleagues have also cited the potential for colonic gas explosion, though arguably this is a very rare scenario and preventive measures seem limited. In their review, they found 11 cases of colonic gas explosion during surgery and nine cases during colonoscopy. Looking back to the 1980s when mannitol was used as the most common bowel prep agent, colonic aspiration evaluation revealed a high concentration of hydrogen in the colon secondary to the mannitol's fermentation by *E. coli*. Though mannitol has largely gone by the wayside, there are still polyethylene glycol solutions with sorbitol, which, if the sorbitol is malabsorbed, can result in formation of combustible gases due to the same fermentation process [14]. Not only is this the case, but sorbitol is present in one's daily diet and malabsorption of sorbitol has been found in up to 60% of normal, healthy patients [15].

was used, there was no resultant fire; (3) in the absence of closed spaces where oxygen or vapor from the prep solution could gather, there was no fire. In this context, the authors found

**Figure 1.** Components of the "fire triangle" that interact to create conditions ultimately responsible for various degrees

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Overview of major risk factors for ORF, grouped according to specific risk contribution, is provided in **Table 1** and **Figure 1**. Additionally, when considering and conducting the assessment, consideration of the delivery method of oxygen is a critical component. The use of a laryngeal mask airway or an endotracheal tube reduces the risk of fire by decreasing the oxy-

From procedure-based standpoint, operations can be categorized as "general risk" or "highrisk" for ORF [12, 18]. For "general risk" procedures, such as abdominal hernia repairs, any flammable skin-prepping solutions should not be allowed to pool and must be dry before the placement of surgical drapes [19]. Assurance of the same is required before using any surgical energy devices (e.g., electrocautery or laser) [19, 20]. In addition, surgical drapes should be applied in a manner that prevents oxygen from flowing into the surgical site or pooling near

that the concentrations of oxygen under drapes could be as high as 50% [16].

of risk for operating room fire.

gen concentration under the drapes and in the patient's upper airway [17].

A rather thorough set of experiments were performed by Barker and Polson after a 73-yearold man's case of bilateral burr holes for evacuation of subdural hematomas ended up in an OR fire. Having experienced this, the group decided to embark on laboratory simulations using a nonflammable plastic manikin and concluded the following: (1) even without oxygen, paper drapes could be ignited by the electrocautery knife, but that fire was slow-burning and self-resolving; (2) when 5-min drying time was implemented, or if no alcohol based solution Avoiding Fire in the Operating Suite: An Intersection of Prevention and Common Sense http://dx.doi.org/10.5772/intechopen.76210 165

**Figure 1.** Components of the "fire triangle" that interact to create conditions ultimately responsible for various degrees of risk for operating room fire.

material [13]. Ladas and colleagues have also cited the potential for colonic gas explosion, though arguably this is a very rare scenario and preventive measures seem limited. In their review, they found 11 cases of colonic gas explosion during surgery and nine cases during colonoscopy. Looking back to the 1980s when mannitol was used as the most common bowel prep agent, colonic aspiration evaluation revealed a high concentration of hydrogen in the colon secondary to the mannitol's fermentation by *E. coli*. Though mannitol has largely gone by the wayside, there are still polyethylene glycol solutions with sorbitol, which, if the sorbitol is malabsorbed, can result in formation of combustible gases due to the same fermentation process [14]. Not only is this the case, but sorbitol is present in one's daily diet and malabsorp-

Risks are grouped by their primary category of "ignition source," "fuel source," and "oxygen source."

A rather thorough set of experiments were performed by Barker and Polson after a 73-yearold man's case of bilateral burr holes for evacuation of subdural hematomas ended up in an OR fire. Having experienced this, the group decided to embark on laboratory simulations using a nonflammable plastic manikin and concluded the following: (1) even without oxygen, paper drapes could be ignited by the electrocautery knife, but that fire was slow-burning and self-resolving; (2) when 5-min drying time was implemented, or if no alcohol based solution

tion of sorbitol has been found in up to 60% of normal, healthy patients [15].

• Flammable prepping agents including tinctures (chlorhexidine, thiomersal, iodophor)

**Risk factors for operating room fires**

164 Vignettes in Patient Safety - Volume 3

• Electrical hemostatic devices

• Fiberoptic light sources and cables

• Drapes, towels, surgical sponges, dressings

**Table 1.** Listing of major risk factors for operating room fire.

• Electrosurgical and electrocautery units

**Ignition sources**

• Defibrillators • Flexible endoscopes • Sparks from surgical drills

**Fuel sources**

• Gowns, hoods, masks

**Oxygen sources** • Oxygen (O2

• Nitrous Oxide

• Mattresses, pillows, blankets • Patient hair (face, scalp, body)

)

• Lasers

was used, there was no resultant fire; (3) in the absence of closed spaces where oxygen or vapor from the prep solution could gather, there was no fire. In this context, the authors found that the concentrations of oxygen under drapes could be as high as 50% [16].

Overview of major risk factors for ORF, grouped according to specific risk contribution, is provided in **Table 1** and **Figure 1**. Additionally, when considering and conducting the assessment, consideration of the delivery method of oxygen is a critical component. The use of a laryngeal mask airway or an endotracheal tube reduces the risk of fire by decreasing the oxygen concentration under the drapes and in the patient's upper airway [17].

From procedure-based standpoint, operations can be categorized as "general risk" or "highrisk" for ORF [12, 18]. For "general risk" procedures, such as abdominal hernia repairs, any flammable skin-prepping solutions should not be allowed to pool and must be dry before the placement of surgical drapes [19]. Assurance of the same is required before using any surgical energy devices (e.g., electrocautery or laser) [19, 20]. In addition, surgical drapes should be applied in a manner that prevents oxygen from flowing into the surgical site or pooling near the operative field [12, 21]. Finally, surgical gauzes and sponges should be moistened when used in proximity to any potential source of ignition [22].

common types of items and categories within the "fire triangle" paradigm. Although beyond the scope of the current discussion, it is also important to mention that non-anesthetic causes of ORFs have been reported, including flammable gastrointestinal gases (mentioned earlier in the

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The final component is an oxidizer [38]. Although most people realize that oxygen greatly enhances the rate of combustion, many do not know that nitrous oxide supports combustion in roughly similar manner. Oxidizers reduce the fuel ignition temperature, thus elevating the

In an event of a fire, healthcare facilities commonly employ the "rescue-alarm-confine-extinguish" or RACE protocol [40, 41]. All team members, regardless of assigned function or seniority, should be aware of the location of pertinent emergency equipment, including the "fire alarm" trigger, fire extinguisher, and phone/extension to be used for notification [42]. Within the OR environment, additional considerations may need to be taken into account, depending on specific circumstances, such as whether the fire involves the patient. Scenarios involving the patient (both cutaneous and within the airway) and those without patient involvement will now be discussed. If the fire directly involves the patient, the initial steps should involve extinguishing the flames and removing any burning material from the patient [2, 43]. Simultaneously, other team members should be tasked with initiating the established "fire response" protocol, including alarm notification, personnel evacuation, removal of flammable materials from the vicinity of the fire, as well as using fire extinguisher to contain and put out the fire [44, 45]. Alarm notification should clearly indicate the precise location of the fire and any critical information regarding the circumstances of the occurrence [42, 45]. Due to the risk of thermal injury, timing of actions and team coordination are critical. The administration of exogenous gases (oxygen and nitrous oxide) should be discontinued immediately. Once fire control is achieved, care for the patient should resume, with specific management based on the degree of danger from smoke in the area.

If the fire is not able to be immediately contained, then evacuation from the room, notification using established facility infrastructure (e.g., facility alarms, the emergency operator, and the OR operational leadership), and immediate notification of the fire department should take place. The surgeon typically recognizes the fire first and thus is involved in extinguishing and removing the fire, primarily by dousing the area with saline. Equipment immediately available in the event of an ORF includes ample supply of sterile saline or water; a "carbon dioxide" or a "water mist" fire extinguisher; replacement tracheal tubes, guides, and facemasks; rigid laryngoscope equipment; sponge and drape sets ready for rapid re-deployment; replacement ventilator circuits, tubes, and lines [2]. Because many drapes are waterproof, it is important for saline to cover all burning areas. If saline is not available, moist surgical towels draped across the operator's forearms may be used to smother the flames, with a sweeping motion away

from the patient's airway. Of note, patting a fire may cause the flames to worsen [46].

During tracheostomy placement and other tracheal procedures, the fire may directly involve the patient's airway [47]. Although rare, this type of event can be fatal [48]. Due to its anatomic location, fire in the tracheobronchial tree is approached differently compared to other

chapter) [35, 36] and surgical lights [37].

risk of a fire and its continued propagation [39].

**7. Fire containment: strategies and procedures**

Examples of "high-risk" procedures include tracheostomy creation (e.g., direct exposure of surgical field to highly concentrated oxygen) or maxillofacial/head and neck surgery (e.g., close proximity between the endotracheal airway and surgical energy source) [23–25]. For such "high-risk" procedures, where proximity exists between an oxidizer and an ignition source, special caution is required by the entire OR team, including close communication and coordination between the surgeon and the anesthesiologist, as well as the use of operating field suctioning to scavenge any excess oxygen [12]. This is demonstrated well in our Clinical Vignette #2, where both the surgeon and the anesthesiologist took immediate and appropriate course of action. In addition to avoiding/limiting the use of nitrous oxide, the concentration of oxygen being delivered to the patient should be minimized, preferably based on close monitoring of patient oxygenation (e.g., pulse oximetry, and if possible tracking of inspired/expired/delivered oxygen concentration) [12].

The use of surgical laser equipment in a high-risk area (e.g., head and neck, trachea) should be done in the presence of laser "resistant" tracheal tubes, intended specifically for a given procedure and type of laser [12, 26, 27]. For any operative work requiring surgical energy application within the airway, reduction in oxygen or nitrous oxide concentration is thought to be safe for anywhere between 1 and 5 min at a time [12]. The same applies to procedures involving immediate proximity of the oxidizer and surgical energy source in the setting of nasal cannula or face mask [12]. Surgical suction should be utilized to scavenge oxygen or nitrous oxide from the oropharynx during cases involving this anatomic area [26].
