Chapter 32 Operating Room Fires and Personnel Injuries Related to Sources of Ignition P.908

Al though f lammable anesthet ics have disappeared from operating rooms,

perioperat ive f i res cont inue to occur. They can have devastat ing consequences,

precipi ta te legal act ion, and take a great psychological to ll on everyone involved.

They usua lly come as a comple te surprise to the staff (1,2,3,4).

Most operat ing room fi res are o f l i t tle consequence and are not reported, making

the actual inc idence dif f icul t to determine (2,5 ,6). Approx imately 10% to 20% of

reported f i res resu lt in serious patient injury (7,8). Fuels present in the operat ing

room include plast ics tha t produce dense black smoke when ignited. The smoke

may conta in toxins and may h inder safe evacuation of the pat ient and staff f rom the

room. Sudden igni tion can present secondary problems (9). It can cause a start le

ref lex , caus ing the surgeon's hand to je rk and potentially cut into unin tended t issue

or set other a reas of the surgical s ite on fi re .

The Fire Triangle For a f i re to occur, there must be three fac tors (f ire tr iangle or triad) p resent: an

igni tion source, a fuel , and an oxid izer to support combustion together in the proper

proport ions and under the right condi t ions (Fig. 32.1).

View Figure

Figure 32.1 Three things are necessary for a fire to occur: an ignition source, fuel, and an oxidizer.

Ignition Source There are a number of igni tion sources in the operat ing room. Most are under the

surgeon's control.

Lasers The acronym laser ( l ight ampl if ication by s timulated emission of radiat ion) def ines

the process by which a form of energy is converted into l ight energy

(10,11,12,13,14,15,16). The term can also refer to the device tha t produces the

l ight or to the l ight i tself .

Lasers use a col imated, coherent, monochromatic , intense beam of electromagnetic

radiation to cut, coagulate, or vaporize tissue.

The rate that the laser energy is delivered is ca lled power and is measured in

watts . The wattage is equal to the amount of energy, measured in joules, d iv ided by

the duration of exposure measured in seconds. Laser power density is the amount

of power d istr ibu ted wi thin an area and is indicated in watts per square cent imeter.

Components of a Laser System The basic components of a laser system are two parallel mirrors encompassing the

laser medium and a power source (Fig. 32.2). In add it ion, there may be an aiming

beam for de livering laser energy tha t is outs ide the v isible range.

Laser Medium

The medium (head) holds the subs tance energized to produce laser l igh t. The

medium, wh ich may be a solid, liquid, o r gas, determines the wavelength of the

emitted radiation . The laser is named for the material used as the medium.

Power Source The power (pumping, pump, exci ta tion) source supplies energy to the laser med ium

to c reate the l ight. When the power source is act ivated, energy is absorbed by

electrons of the atoms in the laser medium, which are e levated to energy levels

above their ground state. They then decay to lower energy levels and emit photons

that are not in phase with one another and travel in all di rections.

Optical Cavity The optical (resonator) cavi ty p rov ides the envi ronment in which the laser medium

is conf ined. Energy released from the medium travels in al l di rect ions. Mirrors are

used to ref lec t and increase the energy of emission. One of the mirrors is no t 100%

ref lec tive and allows a small port ion of the l ight to escape.

Light Guide A light guide (delivery system) di rec ts the laser beam to the surgical s ite (Fig.

32.3). Fiber-optic bundles are a convenient f lex ible condui t for some wavelengths .

Other lasers ut i l ize a hol low tube wi th mirrors aligned to reflect the beam f rom i ts

source through the focusing lens .

Aiming Beam With certa in lasers, it is necessary to use a low-powered v is ib le beam as a marker.

This is usua lly a helium-neon gas laser. I t passes th rough the same optical pa th as

the laser beam.

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View Figure

Figure 32.2 Components of a laser.

Laser Types Types of med ical lasers commonly used in surgery are shown in Table 32 .1.

Laser Hazards Lasers can cause s ignif icant damage to opera ting room personne l (inc lud ing the

anesthesia provider) and the pat ient. Hazards involv ing lasers include f ires ,

atmospheric contamination, eye damage, organ or vessel perforation, and embolism

(10). Figure 32.4 shows a s ign used to warn personne l that a laser is in use.

View Figure

Figure 32.3 This is a schematic representation of a CO2 laser guide as might be found in either an operating microscope or a handheld wand. The guide consists of hollow tubes with hinged, aligned mirrors that reflect the beam from its source through the focusing lens.

A recurrent problem wi th lasers is that they may be activated when not in use

(22,23). Often, a foot switch accidentally act iva tes the laser. The laser may be in a

posit ion where this is not no ticed for some time. When the laser is not actually in

use, i t should be p laced in the STAND-BY mode.

A f i re may resu lt when a laser beam hits a fuel or the laser f iber becomes

damaged. Ign ition can be almost ins tan taneous. Whi le mos t ignition sources must

be in contact with a material to cause ign it ion, a laser can supp ly heat to a fuel

f rom a few centimeters to severa l meters away, so i t can ignite material c lose to the

t ip, at some d istance from the tip , or under several layers of o ther material . A

surface drape can be penetrated by the laser but not igni te . Materials under the

drape may then igni te and burn wi thout being not iced for several minutes (24). The

laser beam can be ref lec ted f rom a metal surface, causing a burn or ign it ing

material in a remote loca tion.

Laser Risk Classification A classif ication system ref lecting laser risk to the patient and personnel has been

developed (25,26,27). The higher the c lass, the more stringent the protec tion

needed.

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TABLE 32.1 Commonly Used Lasers and Associated Personnel Hazards

Laser Medium

Features Potential Hazards to the Eye

Special Considerations

CO2 Readily absorbed by all biologic materials, independent of pigmentation. Tissue destruction is proportional to its water content. Produces a very superficial tissue effect.

Injury to the eye will be confined to the cornea. There is no risk to the retina. Since the laser is absorbed by plastic and glass, ordinary eyeglasses with sideguards can be used for eye protection.

Fires involving both tracheal tubes and supraglottic devices have been reported with this laser.

Nd-YAG

Can be transmitted through fiber-optic fibers. Poorly absorbed by water but well absorbed by pigmented tissue (11).

Retinal damage can occur. Opaque green eyewear or eyewear with clear lenses with a special coating should be worn.

Because it is taken up by pigment, colored markings on tracheal tubes are more likely to be damaged than clear portions (12). Blood or mucus on or in the tracheal tube makes the tube less resistant to the laser beam. Fires have been reported from an Nd-YAG laser passed through the channel of a flexible bronchoscope (17,18). The rigid bronchoscope is recommended for use with this laser, although the flexible scope may be needed to treat hard-to-reach areas (19).

KTP Passes through clear substances but is absorbed by hemoglobin and other pigments (11,20,22).

Retinal damage may occur. Special eyewear with red filter should be worn.

Argon Beam is selectively absorbed by red, orange, and yellow pigment and strongly absorbed by hemoglobin and

Retinal damage may occur. Special opaque orange goggles/eyewear should be worn.

melanin. Fiber-optic bundles can be used to transmit the laser beam.

From Klarr P. Laser complications. In: Atlee J, ed. Complications in Anesthesia. Philadelphia: WB Saunders, 1999:588–590.

Class 1 Lasers Lasers that are totally enclosed or that emit extremely low output fall into c lass 1.

These are safe to v iew.

Class 2 Lasers Low-risk lasers are in c lass 2. Their r isk is approximate ly equivalent to staring at

the sun or o ther brigh t lights that can cause centra l re tinal injury. These are not

hazardous unless someone overcomes their natura l aversion response to bright

l ight.

Class 3 Lasers Class 3 lasers operate at a power level above 1 mW. This is a hazard even if

v iewed only momentari ly . Class 3 lasers are subdiv ided into a and b subclasses .

The 3a subclass cons is ts of lasers in the 1 to 5 mw power range. These lasers pose

a moderate ocular hazard. Class 3b inc ludes lasers that emit between 5 and 500

mW of output power. Even momentary v iewing of these lasers is potential ly

hazardous to the eye. They may also be a hazard to skin.

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View Figure

Figure 32.4 Note that the laser class is on the sign.

Class 4 Lasers Any cont inuous wave laser wi th a power output above 500 mW is in c lass 4 . These

lasers pose serious skin, eye, and f i re hazards.

Igni tion risk is re lated to a number of fac tors beside the laser c lassif ication . Class

3b and 4 lasers are cons idered to be igni tion hazards. The igni t ion risk of other

c lasses of lasers wi l l depend on how they are focused, the t ime of exposure, and

the oxidizers and fuels tha t are present.

Metal instruments can become overheated with pro longed laser use and could

cause a burn (28).

Electrosurgery Unit Electrosurgery (radio frequency) apparatus is so widely used that there is of ten

complacency about reading the instruct ion manual or following safe pract ices

(29,30). Electrosurgery units are the mos t common igni tion source in surgica l f i res

(6). The instruction manua l should be s tudied at the beginning of a tra ining program

and reviewed periodica lly. A brief set of operat ing instruc tions should be readi ly

availab le on the instrument (31).

Terminology The vocabulary concerning electrosurgery is somewhat confusing (32). This chapter

wi l l def ine e lec trosurgery devices as those that employ a h igh-f requency (radio

f requency) electric current passing through t issues to cut, coagulate, or prov ide a

blend of cutting and coagu lat ion. Elec trocautery ut i l izes a heated wire or blade,

usual ly at the end of a probe fo r coagulation . Most elec trocautery devices are

battery-opera ted.

Physics There are three modes avai lable on modern electrosurgery devices .

Cutting Mode The cutt ing mode uses a continuous s ine wave. Heating is rap id and produces h igh

temperatures that explode cel ls that come in contact wi th the electrode. This

produces a cut in the tissue.

Coagulation Mode The coagu lat ion mode features short bursts of a dampened s ine wave. Less heat is

produced s ince the current is not cont inuous. Tissue desiccat ion occurs , and the

ends of blood vessels are thermally sealed .

Blend Mode The blend (cut-coagulation) mode employs a waveform and voltage between tha t of

the cutting and coagu la tion cycle . The rela tive amount of cutting or coagulat ion

depends on the lengths of the bursts of voltage. Severa l blend se tt ings may be

availab le on an elec trosurgical uni t (33).

Types Monopolar With monopolar (unipolar) electrosurgery un its , e lectrons f low f rom the genera tor to

the act ive electrode and through the patient to the dispers ive (return , inact ive)

electrode, sometimes incorrect ly called the grounding pad (Fig. 32.5). The curren t

disperses from high densi ty at the tip of the act ive electrode to a lower dens ity v ia

the lowest impedance pathway tha t it can f ind .

Generator The elec trically powered generator (power uni t) c rea tes a radio frequency current

that passes through the active electrode. The effect on tissue depends on the

current intensi ty, the type of current employed, the durat ion of exposure to the

current, the hand piece used, and the dispers ive electrode (34). Coagulat ion

requires longer contact wi th the probe than cutt ing. As electrica l energy is appl ied

to the t issue, char forms. Since char has h igher impedance, more current d iss ipates

di rectly to the dispers ive elec trode and the ef fect is reduced (34).

Active Electrode

The active elec trode has a handle and is connected to the generator by a f lex ible

wi re. It d irects current f low to the surgical si te. The tip of the act ive electrode may

be a blade, spatula, ball , lancet, loop, forceps , need le po int, or suct ion tip. I t may

be disposab le or reusable. The t ip

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configuration determines i ts abil i ty to desiccate tissue. A needle-tip electrode

concentrates more power on t issue contact than does a paddle or ba ll -shaped

electrode (34). At a given electrode vol tage, the paddle-shaped t ip p resents a

higher power at the edge than on the flat port ion. The electrode may be activa ted

by a hand contro l or foot switch. The control may also be used to switch f rom one

mode to another.

View Figure

Figure 32.5 Monopolar electrosurgery unit.

Dispersive Electrode The dispers ive (inactive, return) electrode (grounding or ground electrode, pla te, or

pad) col lects the current from the patient and returns it to the generator to

comple te the c i rcu it . The large contact surface of the pad provides low impedance.

Most pads present ly in use are prejel led. Reusab le metal p lates used in conjunct ion

wi th conduc tive ge l are rarely used today. With some electrosurgery uni ts , two

dispers ive e lec trodes should be used (35).

Safety System

Modern electrosurgical uni ts possess a return e lec trode (contac t quali ty) moni to ring

system. This ensures tha t the patient is connec ted to the return e lec trode (34,36).

Current f lowing to the ac tive electrode is measured and compared with current

returning f rom the d ispers ive electrode. If the curren ts are not ba lanced, the uni t is

deactivated. A more recent innovation is active electrode monitoring (AEM)

(37,38,39,40). This continuously moni tors the electrical c ircui t and automatically

shuts down the generator and sounds an ala rm if dangerous e lectrical leakage

occurs. Newer generators can sense dramatic changes in t issue impedance or

temperature changes at the return electrode (33,41). Some modern electrosurgery

machines are equipped wi th “spl i t pads” (42). The uni t wi l l not func tion unless both

halves of the pad are in contact wi th the patient.

Bipolar The bipo lar electrosurgery unit is composed o f a generator and two electrodes

located wi th in mill imeters of each other. The energy f low is be tween the two

electrodes , and no current f lows through the patient 's body. This al lows the energy

to be local ized more precise ly. The current densi ty in the t issues surrounding the

ac tive electrode is substant ially less than that for monopolar elec trodes, and

deeper t issue layers are preserved wi th lower vol tage and power requirements. This

type of e lec trosurgery un it can coagulate even when the tip is immersed in b lood.

Bipolar units cannot be used fo r cutting .

Bipolar elec trodes are produced in a variety o f conf igurat ions: hooks , spatulas ,

sc issors, forceps , and needles (29 ,43). Of ten, these devices are batte ry-opera ted.

There are reports that the ON-OFF swi tch on one of these dev ices did not always

deactivate the dev ice when it was set aside (44 ,45). The hot t ip could then set

drapes on f i re. At least one device could be act ivated by another device's wire less

remote-control uni t or by f luorescent room l ights (46).

Hazards Associated with Electrosurgery Mishaps with the elec trosurgery uni t of ten involve faul ty re turn electrodes, improper

electrode placement, or al te rnate low-impedance outlets. Insuff ic ient contact wi th

the dispersive pad can resul t in pa tient burns and/or burns to others who are in

contact wi th the pat ient. Among the low-impedance al te rnatives are

electrocardiogram (ECG) monitoring elec trodes, temperature probes, urinary

ca theters, metall ic parts of surgica l tables, heating pads, and oximeters (47).

About 68% of reported surgical f i res involve e lectrosurgical equ ipment (48). Fires

associated wi th the electrosurgery unit are of ten associated with an oxidizer-

enriched atmosphere. When the electrosurgery uni t is used, heat vaporizes t issue

or expels tissue embers from the t ip. In room air, t issue vapors do not igni te, and

embers are quick ly extinguished. In an oxidizer-enriched atmosphere, the vapors

can ignite into a brief f lame, and embers can fly several inches and burn unt i l they

are consumed. A f la re of evolved gases can d irectly ignite any convenient fuel . The

electrical wires associa ted wi th the electrosurgery electrode may develop a short

c i rcui t, wh ich could resul t in a f ire (49).

During laparoscopic surgery, burns that are sometimes fatal can occur ou tside the

surgeon's v iew when using an elec trosurgery uni t (14,29,33,38,40,50,51,52). These

are usua lly caused by insu lat ion fai lure, di rect coupling, or capacit ive coup ling.

I f a defect occurs in the active electrode's insulation , current can f low through the

defec t. Defec ts can resul t f rom improper handling or damage to both reusable and

disposable electrodes . A number of devices are avai lable to detect insula tion

defec ts (33,40,51). Act ive electrode monitoring cont inuously monitors the elec trical

c i rcui t and automatical ly shuts down the generator and sounds an alarm if

dangerous elec trical leakage occurs (37,38,39,40).

Capaci ta tive coupling occurs when the electrosurgical current induces s tray

currents on other nearby conductors . It can occur even through intact insulat ion . It

occurs as a result of the active e lectrode contacting or coming into very c lose

proximity to a non-insula ted metal ins trument (such as a laparoscope) in the

surgical field. If the electrical ly-energized laparoscope has been placed through a

metal cannula, the current wi l l s imply f low to the pat ient's abdominal wal l . However,

i f the laparoscope has been placed th rough a nonconduct ive cannu la, the current

cannot f low to the abdomina l wal l. In th is case, any piece of bowel o r other internal

t issue touch ing the laparoscope can be burned. Capaci tative coupling is always

present and cannot be to tal ly eliminated.

Argon Beam Coagulator The argon beam (enhanced) coagulator (ABC) is solely a coagu la ting instrument.

Rad io f requency monopo lar curren t is delivered through a f low of ionized argon

gas.

P.913

The f low is al te red as the power is changed. The t ip does not touch the tissue. I f

the tip is greater than 1 cm from the t issue surface, only a gent le s tream of argon

wi l l f low. When the tip is 1 cm or less f rom the tissue surface, the ac tive mode

occurs. If the nozzle t ip glows red, the tip is too close to the t issue or the power

se tt ing is too high.

Fiber-optic Illumination System A f iber-optic i l luminat ion system consis ts of a l ight source and l ight-transmitting

cable . The cable is connected to an endoscope or headligh t. The term cold l ight ,

used to describe l ight f rom a f iber-opt ic source, is incorrec tly assumed by many to

mean that heat is not generated. Actual ly co ld l ight refers to l ight in which the

amount of inf ra red radiat ion has been reduced (53). These light sources can

provide several hundred watts of v is ible, infra red, and ul trav iolet light. Al though

some of these wavelengths can be f i l tered out, the power is typical ly focused into a

f iber-opt ic cable of smal l d iameter tha t can deliver a h igh-power densi ty .

A number of f ires have been igni ted when the unprotected end of the f iber-optic

cable was allowed to res t on a drape (6 ,49 ,53,54,55,56,57). The cable end can

reta in a signi ficant amount of heat a fter be ing d isconnected from the l ight source.

Defibrillator When a def ibri l la tor is act ivated, a spark may be generated if insuff icient force is

applied to the paddles; if the paddle pad is too smal l; if paddles are applied over an

i rregular surface or bony prominence or near an ECG electrode; when insuff ic ient,

excess or the wrong kind of gel is used; or if there is another conductive medium

between the paddles (6 ,58 ,59). I f disposable def ibri l la tion pads are used to

increase e lec trical conduction between the paddle and the patien t, an arc can occur

i f the surface of the paddle is not comple tely on the pad, if the pad is smal ler than

the padd le, if there is a fold in the pad, o r if the pad is dry.

Pressure Regulators When gas is al lowed to f low f rom a high-pressure to a low-pressure chamber,

recompression can cause a rap id rise in temperature. Materials that cannot

wi thstand both 100% oxygen and high temperatures wil l igni te . This hazard is

associated mostly with aluminum oxygen regula tors (60,61,62,63,64,65,66,67,68).

Another cause of heat in a pressure regu la tor is part ic le impact f rom contaminants.

Tef lon tape, chips f rom seal materials , or hydrocarbon contaminants may be

present (69).

Surgical Lights Surgical l ights can be a source of igni tion. I f the light does not have the proper

mechanism to diss ipa te inf rared radia tion or i f that mechanism fails , the patient o r

personnel envi ronment can be exposed to energy levels high enough to cause

burns or f i res (70,71). The heat f rom a surgical l ight can contac t and rupture a hose

f rom the medical gas pipel ine system (72).

Electrical Faults An electrica l f i re can occur in any env ironment where there is electrical equipment.

A short c i rcui t can occur in an anesthesia mach ine (73,74,75). In one reported

case, a short circu it in a laryngoscope wi th a rechargeable handle caused f lames to

shoot f rom the charging end of the handle (76). Elec trical arc ing in surg ical booms

has been reported to cause fi res (77,78).

Other Ignit ion Sources Other reported sources of ignit ion in opera ting room f i res include resectoscopes,

heat lamps, heated probes , pneumatic tourniquets, denta l and orthopedic burs and

dril ls , heated-wire breath ing tubes, and humid if ie rs (1,79,80,81,82,83,84).

Fuels Fuels abound in the operating room. A fuel is anything that can burn, inc luding

most things tha t come in contact with pat ients as we ll as the patients themselves.

Tracheal Tubes The risk and characteris t ics of a tracheal tube f ire wil l depend on the type of tube

used. In most cases , igni tion requires the tube to be penetra ted (85). The f ire

begins on the ins ide rim of the penetrat ion area and then spreads both wi th and

against the flow of ox id iz ing gas.

Polyvinyl Chloride Tubes Polyv inyl ch loride (PVC) tubes are combus tible in an ox idizer-enriched atmosphere

wi th a carbon d ioxide (CO2) laser. Once igni ted and penetrated, a PVC tube can

susta in a torchlike f lame. PVC tubes wi thout markings are re lat ively res is tant to the

Nd-YAG laser, but mark ings inc rease the risk (86). I f there is blood, mucus , or

sa liva on the tube, the risk of f i re is inc reased. The inju ries associated wi th PVC

tube f i res are more severe than wi th other types of tubes (87,88).

Red Rubber Tubes Red rubber tubes are combus tible with the CO2 , potassium t itanyl phosphate (KTP),

and Nd-YAG lasers (86,87,88,89,90). A major p rob lem is the inabil ity to see

through the tube. Should an intraluminal f i re develop, it may go undetec ted for a

longer period of time than with other tubes .

Damage to the tracheobronchial tree af te r an in traluminal f ire may be less severe

wi th a red rubber tube than a PVC tube (87). Red rubber tubes are less l ikely to

soften, deform, or fragment if ignited than are o ther tubes. Another advantage is

that they can be quickly

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removed f rom the pat ient (91). The high pressure in the cuff causes it to def late

more quickly than is possible with a low-pressure cuff .

Silicone Tubes A sil icone tube is more resistant to penetration by a CO2 laser than other tubes

(87). If ign ited, a s i l icone tube rapidly becomes a bri tt le ash tha t crumbles eas ily

and may be aspira ted , ra is ing the possibil i ty of future problems with s il icosis

(87,90,92,93). However, the acute injuries are less severe than with red rubber and

PVC tubes (88).

Laser-resistant Tubes A number of ready-to-use laser-resistant tubes and tube wraps are avai lable and

are desc ribed in Chapter 19. They should meet the requirements of Inte rnational

Standards Organ ization (ISO) 14408 (93). It is importan t to remember tha t laser-

resistant does not mean laser-proof . Laser-resistant tubes can igni te, especial ly i f

manufac turer's warnings, precautions, or directions fo r use are not followed. If a

laser tube is used with a laser other than that for wh ich i t was designed or a

f lammable part such as the cuf f is exposed, it wi l l catch f ire (92 ,94). Laser-resistan t

tubes are usually not res is tan t to other heat sources such as an electrocautery

penci l.

Supraglottic Airway Devices The relative resistance o f suprag lott ic ai rway dev ices depends on their

composi tion . Those devices tha t are made of s i licone rubber such as the LMA-

Classic, LMA-Flexible , and LMA-ProSeal are s ign if icant ly more resis tant to the CO2

laser than are PVC tracheal tubes (95). Many disposable supraglottic dev ices are

made of PVC and are probably as suscept ible to fi res as tracheal tubes of the same

composi tion .

Surgical Products Surgical drapes, towe ls , and dressings are common fue ls for opera ting room f i res .

Of ten , the drape is igni ted f rom another f ire (24). Whi le many drapes are resis tan t

to ignit ion in room a ir, the oxidizer-enriched a tmosphere that is often present may

cause them to burn with v igor (49,96,97,98,99,100,101,102,103,104).

Disposable drapes may be part icularly diff icul t to deal wi th during a f i re because

they are water repellen t. Addi tion of water may even spread the f lame. Laser-

resistant drapes are avai lab le . Some synthetic drapes wi l l mel t away f rom the laser

rather than igni te (103).

There are numerous reports of surgical sponges, gauze pads, and swabs being

igni ted (49,105,106,107,108,109,110,111,112,113). Wet sponges may be used to

protect a tracheal tube from a laser beam. However, if they are allowed to dry out,

they become f lammable.

Adhesive Substances Adhesive tape can be the fuel for a fi re (114). Co llodion and benzo in are

f lammable .

Skin Preparatory Solutions Flammable volat i le organic so lut ions are often used to prepare the sk in prior to

surgery. If the l iqu id or vapor is contacted by an igni tion source , a flame can resu lt

(1,101,115,116,117,118,119,120,121). Alcohol-based solut ions are espec ia lly

f lammable . They can also in fi l t rate and pool under the drapes. When this happens,

they are slow to dissipate. Alcohol-based f ires have a f lame tha t is d if f icult to see.

Of ten , the result of the f lame is the f i rs t thing not iced.

Intestinal Gases Gases that accumulate in the bowel (especial ly hydrogen, hydrogen sulf ide , and

methane) can be the fuel for a fi re o r exp los ion if an elec trosurgery uni t is used to

open the bowel (105). Proper bowel preparation may prevent this (122). Suff ic ient

oxygen to support combustion is normally not present in intestina l gas . However,

ni trous oxide may diffuse into the intest inal lumen, c reating a f lammable mixture.

Oxygen Cannulas Oxygen cannulas are made of plas tic that can burn . They carry 100% oxygen. If

touched by a hot e lec trosurgery probe or a laser beam, they burn readily. Even if

not di rec tly contac ted, the area around them may be so oxygen-rich that a smal l

spark can turn in to a burning ember tha t can igni te the cannula.

Lubricants and Ointments

Petro leum-based ointments that are used in an oxidizer-enriched a tmosphere wi l l

igni te when enough heat is present to cause vaporizat ion (105,123,124). Water-

based lubricants wi l l not burn and can be used to coat ha ir to make i t f i re -resistant.

Body Hair Body hair, including eyelashes, moustaches, and beards can be involved in a f i re

(105,106,125,126). Coating the hair with a water-based lubricant wil l decrease the

risk .

Surface flame propagation occurs where there are fine surface f ibers of fabric o r

body hair (127). In the presence of an ox id izer, these f ine f ibers can be igni ted.

Of ten , the skin or underlying fabric is not burned. The surface f i re races in the

di rection of the oxygen source, where the oxygen supply tubing may be ignited

(58).

Other Combustible Substances A number of artic les used in or near the patient can serve as the f lammable

material . These include (but are not l imited to ) oxygen tubings, endoscopes, smoke

evacuator hoses, esophageal s te thoscopes, breath ing tubes, reservoir bags, eye

patches, s ten ts , masks, nasogastric tubes, en teric feeding tubes, rubber and plas tic

nasopharyngea l ai rways, covers, paper products, blood pressure cuffs , aeroso l

adhesives, tourniquets, gloves, s tethoscope tubing , th roat packs, eggcrate foam

P.915

mattresses, bandages, stockinettes, d ressings, pil lows, glue, gowns, straps, caps

and hoods , rubber elec trosurgica l uni t probe sheaths, shoe covers, loca l anesthetic

spray, and organic gas f rom a necro tic tumor

(106,116,128,129,130,131,132,133,134,135,136,137).

Alcohol-based hand sani tizers (gels, foams, and liqu ids ) are h ighly f lammable

(138). They shou ld be stored in a cabinet that is designed fo r flammable materials .

However, a study pub lished in 2003 found no fi res attribu tab le to hand sanit izers,

and the National Fire Protec tion Associat ion now a llows alcohol-based hand

sanit izer d ispensers in corridors and other public a reas, provided certain

restric t ions are observed (139). I f a dispenser is mounted in a hallway, the corridor

must be at leas t 6 fee t wide. The dispenser can project up to 6 inches f rom the wal l

and mus t be instal led above handrai l height.

Oxidizers

With an oxidizer-enriched atmosphere , a f i re igni tes easier, burns more v igorously,

spreads more rapidly, and is more d if f icu lt to extinguish . The oxidizers of g reates t

inte res t are oxygen and ni trous oxide. Ni trous oxide supports combustion and in the

process releases the energy of i ts formation, providing increased heat. Thus , any

mixture of oxygen and ni trous oxide wil l support combustion. Air wi l l a lso support

combustion, because it contains oxygen.

Because oxygen is heavier than ai r, i t collec ts in low-lying areas, inc lud ing drape

folds. Some materia ls such as drapes and towels absorb oxygen and reta in i t fo r

some t ime (1,127). Tenting drapes wi l l al low oxygen to dra in off toward the f loor

and be d iluted by ai r c i rculation.

Common Scenarios

Airway Fires During airway surgery, all of the th ree necessary components are in close

proximity: a combus tible subs tance (trachea l tube, gauze, etc.), an igni t ion source

(laser or e lectrosurgery apparatus), and gas to support combustion (oxygen wi th or

wi thout ni trous oxide). An ai rway f i re is part icularly serious because a considerab le

amount of heat is genera ted in a smal l area, and the smoke and gases f rom such

f ires can be b lown deep in to the pat ient's lungs .

Using Electrosurgery during Tracheostomy Many a irway f i res have occurred while using the electrosurgery uni t during

tracheos tomy

(9,105,128,130,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154).

Of ten , the patien t is being given 100% oxygen in ant ic ipa tion of interrupted

venti lation and/or because of the underly ing c linical cond ition. If the tracheal tube

or cuff is contacted, an oxidizer wi l l be released. Current ly , there is no tracheal

tube that is safe for use wi th electrosurgical devices or electrocautery, al though

some are more resistant to igni tion than others (155).

Using Electrosurgery in the Mouth Using electrosurgery in the oral cavi ty may resul t in a f i re

(6,156,157,158,159,160,161,162). The tracheal tube is of ten the fuel , but o ther

i tems such as sponges or patient t issue may be involved. Of ten, wet gauze is used

in the throat to catch sec ret ions or to pro tect the tracheal tube. If there is a leak

around the tube, the gauze can becomes oxidizer-enriched and dry ou t more

quick ly.

Laser-induced Tracheal Tube Fires The l ikelihood that a laser wil l contact the tracheal tube during ai rway procedures

is high (163). Cuffed tubes are more l ikely to be contacted than noncuffed tubes.

The tube may be exposed to ei ther the di rec t or ref lec ted laser beam. Flaming

t issue in c lose proximity to the tube may cause it to ignite (164).

In addi tion to local damage in the larynx, injury can occur to the lower a irway and

the parenchymal t issue in the lung. The products of combustion may be b lown into

the lungs.

The cuff is the most vulnerable part of the tracheal tube. It cannot be wrapped, and

laser-resistan t tubes do not have laser-res is tan t cuffs .

Wet cotton sponges are of ten used around the tube to protect the cuff f rom the

laser beam. If these dry out, they can become fuel for a f ire (165). Tape that is

used to secure the tube can igni te.

During lower ai rway surgery using a laser, the cable may be passed through the

inside of a tracheal tube. The tracheal tube should be placed just below the vocal

cords so that the t ip is as fa r away f rom the operat ive s ite as possible.

Other Head and Neck Fires Head and neck f i res can occur during local anesthes ia procedures when

electrosurgery apparatus is used (6,49,56,126,166,167,168,169,170,171,172,173).

Of ten , oxygen is being administe red, and i t may diffuse into the surg ical area. Any

f lammable i tem in the v ic ini ty can catch f ire.

Fires Involving Pressure Regulators While no t a frequent occurrence, a f ire in a regulator can be d isastrous (174).

These fi res may resul t f rom adiabat ic compress ion or partic le ignit ion in which

debris is b lown f rom the cyl inder into the regulator wi th suffic ient energy to cause

igni tion. Improper pressure regulator assembly may also cause a f i re.

P.916

Regula tors wi th aluminum components are more l ike ly to burn than other

regulators . The Food and Drug Adminis trat ion (FDA) and the National Ins ti tute for

Occupational Safe ty and Heal th (NIOSH) now recommend that aluminum regulators

be replaced wi th ones wi th brass components (64,66). A number of aluminum

oxygen regulators have been recalled (67).

Intraperitoneal Fires Severa l explosions have been reported during laparoscopy when nitrous oxide was

used as the insuff lating gas (122,175,176,177). Ni trous oxide in the inspired gases

wi l l dif fuse into the peritoneal cavi ty and may reach a high enough concentrat ion to

support combustion (178,179). Fires have also resul ted f rom inf lat ing the peri tonea l

cavity wi th an oxygen-CO2 mixture instead of pure CO2 (180,181). The Pin Index

Safety System (Chapter 1) wi l l not p revent this error, because the index ho les for

tanks wi th 100% CO2 are the same as for any tank wi th greater than 7% CO2 .

Fires during Defibrillation Oxygen is always used during resusci tation, and the source is of ten disconnected

and p laced near the head (58,182,183). This may allow oxygen to f low over the

defibri l la tion electrodes (184). A spark caused by placement of the def ibri l lato r

paddle or electrode close to an ECG elec trode or poor contact be tween the

patient 's sk in and the def ibri l lator paddle or electrode may ignite hair or other

combustible materials in the area (183,185).

Fires in Canisters Fires in CO2 absorbent canisters have been reported

(186,187,188,189,190,191,192,193). These are d iscussed in more detail in Chapter

9.

Personnel Risks

Smoke Hazards Potent ial ly hazardous ai rborne contaminants are formed from tissue vaporization

when a laser is used. These by-products have the potent ial to be mutagenic,

carc inogenic, teratogenic, or a vector for v iral infect ion (10,194). Elec trosurgery

devices and bone saws also produce vaporized f ragments that have the same

hazards (25).

Inhaling potent ia lly hazardous ai rborne contaminants can be kept to a minimum by

scavenging the smoke. This wi l l help to give the surgeon a c learer v iew o f the

surgical field and removes o ffensive and irrita ting odors. Various smoke evacuators

are avai lable (103,195). To be most effect ive, the evacuator nozzle should be

posit ioned as c lose as possible to the operative f ie ld and be func tiona l before,

during and for 30 seconds after t issue is vaporized (196).

Personnel masks should be removed and discarded as soon as poss ib le af te r use

(196). Standard surgical masks f i l ter ou t partic les down to about 3 microns in

diameter. The laser plume has partic les as small as 0.31 microns . High-eff ic iency

masks can f il te r partic les down to 0.30 mic rons, bu t they are dif f icul t to breathe

through and lose their eff iciency when wet (10,103).

Ocular Injuries The laser beam may be di rected over some distance. The area of hazard may not

be l imi ted to the immediate surgical area and may present risk to operating room

personnel (25). The surgeon is not highly susceptible to injury because of the

safety dev ices bui lt into the ins trument. However, if the ins trument is accidental ly

ac tivated, he is exposed to the same hazards as other personnel .

The eye is especially vulnerable to injury. Because CO2 laser beams are absorbed

wi th in the fi rs t 200 µm of t issue, they are a hazard to the cornea (197). Argon, KTP,

and Nd-YAG lasers are more like ly to cause damage to the retina . The ex tent of

damage wil l depend on wh ich part of the retina is affected. Permanent v isual loss

may resul t (25).

All personnel in the area where a laser is used should wear appropriate protect ive

eyewear. This may inc lude goggles, face shields, spectacles , or presc ription

eyewear using special materials or reflec tive coatings (or a combination of both),

se lec ted to reduce the potent ial ocular exposure. The safety eyewear should be

marked according to the wavelength (laser type) (Fig. 32.6). I t should be noted that

laser safety eyewear is not des igned fo r looking di rectly at a laser beam (16). The

patient 's eyes should be c losed and covered wi th saline-soaked gauze or a

nonshiny metal shield . Awake patients should wear goggles specif ic for the laser

being used. Windows in the room should be covered and a warning sign placed

P.917

on the operat ing room door at eye level (Fig. 32.4). Spare eyeware should be

availab le at a ll entrances.

View Figure

Figure 32.6 All laser-protective eyewear should be clearly and permanently labeled.

Electrical Shock Another concern is electrical shock from the e lec trosurgery device. A common

pract ice among surgeons is to al low an assistant to touch the dista l end of a

forceps wi th the act ive electrode f rom the electrosurgery apparatus. This act ion

makes the forceps the active electrode. A glove may not offer suffic ient p rotec tion

f rom the electrical c ircui t . Holes appear in as many as 15% of g loves.

There are ways to minimize the shock potential wh ile using electrosurgery. The

ac tive electrode should be f irmly in contact wi th the forceps before i t is energized.

The person holding the forceps should try to contact i t in as large an area as

possible to spread the concentration of the charge.

Fire Prevention The best way to deal with fi res is to prevent them f rom start ing (127,198). Fi res can

be avoided by not allowing the th ree elements of the f ire tr iangle to come together

at the same t ime.

Controlling Ignition Sources One way to reduce f ires is to properly use equipment that might ac t as an igni tion

source. I t is important to read instruct ion manuals and to alter techniques to f i t

these instructions.

Lasers

Personnel who use lasers should take a cert if ied laser course (6,23,26,103). They

should practice their techn ique on inanimate ob jec ts and gain experience a t the

hands of an experienced c linic ian. Specif ic personnel should be designated to

moni tor and prevent laser hazards.

A laser protocol should be developed and fo llowed. Lasers should be test f ired onto

a safe surface before use to ensure tha t the beams are properly al igned. Lasers

should always be kept in the standby mode except when needed. The lowest power

densi ty and shortest pu lse dura tion that wi l l do the job should be used. The laser

should be activated only when the tip is under the surgeon's d irect v is ion. The laser

should be placed in standby mode before removing i t f rom the surg ical s i te.

Laser f ibers should not be c lipped to drapes because the f ibers may be broken. The

laser fiber should be careful ly passed through an endoscope before in troducing the

scope into the pat ient to minimize the risk of f iber damage. The f iber's funct ionali ty

should be verif ied before insert ing the endoscope into the pat ient.

I f a laser contact t ip is used, the t ip wil l remain hot for several seconds. Bl ind entry

into cavi ties wi th this tip should be avoided (199). The risk of tracheal tube igni tion

wi l l be lowered if the laser is activated during the expiratory pause (200).

Electrosurgery Unit The elec trosurgery uni t should not be used during tracheostomy

(31,34,50,111,171,201,202,203,204). Bleeding should not be trea ted wi th

electrosurgery af ter f lammable dressings have been appl ied.

A bipolar electrosurgery uni t should be used whenever possible . This wi l l reduce

the curren t densi ty in the t issues surrounding the ac tive electrode and minimize the

potential for di rect coupl ing. Bipolar units work at lower voltages and are not

associated wi th insulation fai lure .

Monopolar un its should have a means to moni tor the return electrode or ac tive

electrode. Us ing active e lec trode monitoring wi l l min imize the risk of s tray

electrosurgical burns (38). Before each use, the electrosurgery uni t and assoc ia ted

safety features should be inspected for s igns of damage and tested to ensure that

the uni t is functioning correct ly. If i t is not work ing properly or is damaged, the

electrosurgical apparatus should be immediately removed f rom serv ice. The uni t

should be pro tec ted f rom sp il ls . Unintentional act ivation may occur i f f lu ids enter

the generator. The alarm system should be checked prior to applying the dispers ive

electrode. The act ive electrode should have a t ip that is secure, because a loose

t ip may cause a spark. Prejel led dispers ive electrode pads should be checked for

uniform gel dis tr ibution and absence of exposed wires before being applied to the

patient. Outdated or previously opened but unused dispers ive e lectrode pads

should not be used, because the gel can undergo electrolys is and/or desicca tion. If

a dispers ive elec trode pad requiring gel is used, the pad shou ld be checked

careful ly to identify any dry spots on i ts surface before it is placed on the patient.

Af ter the patient has been posi tioned, the connect ion between the pat ient and the

unit should be establ ished by p lac ing the dispers ive electrode on a nonhairy a rea of

c lean, dry sk in. The dispers ive electrode should be the appropria te s ize for a

patient ( i.e. , neonate, infant, ped iatric , adult) and never be cu t to reduce its size.

The dispers ive electrode should be app lied to c lean, dry skin over a large, wel l-

perfused muscle mass as c lose to the operative s i te as practica l, avoiding bony

prominences, scar t issue, skin over a metal prosthesis, o r dis tal to a tourniquet.

Excessive hair shou ld be removed before apply ing the dispers ive e lec trode,

because hair wil l insu late the pad from the patient. The pad's ent ire surface area

should main tain uniform body contact. There should not be any ten ting, gaping, o r

moisture under the pad. This wil l interfere with adhesion to the sk in and decrease

the contac t surface. The dispers ive electrode

P.918

should not be moved to another s i te a fter ini tial appl ication. The status of the

dispers ive e lec trode should be checked if any tension is applied to the cord or i f

the pat ient is reposi tioned after the pad is appl ied. A used dispers ive electrode

should not be reapp lied.

Electrocardiographic electrodes should be placed as far as possible from the

operative si te to minimize the alternate f low o f current through the electrodes and

moni tor to g round.

I f insulated electrosurgical elec trode probes are required, only commercial ly

availab le insulated probes should be used (9). Insulating s leeves cut f rom catheters

or o ther materials shou ld no t be used to sheathe probes.

The lowes t power settings tha t are effective for the surgical procedure , as

determined by the surgeon in conjunc tion wi th the manufacturer's recommendation,

should be used. The ent i re ci rcui t should be checked if the operator requests higher

power sett ings because of ineffectual results .

The elec trosurgery uni t should be act ivated only when the tip is under the

surgeon's direc t v ision and only by the person using i t . Cords shou ld no t be

c lamped with or wound around any objec ts . The electrosurgery probe should be

kept c lean to minimize the risk of adherent t issue incandescing or f laming. The

electrosurgical penc il should be placed in a holster when i t is not in act ive use. The

electrosurgical uni t should be placed in s tandby mode whenever i t is no t in active

use. Unnecessary foo t swi tches should be removed so that they are not

accidentally ac tivated .

During laparoscopic surgery, all-metal or a ll-p lastic cannulas should be used and

not a hybrid cannula system (i.e. , a combination of plastic and metal cannulas )

(37). Electrosurgery elec trodes should not be used ins ide metal suct ion i rrigators.

The elec trosurgica l uni t should be deac tivated before removing it f rom the surgical

s i te. Even after deact ivation , the probe t ip may retain enough heat for a few

seconds to mel t plast ics or igni te some fuels, so it shou ld be placed ins ide a c lean,

wel l -insulated holder or broken off . In addi tion to protecting the t ip, this makes i t

more dif f icult to acc identally ac tivate the switch . The t ip should be broken, and a

safety cover should be placed over the tip and act ivation swi tch before the device

is discarded (205).

Argon-enhanced Coagulation All safety measures observed for the electrosurgical unit shou ld be observed for

argon-enhanced coagulation (31). The electrode should not be placed in di rect

contact wi th t issue. The hand piece should be moved away f rom the pat ient's t issue

af te r each activation. The argon gas f low and the argon coagu lator should be

ac tivated simul taneously. The argon gas l ine should be purged of ai r before each

procedure and by act ivat ing the system after moderate delays between act ivat ions.

Fiber-optic Light Sources All connec tions should be made before the l ight source is activated, because the

end of the cable can cause a f i re (53). An act ive f iber-optic cable should not be

placed on flammable material . The l ight source shou ld be turned OFF before

disconnecting the cab le. The end of a f iber-optic cable can retain a signif icant

amount of heat after be ing disconnected from the l ight source (206). Therefore, i t is

importan t to be careful where one places the end of a f iber-op tic cord.

Heated Humidifiers Only a breath ing tube and heat ing ci rcu it labeled for use with a spec if ic humid if ier

should be used (207). Heated breathing c i rcui ts should not be covered wi th sheets,

blankets, towels, clothing, o r other material. They should not rest on surfaces such

as the patient, operat ing table, blankets, o r medical equipment. Instead, a boom

arm or tube tree shou ld be used to support them. A heated-wire breathing ci rcui t

should not be turned ON before f low has been ini tiated. I f there is no f low (as

during cardiopulmonary bypass ), the heater should be turned OFF (208).

Defibrillators When us ing a defibri l lato r, care should be taken to hold the paddles f i rmly and

posit ion them properly. Disposable conduc tive pads should be larger than the meta l

surface of the paddle and be wi thin their expiration date. This wil l prevent arc ing

when the paddles are activa ted (58). ECG electrodes should be appl ied as far as

possible f rom the def ibri l lat ion pads.

Electrical Faults All electrica l cords should be regularly inspec ted for cuts and nicks in the

insulat ion, f rayed insulat ion, and loose connections at the plug or receptac le ends

(209). Al l plugs should be pushed completely in to the receptacles to prevent p rong-

to-prong arc ing (210).

Managing Fuels Tracheal Tubes

Non-intubation Techniques Since the tracheal tube is of ten the fuel for the f i re , anes thetic techn iques that do

not require a tracheal tube wi l l el iminate one component of the f i re triad (92).

These inc lude apnea, jet vent i lat ion, and spontaneous breathing.

Apnea With the apneic technique, the pat ient is vent i lated by us ing a mask or tracheal

tube, and these are withdrawn as the laser is used (92,93,211). Af ter a period of

t ime, vent i lat ion is reinstated. This is repeated as long as needed to perform the

surgery.

Insufflation Patients may be al lowed to spontaneously breathe a combinat ion of oxygen and

anesthet ic agents whi le laser procedures are undertaken. The gases are

administered through a catheter or hook in the

P.919

corner of the mouth tha t is wel l out of the way of the laser beam. The suc tion

channe l of a laryngoscope may be used to insuff late oxygen. Operat ing room

pollut ion wi th anesthet ic agents may be high wi th this technique. Oxidizers should

be used as sparingly as possible s ince the insuff lated gas cou ld support

combustion.

Jet Ventilation Jet vent i la tion techniques ei ther v ia a metal bronchoscope or a catheter inserted

through the crico thyroid membrane may be used (212). A h igh-veloci ty jet of oxygen

or helium and oxygen can be di rec ted into the ai rway above or below the glo tt is by

us ing various apparatus (21,92,93,196,213,214).

There has been a f i re reported with th is technique (215). An errant laser strike

igni ted the surgeon's glove. The resul tan t burning vapors were entra ined into the

patient 's airway. The patient's mustache was also igni ted , and the pat ient suffered

fac ial burns .

Filling the Cuff with Saline The cuff is the most vulnerable part of the tracheal tube, regardless of the tube or

cuff materia l. If a laser beam penetrates an ai r-f i l led cuff , gas can leak in to the

operative field, and if the oxygen concentrat ion is high, the risk of f i re is great.

Fluid in a cuf f ac ts as a heat s ink and makes the cuff less easy to perforate

(216,217). Fi l ling the tracheal tube cuff wi th a l idocaine jelly-plus -saline mixture no t

only prevents the cuff f rom being igni ted but may plug small holes in the cuff

resul ting f rom a laser h it (218).

I f the cuff is perfora ted, a je t of f lu id may ex tingu ish the f ire. If perfo rated, fluid-

f il led cuffs reta in their shape longer than a ir-f i l led cuffs . Care must be taken to

remove all ai r f rom the cuff , because any remaining ai r wil l sett le in the most

superior part of the cuff , which is the part most l ikely to be h it by the laser beam.

Addit ion of methylene blue or o ther biocompatible and highly v isible dye to the

sa line wi l l help the surgeon to recognize a perforated cuff . Some surgeons object to

the addi t ion of methylene blue because if the cuff is punc tured, the color of the

t issues is al tered, making it dif f icu lt to recognize pathology.

Protective Wrappings The tube can be covered wi th a protective wrapping. These are discussed in

greater de tai l in Chapter 19.

Merocel wrap (Laser-GuardTM) was found to be acceptable for surg ical levels of

CO2 , KTP, and Nd-YAG lasers (219,220,221,222). Merocel-wrapped tubes are not

more combus tible if they are coated with blood (223). Reflec ted laser beams have

not been a problem with th is wrap (224). This product is easier to apply than

metall ic tapes (225).

Aluminum and copper tapes are effective for use with the CO2 and Nd-YAG lasers if

the tube is meticulously wrapped (226,227,228). However, a f i re can occur if the

laser contacts part of the tube that is not wrapped (229,230). A wrapped red rubber

tube does not offer protection f rom the KTP laser (86). The adhesive backing or

surface coating of some tapes can be ign ited by laser beams (92). The presence of

blood on the surface of foi l-wrapped tubes makes combustion more l ikely to occur

(223). Tape-wrapped tubes may unravel, leaving portions of the tube exposed. I f

the wrapping is dislodged, i t could obstruct the airway. A wrapped tube may catch

f ire (231,232). Meta ll ic tapes may ref lect the laser to nontargeted areas (224).

Spiral wrappings may cause the tube to k ink . Any wrapping adds thickness to the

tracheal tube, which could be a problem for the surgeon.

Protecting the Cuff with Wet Covers As a fu rther p recaut ion, moist cottono ids, sponges, or pledgets can be placed on

the cuff (92,233,234). Cotton gauze is a good choice because i t s tays wet longer

than other covers and has low energy transmission (235). Wet gauze wi l l also

protect the shaft (236). These have been found to be especial ly help ful with the

CO2 laser (234). The Nd-YAG, KTP, and argon lasers may allow some energy to

penetrate the pledget and rup ture the cuff (235).

I t is important that wet covers be kept moist. Laser beam h its may dry them, and if

that happens, they lose their protect ive effect. Further hi ts can cause the

co ttonoids and/or cuff to ign ite. Al l these must be retrieved af ter surgery.

Special Tracheal Tubes Ready-to-use laser-resis tant tubes are discussed in Chapter 19. Laser res istant

means tha t the material can wi thstand l imi ted laser energy wi th l i tt le o r no damage.

The use of a special laser tube does not necessari ly prevent a f ire during laser

surgery (237). Even though the tube is labeled laser-resistant, the cuff wi l l not be

resistant, and special p recautions need to be taken to protect it . A fi re may occur i f

the pro tec tive wet gauze over the cuff dries or is displaced.

No laser-resistant tracheal tube is completely safe f rom all types of lasers under all

condi tions . All of these tubes can be damaged or igni ted by lasers for which they

are not intended or by high laser energies (238,239). Some are made more

combustible by blood (223). Tubes sold for use with lasers should indicate the type

of laser fo r which they are sui ted as we ll as the condi tions (power, power densi ty,

spot s ize, oxygen concentra tion) under which the tube is safe to use. Stric t

adherence to manufacturer's warnings and d irections is essential .

I f the Nd-YAG laser is used through a f iber-optic bronchoscope passed th rough a

tracheal tube, i t is best to use an unmarked PVC tube (240). The tracheal tube

should be placed just below the vocal cords so tha t the t ip is as far away from the

operative si te as possible. I t should be remembered tha t the cover on the f iber-

optic endoscope is plast ic and can burn.

Some laser-res is tan t tubes are more resistant to f i re than conventiona l tracheal

tubes when contacted by elec trosurgical instruments (155).

P.920

When laser contac t tips are used, there is an even greater opportuni ty for igni tion .

They can get hot enough to melt and burn plast ics even when the laser is inac tive

(241).

Double-cuff tubes are not more resistant to leaks that wil l occur af ter cuff puncture

but do al low a sea l to be maintained if one cuff remains intact. The second cuff is

s t i l l vulnerable to puncture (239).

There are disadvantages assoc ia ted wi th laser-resis tant tubes . They are more

expensive than PVC and red rubber tubes. Since these tubes are often used for

patients who have had previous laryngeal surgery, the anatomy may be dis to rted,

making intubat ion diff icult . Some laser-resistant tubes are so st if f that i t is dif f icult

to pass a stylet or use wi th a specia lized laryngoscope such as the Bu llard

laryngoscope (Chapter 18). Therefore , a diff icult intubation may become even more

challenging when these tubes are needed.

Using Smaller Tracheal Tubes Smal l -diameter trachea l tubes require higher power densit ies fo r ignit ion than

large-d iameter tubes because the higher gas f low cools smaller tubes more quick ly

than larger tubes. Also, the smal le r the tracheal tube, the less l ikely i t is to be hi t

by an igni t ion source.

Making the Tracheal Tube Easy to Remove The tube should be f ixed so that it can be removed rapidly, if necessary. If the tube

is to be removed, th is should be done immediately after igni tion to minimize

damage to the ai rway and lungs. If the tube continues to burn, i t may be very

diff icul t to remove. Some tracheal tubes break apart as they burn . If the tube is

wrapped, the wrapping may break in to pieces tha t could lodge in the airway.

Some tubes are easier to remove than others (91). PVC tubes wi th sal ine-f il led

cuffs are more diff icult to remove than red rubber tubes . The fastest way to deflate

a fluid-f i l led cuff is to remove the contents wi th a syringe rather than cu tt ing the

pi lot bal loon. Unclamping the inf lation tube on a red rubber tube wi l l result in rapid

release of the cuff contents.

Wetting Fuels The use of wet towe ls , packers, or sponges around the surgical s ite can prevent

igni tion of materials near the s i te . Gauze or sponges used with uncuffed tracheal

tubes to minimize gas leakage in to the pharynx and sponges , gauze, and pledges

(and their s tr ings) used to protec t the tracheal tube cuff should be moistened and

not allowed to dry.

Hair that is near the opera tive si te (e.g., eyebrows, beards , and moustaches)

should be made nonflammable by coating i t thoroughly wi th a water-soluble

lubricating jelly .

Proper Preparation Practices Water-based solut ions should be used to decontaminate the skin prior to surgery

whenever possible . If a lcohol-containing solut ions must be used, a minimum of the

agent should be used and appl ied l ike paint, no t in a thick, runny coat. The so lu tion

should not be applied in a manner tha t allows dripping, pooling, or wicking. I f

so lut ion drips away from the surgica l s i te , it should be immediate ly blotted with a

gauze sponge before it can soak into any absorbent material . Any soaked materials

should be removed. Daubing of p rep pooled on skin (in the umbil icus or c ricoid

notch) may be needed. Draping should be delayed to al low the solution to fully

vaporize and become d iluted in room air. Th is could take 10 minutes or longer

(1,117). Incise (adhesive, occ lus ive) drapes should be used, if possible, to iso late

head and neck inc is ions from oxygen-enriched atmospheres and from flammable

vapors beneath the drapes (120). I f the incise material does not adhere to the

patient, the prep is l ikely s ti ll wet, and the pat ien t should be redraped once the

prep is ful ly d ry.

Correct Product Choices I t is important to consider the f i re potent ial when choosing equipment. The

anesthesia provider should be aware of the c i rcumstances under which a f i re can

occur and strive to use the product that wi l l have the lowest flammabil ity under

condi tions where i t wi l l be used.

Fi re /laser-res is tan t drapes should be used when exposure to igni tion is poss ib le. It

is important that the drape is tested with the type of ignit ion source that is to be

used. A standard for testing drapes using the CO2 laser has been published (242).

Laser-resistant anesthes ia c i rcui t protectors and drapes are available. These are

aluminized to def lec t the laser beam. There is sti l l the possibi l i ty tha t the beam may

be reflec ted onto a flammable surface and start a f ire (243).

The use of a metall ic Y-piece and elbow wi l l ensure tha t tracheal tube combus tion

wi l l not spread to the anes thesia breathing system (244).

Other Measures A number of other measures may be benef ic ial in preventing a f ire. The tracheal

tube should be withdrawn to above the s i te of surgery during tracheotomy. The use

of posi tive end-expira tory pressure (PEEP) may decrease the risk of a irway f i re in

some cases (245,246). Nurs ing personnel can reduce the combustible load in the

room by removing disposable paper wrappers and covers before the start of the

case. Not only does this reduce the fuel in the room, bu t it a lso reduces the waste

that mus t be disposed as “red bag” wi th i ts higher disposal costs (2).

Minimizing Oxidizer Concentrations The f ire risk can be reduced by remov ing or iso la ting the oxidizer f rom the surgical

area or minimizing i ts concentrat ion.

P.921

During def ibri l lat ion, all sources of oxygen should be comple tely removed f rom the

area around the pat ient.

Oxygen should be adminis te red only when indicated and in no h igher concentration

than is needed (as gu ided by oxygen saturat ion monitoring).

There are several ways of supp ly ing a gas with an oxygen concentra tion greater

than 21% but less than 100% to the pat ient. An oxygen and an ai r f lowmeter can be

connec ted by using a Y-piece (Fig. 32 .7), or a blender can be used. If the machine

has an a ir f lowmeter, a mixture of oxygen in a ir can be set and del ivered to

common gas outlet (247). If the common gas outlet can be accessed, a nasal

cannula can be mated to the outlet by using a 5-mm tracheal tube connector. I f the

common gas outlet cannot be accessed, a ci rc le sys tem can be attached to the

machine, the adjustable pressure l imi ting (APL) va lve c losed, and the selector

swi tch set to BAG. A nasal cannula can then be attached to the Y-piece. This

arrangement may cause the cont inuous positive pressure alarm to be activated. A

forced-air convect ion machine can be used to prov ide a high f low o f ai r around the

patient 's head whi le a nasal cannu la delivers a low f low of 100% oxygen to the

patient.

View Figure

Figure 32.7 Gas from an oxygen flowmeter and an air flowmeter can be connected to produce a gas with an oxygen concentration of less than 100%.

I f possible , the oxygen flow should be discont inued for at leas t 1 minute before

heat-produc ing surg ical instruments are used (248,249). When the heat source is

no longer used and any t issue embers are ext inguished, oxygen administra tion can

be resumed.

During head and neck surgery, a barrier should be established between the oxygen-

enriched atmosphere beneath the drapes and the surgica l field, if possible. Th is

can often be accompl ished wi th an adhesive (incise, occlusive) drape (2,117).

When gas is used to venti late the area under the drapes and prevent CO2

accumulat ion, the lowest acceptab le concentrat ion of oxygen should be used (250).

Forming an open tent wi th the drapes wil l prevent gases from collecting and allow

oxygen to diss ipate (56 ,170). Since oxygen is s light ly heav ier than room air as long

as there is some way for the oxygen to get in and out of a space, i t wi l l tend to f low

toward the f loor. Actively scavenging the space beneath drapes wi th a suct ion

device wil l lower oxygen concentrat ions s ign if icant ly (251). Dev ices that combine

oxygen de livery wi th suction to prevent oxygen bui ldup under the drape have been

described (252,253). A fan can be used to blow the accumulated oxygen away f rom

the pat ient. Direct ing the f low o f nasa l oxygen through a nasal ai rway wil l lower the

oxygen concentration a t the sk in (254).

Hea lth care ins ti tu tions should consider purchasing anesthesia workstat ions tha t

include internal pipel ines and f lowmeters for ai r (248). This makes it easy to switch

patient venti lat ion beneath the drapes f rom oxygen to air before the use of heat-

producing surgical instruments. An ex ternal f lowmeter can be added to an

anesthesia mach ine if piped air is available (Fig. 32.7).

Ni trogen, ai r, o r hel ium may be used to reduce the inspired oxygen concentrat ion to

the lowest level that wi l l provide acceptable patien t oxygenation. Nitrous oxide

supports combus tion and should not be used as the di luent gas (255,256,257).

Helium is a good heat conduc tor and may offe r a s ligh t pro tective effect wi th the

CO2 bu t not the KTP laser (258,259). The use of hel ium may decrease the

resistance of the gases passing through the tracheal tube (260,261).

P.922

Ni trogen insuff lation can s ignif icantly reduce the inc idence of laser-induced

tracheal tube cuff f i res (262). This can be accompl ished by attaching a catheter

covered with a laser-resistant wrap to the tracheal tube. Ni trogen is then insuff lated

through the catheter. This technique should be undertaken wi th caut ion, as a

hypoxic mix ture may possibly be adminis te red.

Al though using lower inspired oxygen concentrat ions wi l l reduce the risk of igni t ion ,

i t wi l l not tota lly prevent it . If there is a s igni ficant leak around the tracheal tube

cuff , the anes thesia prov ider may f i l l the reservoir bag by pushing the oxygen f lush .

This wi l l result in an elevated oxygen concentra tion. A more appropria te response

wou ld be to inc rease the f resh gas f low wh ile main ta ining the same inspired oxygen

concentration or to replace the tracheal tube.

When elec trosurgery is used in the oral cavity , the use of a cu ffed tracheal tube wi l l

minimize the oxidizer level . Leaks around the tube may result in f ires (161,263). I f

an uncuf fed tube mus t be used, an occlusive pharyngeal pack moistened with a

nonf lammable l iquid wi l l reduce the gas f low into the oral cavi ty (264). Insuff la ting

the mouth with gases such as helium, CO2 , or n itrogen wi l l reduce the oxidizer

concentrat ion . The oropharynx can be scavenged wi th separate suct ion.

Pneumatic power tools shou ld be opera ted wi th n itrogen or ai r. Inf latable

tourniquets should be inf la ted wi th ai r or nitrogen but not oxygen or ni trous oxide

(56,79,265). Ni trous ox ide should not be used for insuff la ting the abdominal cav ity

during laparoscopy (266,267,268).

Preventing Pressure Regulator Fires Fires in regulators can be minimized by not al lowing them to become contaminated

wi th oi l , grease, or other combus tible materials o r c leaned with a f lammable agent

such as alcohol (122,269). Before a regula tor is f it ted to a cyl inder, partic les should

be cleared f rom the cylinder ou tlet by remov ing the protect ive cap or seal and

s lowly and briefly opening (“cracking”) the valve wi th the port pointed away f rom

the user and any other persons . A cyl inder valve should always be opened slowly to

al low heat to be dissipated as the gas is recompressed. Consideration should be

given to rep lacing aluminum regulators with those made f rom brass. Rules for

handling cylinders are discussed in Chapter 1.

Fire Plan Each heal th care fac il i ty should formulate a plan for deal ing quickly wi th an

operating room f ire (1 ,6,56,58,127,171,202,206,240,270,271,272,273,274). Surgica l

teams should be trained in and prac tice dri l ls for keeping minor f i res f rom gett ing

out of control and manag ing f ires that do get out of control . They should know the

locat ion and proper use of a larm boxes, gas shut-o ff valves, and fi re extinguishers.

Evacuation procedures should be reviewed periodically.

I t is important to immediately cal l for help, decide who is going to f ight the fi re ,

when i t wi l l be appropriate to leave the room, and how to care for the pat ient during

the f i re .

Burning material on or in the pat ient of ten can be ex tingu ished effec tively and

safely by hand or wi th a nonflammable liqu id (e .g ., saline f rom a bas in on the scrub

table) or wet c loth. With laser surgery in the a irway, a t least two syringes f il led with

sodium chloride should a lways be available to ex tingu ish the f ire (275). Larger

areas can be smothered with a blanket or wet towe l. Fi re b lankets are not

recommended (8 ,276). If the drape is water-resis tant, water poured on i t wi l l be

ineffective (277). The f ire wi l l burn on the unders ide. The only effect ive technique

is to pul l the burning materials from the patient.

Fires tha t involve electrica l components are best handled by disconnect ing the

device from i ts electric power supply and removing the dev ice f rom the room.

The f low o f oxygen, n itrous oxide, or ai r to any involved equipment should be

turned OFF, if this can be accompl ished wi thout injury to personnel or the pat ient.

Most pat ients can tolerate short periods of oxygen deprivation . The patient should

be venti lated with ai r and intravenous agents used to mainta in anesthesia unt i l all

possible sources of f i re or reigni t ion are suppressed. It may be necessary to c lose

the oxygen and ni trous oxide shut-off valves to the affected room (58,278,279).

Cyl inder valves should be c losed and all cylinders removed from the area. If

supplemental oxygen is necessary to oxygenate the pat ient, the patient should be

moved to the nearest area where oxygen can be safely used (56).

I f an ai rway f i re occurs, the breath ing system shou ld be disconnected from the

tracheal tube to stop gas f low. If this s i te is not easi ly accessible or the operator

may be burned in the process o f disconnecting the tube, the breathing system can

be disconnected at the absorber (280).

The trachea l tube should no t be unduly secured so that i t can be removed quick ly.

Al though immediate removal of the tracheal tube and protective devices is usua lly

recommended wi th an ai rway f i re , th is may not always be the bes t course of act ion

(148,281). The risk:benefi t ratio of extubat ion needs to be considered. A stylet or

ai rway exchange catheter can be used to subst i tute a new tube the burned tube for.

I f the decis ion to remove the tube has been made, sal ine-f i lled cuffs on plast ic

tubes can be def la ted faster by aspira ting the f luid than by cutt ing the p ilot tube

(91). With red rubber tubes, unclamping the pilot tube is fastest.

P.923

The airway should be re-establ ished and the patient vent ilated wi th ai r unt i l i t is

certain that nothing remains burning . Then, 100% oxygen should be administered.

A search for f ragments tha t remain in the trachea and assessment of damage to the

larynx and tracheobronchial tree shou ld be made.

Extinguishing a Fire Although mos t operat ing rooms have a sprink ler system, sprinklers are frequently

not effec tive wi th operat ing room f ires (206). This is because the sprink le rs are

rare ly located over the operating room table and are heat ac tivated. Operating room

f ires tend to give off a lot of smoke and tox ic produc ts bu t not necessarily enough

heat to immediately activate the sprinklers . Therefore, i t is important the all

operating room personnel are fami liar wi th f i re extinguishers .

Location Strategically placed portable fi re ext inguishers are an important part of any f ire

protect ion program (1 ,282,283). They shou ld be located in conspicuous, readi ly

access ib le loca tions that a re known by al l operat ing room staff (F ig. 32.8).

Hands-on experience with f i re ex tingu ishers is essent ial to a f ire safety education

program (284). Sett ing up real f i res in a park ing lot and prov iding practice wi th

ex tinguishers can have valuable payoffs during an actual f i re.

Use Use of any f ire extinguisher can be recalled by the acronym, pass . Pul l the p in. Aim

the horn or nozzle a t the base of the f ire. Squeeze the trigger o r handle wh ile

holding the ext inguisher upright. Sweep the ext inguisher from side to side, covering

the area of the f i re. Ins truct ions are found on the f ire ext inguisher (F ig. 32.9). The

pin and hose are shown in F igures 32.10 and 32.11.

Choice of Extinguisher The choice of ex tingu isher should be based on the pred ic ted f ire risk for that

locat ion (282,285,286). Fi res are c lassif ied according to their fuel. Class A f i res

include small masses of ordinary combus tibles—-c lo th, paper, and most plas tics.

Fi res involv ing f lammable l iqu ids or grease are in c lass B. Electrical ly energized

f ires are c lass C. Two standard sets of f i re c lass labels exist: a tradi tional le ttering

system and a newer universal pictograph system tha t does not require the user to

be famil iar wi th the alphabet f ire c lass codes (F ig. 32.9).

View Figure

Figure 32.8 Fire extinguishers should be in conspicuous locations, well known to all operating room staff.

Halogenated Agents Halogenated ext inguishing agents are l iquids that upon discharge under relatively

high pressure surround a f ire with a combinat ion of vapor and l iquid droplets (mist).

Halogenated agents are ideal ly sui ted for f ighting f ires involv ing electronic

equipment and f i res in areas where electrical or electronic equipment is nearby.

Halon was the agent of choice fo r operating room f ires fo r many years (202). I t has

the abi li ty to penetrate burning material and to smother and cool the chemical

react ion of the fi re . While usual ly marked for c lass B and C f ires, i t is also effec tive

against class A f ires found in the opera ting room. Unfortunately, because of

environmental concerns, halon ext inguishers are no longer avai lable . If present in

an opera ting room, they may be used but cannot be recharged. The National Fi re

Protect ion Association requires that nonrechargeable

P.924

P.925

ex tinguishers be removed from serv ice 12 years from the date of manufacture

(287). In response to the prohibi tions on the use of ha lon , a number of

ex tinguishing agents have been developed to rep lace it (282,288,289) (Fig. 32 .12).

View Figure

Figure 32.9 The instructions for using the fire extinguisher are printed on the extinguisher.

View Figure

Figure 32.10 The pin that needs to be pulled to activate the extinguisher is in the handle at the top of the extinguisher. The hose is normally attached to the side of the extinguisher. This figure also shows the pressure gauge, which indicates that the extinguisher is usable, and the monthly checkout list, which shows that the extinguisher has been checked, the extinguisher and hose is undamaged, and the pressure is in the use range.

View Figure

Figure 32.11 Close-up of pin and pressure gauge at top of extinguisher.

View Figure

Figure 32.12 There are several substitutes for halon available.

Carbon Dioxide CO2 ex tinguishers emit a fog of CO2 gas with l iquid and solid partic les that rapidly

vaporize to cool and smother a f i re. Although they carry a B and C rat ing, they can

be used to ex tinguish small class A fi res. CO2 f ire ext inguishers are heav ier and

bulk ier than halon-type devices . CO2 ext inguishers do not leave a residue but do

emit l iquid and sol id components that rap idly vaporize . This causes rapid cool ing

that might cause f reezing i f i t comes into contact wi th exposed skin or internal

organs (283,290).

Water Pressurized-water ext inguishers are chiefly ef fec tive against c lass A f ires . They are

more dif f icult to use than CO2 and halon-type extinguishers. To put ou t fi res on

water-repel lant d rapes, a f inger mus t be placed over the nozzle to produce a f ine

spray. A s tream or splash of water could fan the f i re (1). A non-magnetic water mis t

ex tinguisher is avai lable for use in the MRI unit magnet room.

View Figure

Figure 32.13 All operating room personnel must know where the fire alarm is located. The instructions for activating it are printed on the fire alarm.

I f the f i re starts to get out of control , the f i re alarm (Fig . 32.13) should be sounded,

and the f ire department should be not if ied to give f iref igh ters ample time to respond

(1). F iref igh ters would ra ther f ind that a small f i re has been ext inguished than see

smoke bil lowing out of a bui ld ing—especially in a health care faci l i ty .

The patient and staff should be evacuated if the f i re and smoke are excessive

(210). In some s i tua tions , however, it may be more hazardous to move the pat ient

than to a ttempt to ext inguish or contain the f i re. The attending physician must

determine which would present the lesser hazard .

The doors should be c losed to contain the smoke and isola te the f i re . Wet sheets or

towels can be stuffed under the doors to reduce the spread of smoke f rom the

room.

Whatever steps are necessary should be taken to protect or evacuate pat ients in

adjacent a reas.

Af ter the f ire, involved materials and dev ices should remain in place for the f ire

department invest igators . Notes should be made as soon as poss ible af te r the f ire

and an inc ident report comple ted.

P.926

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P.929

Questions For the fol lowing quest ions, select the correct answer

1. The percentage of operating room fires that result in patient injury is A. 10% to 20%

B. 20% to 30%

C. 30% to 40%

D. 40% to 50%

E. 50% to 75%

View Answer2. Which of the following is most commonly involved in operating room fires? A. Lasers

B. Elec trosurgery equipment

C. Argon beam coagula tors

D. Fiber-opt ic i l luminat ion systems

E. Def ibri l la tors

View Answer3. Which type of tracheal tube will cause the most severe damage to the tracheobronchia l tree if i t catches fire?

A. Red rubber

B. Si l icone

C. Laser resistant

D. PVC

View Answer4. In order to filter out potentia l airborne contaminants, the surgical mask must be able to fi lter particles of which size? A. 30 microns

B. 3 microns

C. 0.3 mic rons

D. 0. 03 mic rons

E. 0.003 microns

View Answer5. Wet cotton gauze will protect the shaft and cuff of a tube best w ith which laser?

A. Argon

B. KTP

C. Nd-YAG

D. CO2

View Answer6. A clear, unmarked PVC tube is relatively resistant to be used with which laser?

A. Argon

B. KTP

C. Nd-YAG

D. CO2

View AnswerFor the following quest ions, answer

• i f A, B, and C are correct

• i f A and C are correct

• i f B and D are correct

• i f D is correct

• i f A, B, C, and D are correct.

7. The factors necessary to start a fire include

A. Igni tion source

B. Fuel

C. Oxidizers

D. Lasers

View Answer8. The characteristics of laser l ight inc lude

A. Coherency

B. Monochromatic i ty

C. Coll imated

D. Ul trav iolen t

View Answer9. Which factors determine the ignition risk with a laser? A. Laser medium being used

B. How the laser is focused

C. Class of laser

D. Exposure t ime

View Answer10. Common errors when using e lectrosurgical equipment include A. Improper p lacement of dispers ive elec trode

B. Insuff ic ient dispers ive elec trode contact

C. Faulty re turn electrode

D. Insu lat ing the patien t from the opera ting room table

View Answer11. Measures to minimize the risk of a tracheal tube fire from a laser include A. Fil l ing the cuf f wi th saline

B. Minimiz ing the laser power densi ty and durat ion

C. Us ing a laser-resis tan t tube

D. Us ing low oxygen concentrations in the inspired gas

View Answer12. Concerning laser-induced tracheal tube fires A. The tube may be contacted by a ref lec ted laser beam

B. The cuff is laser-resis tant

C. Cotton sponges that p rotect the cuff may dry ou t

D. Use of an uncuffed tube increases the risk

View Answer13. Which laser(s) is (are) l ikely to damage the retina?

A. KTP

B. Nd-YAG

C. Argon

D. CO2

View Answer14. Which laser(s) is (are) l ikely to damage only the cornea? A. KTP

B. Nd-YAG

C. Argon

D. CO2

View Answer