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Prepared by the Healthcare Insurance Reciprocal of Canada (HIROC)

Involved Procedure

  • Laparoscopic ovarian cystectomy and myomectomy1
  • Double lung transplantation2
  • Post-operative care4,17
  • Transesophageal echocardiography5
  • Haemorrhoidectomy6
  • Coronary artery bypass grafting6
  • Orthopaedic surgery6,8
  • Caesarean section7,19
  • Cervicomedullary exploration and decompression9
  • Transillumination10
  • Excision of papilloma on upper eyelid11
  • Adhesiolysis of a digital flexion12
  • Bunionectomy17

Type of Fire/Burn

  • Chemical1,5,10,22
  • Thermal4,7,9,10,11,12,14,15,16,17,20

Sources/Causes and Contributing Factors Associated With Fire/Burn

  • Alcohol1,3,10,12,13,19,22
  • Electro-surgical equipment1,2,6,9,11,13,14,15,16,19
  • Drapes1,8
  • Sponge2
  • Endotracheal tube2
  • Oxygen2,13
  • Heat Pack4
  • Anaesthetic4,17
  • Equipment/environmental disinfectant5,10
  • Gas system failure7
  • Pulse lavage system8
  • Fibre optic light10
  • Cosmetic products11
  • Casting17
  • Pulse oximeter20
  • Tourniquet22

Recommended Mitigation Strategies

Staff Education

  • All personnel working in the operating room should have an annual fire education complemented with fire drills.18

Skin Preparation Solutions

  • Avoid the use of 10 per cent povidone-iodine in alcohol solution, thimerosal in 50 per cent alcohol solution, 70 per cent chlorhexidine hand rub, and methanol or ethanol for skin cleaning in the operative field.1
  • The use of undiluted isopropyl alcohol should be avoided in the care of neonatal patients; when used, isopropyl alcohol should not be left on the skin of a neonate for a prolonged period of time.10
  • Alcohol-based skin preparation solutions should be applied using a purpose built applicator that allows the dissipation of vapour, minimizes pooling and excess application of solution, and controls the flow of solution.3
  • When alcohol-based skin preparations have been used, wait for at least three minutes for the solution to try and wipe the skin with a cotton swab before draping the operative field.1,3,6,12,16,19
  • Remove any materials (e.g. swabs), drapes or gowns that have been soaked with alcohol-based skin preparations prior to commencing surgical procedures.3,8,12,19
  • Use water-soluble lubricants (e.g. K-Y Jelly) as opposed to petroleum-based ointments.19

Disinfectants

  • Adherence to disinfection procedures and strict compliance with equipment-related technical information instructions.5
  • The use of benzethonium chloride should be avoided in neonatal care environments.10
  • When using disinfectant products within neonatal care environments, healthcare workers should allow adequate time for drying and appropriate ventilation of any fumes.10

Pre-Operative Preparation

  • Surgical team communication of fire risk and prevention during the pre-surgical checklist, as well as intraoperatively (e.g. timing of the use of electrocautery with discontinuing supplemental oxygen).13,18,21
  • Drape the patient with a clear plastic adhesive drape to prevent the collection of flammable vapours beneath the drapes.1,6,14
  • Drapes fabricated from cellulose should be avoided.8
  • During ophthalmic procedures involving electro-surgical equipment, measures should be taken to ensure a make-up free ophthalmic field.11

Intraoperative Period

  • When a fire breaks out in the OR, extinguish it using fire extinguishers; surgeons must know the location of a fire extinguisher and all surgeons and members of the operating team should be well-informed regarding the fire safety procotol.1,2,8,13,16,18,21
  • Sources of ignition (e.g. electrosurgical units, lasers, fiberoptic light sources, defibrillators) must be readily identified and controlled to optimize fire safety.8,13,19,21
  • Surgical staff should maintain a continuous awareness about the presence and removal of potential fuels (e.g. prepping agents, dressings, linen, equipment, bodily tissues).19,21
  • Avoid dry sponges when cauterizing near the airway.2

Post-Operative Period

  • When providing care to post-operative, casted or splinted patients, any complaint of pain should be thoroughly investigated, with special consideration given to avoiding thermal injuries – temperature measurements of skin should be done prior to the administration of opioids and additional touch-up nerve blocks should not be done without a thorough evaluation of the plaster cast and underlying skin.17

Oxygen Precautions

  • Lowest percentage of FiO2 should be used while operating on the airway.2,13,19
  • If an open O2 source is used during the course of a head and neck procedure, the oxygen concentration should be less than 30 per cent.16
  • Use a sealed gas delivery device, such as an endotracheal tube or laryngeal mask airway, if deep sedation is required during a procedure.13
  • Ensure that there is no air leak from the endotracheal tube in the operative field.2,13
  • Prevent oxygen from collecting under drapes by creating a venting system using IV poles or other attachments to tent drapes.13
  • Colour coding of gas cylinders.7
  • Capnography or gas analysis should be employed during procedures involving anaesthesia.7

Procedures Involving Electro-Surgical Instruments

Grounding Pads

  • During procedures involving electro-surgical equipment, ensure that the grounding pad is adequately applied with firm contact to the skin over an adequate surface area; non-adhesive grounding pads should be secured with bandage; and the position of all pad should be re-checked if the patient's position is changed intra-operatively.6,14,15
  • Grounds pads should not be placed on the following areas: areas with little muscle, such as bony prominences (e.g. elbow joint, lower forearm); areas with a lot of body hair (e.g. hairy forearm, unshaved thigh); areas with soft tissue (e.g. lower legs).14,15
  • Placement of grounding pads should take into account existing indwelling hardware; avoid grounding pad placement immediately adjacent to or overlying indwelling hardware.9
  • During craniofacial procedures involving electro-surgical equipment, the grounding pad (i.e. indifferent electrode) should ideally be placed on the following locations – the mid-sternum, thoracic spine at T6, lateral chest wall mid-way between the axilla and 12th rib, or lower anterior abdominal quadrant; placement at the sites listed previously may reduce the risk of alternate-site burns – indifferent electrode placement on the thigh and forearm should be avoided.9

Electro-Surgical Instrument

  • When using electro-surgical equipment, minimize the time it is used and use non-flammable equipment.1,2,19
  • Use of bipolar electrocautery to minimize the amount of leakage of current.2,6,19
  • Effort should be taken to limit the use of electro-surgical equipment at high currents for prolonged periods of time without interruption.15
  • Avoid close proximity of an activated electro-surgical device on tissue immediately adjacent to vulnerable tissue such as bowel, ureter, and blood vessels.16
  • Surgical teams should inspect electro-surgical instruments prior to procedures for any defects in insulation, with particular attention to the active electrode.16
  • Employ the use of porosity detectors in sterile processing before electrosurgical instrument sterilization to detect insulation failure.16
  • Laparoscopic ports should be placed so that the shafts of electro-surgical instruments do not lie adjacent to vulnerable tissue.16
  • Avoid contact of monopolar active electrodes with other conductive instruments or materials while energy is being delivered to the active electrode.16
  • Avoid close proximity of monopolar active electrodes to instruments that do not have insulation along their shafts.16
  • Ensure that laparoscopic port placement does not allow the shafts of instruments to touch vulnerable tissues.16
  • Avoid the use of combined (or "hybrid") metal and plastic laparoscopic trocars when using the monopolar instruments (e.g. "bovie" instrument).16
  • Use alternative energy-based surgical devices instead of the monopolar "bovie" instrument, such as traditional bipolar, ultrasonic instruments, and advanced bipolar devices.16
  • Avoid inadvertent activation injuries by: (1) utilizing a "bovie" pencil holder, (2) avoid placing energy-based devices on drapes adjacent to where surgical team members might lean, and (3) have instrument activation tones loud enough to be heard by the surgical team.16
  • Avoid electro-surgical instrument interaction with other electronic devices by: (1) decreasing generator power setting, (2) using cut mode in preference to coagulation mode, (3) employing the desiccation technique rather than the fulguration technique, and (4) orienting the active electrode cord from the patient's feet to avoid proximity of the active electrode cord to electronic devices.16
  • Activate the electrosurgical unit only when the tip is in view and deactivate it before it leaves the surgical site.16
  • Electro-surgical "bovie" pencils or laparascopic devices should be in holsters when not in use and rubber sleeves should never be used over electro-surgical equipment.16,19

Pulse Oximeters

  • Standardize the makes and models of organizational pulse oximeters to avoid mixing of equipment.20
  • Label pulse oximeter monitors and sensors with warnings regarding incompatibility; avoid reuse of disposable probes.20
  • Engage in regular inspection of pulse oximetry equipment to exclude damaged sensors or protective covers, defective insulation, or exposed electronics.20
  • When utilizing pulse oximetry, engage in frequent assessment of monitor sites; special attention should be paid to high-risk patient groups, such as neonates, the elderly, and the critically unwell.20
  • Engage in frequent relocation of pulse oximetry probes during prolonged use and review the underlying skin.20
  • Avoid taping pulse oximetry probes to an extremity; alternate extremities used.20
  • Engage in regular review of insensate limbs during anaesthesia where prolonged pulse oximetry may be used.20

Tourniquets

  • When applying a tourniquet, a waterproof barrier is recommended to isolate the tourniquet to prevent pooling and impregnation of the padding.22
  • When a tourniquet is applied, engage in routine inspection of the tourniquet after surgery, particularly after a spinal anesthetic, where sensation may be absent for several hours after surgery.22

Heat Packs

  • Heat packs are not to be heated in microwaves and should only be warmed in warm storage cabinets (e.g. warm blanket storage units or fluid warming units).4
  • Caution should be employed when applying a heat pack to potentially anesthetised skin.4

Fiber Optic Light Sources

  • When utilizing fiber optic light sources in the care of neonatal patients, a filter to block out light with a wavelength less than 570nm should be employed.10

Transillumination

  • Caution is advised when employing transillumination in the care of neonatal patients.10

Works Cited

  1. Chung S, Lee H, Him T, Kim J. A patient who was burned in the operative field: a case report. Turkish Journal of Trauma & Emergency Surgery. 2012; 18 (3): 274-276. doi: 10.5505/tjtes.2012.49225.
  2. Bansal A, Bhama JK, Varga JM, Toyoda Y. Airway fire during double-lung transplantation. Interactive Cardiovascular Thorac Surgery. 2013; 17(6): 1059-1060. doi: 10.1093/icvts/ivt357.
  3. Rocos B, Donaldson LJ. Alcohol skin preparation causes surgical fires. Annals of The Royal College of Surgeons of England. 2012; 94 (2): 87-89. doi: 10.1308/003588412X13171221501221.
  4. Walker SR. Anesthetic burns: a burn injury due to combination of local anaesthetic and heat pack. Archives of Clinical Experimental Surgery. 2012; 1 (2): 127-128. doi: 10.5455/aces.20120206110836
  5. Venticinque SG, Kashyap VS, O'Connell RJ. Chemical burn injury secondary to intraoperative transesophageal echocardiography. Anesthesia & Analgesia Journal. 2003; 97 (5): 1260-1261.
  6. Saaiq M, Zaib S, Ahmad S. Electrocautery burns: Experience with three cases and review of literature. Annals of Burns and Fire Disasters. 2012; 25(4). 203-206.
  7. Aghdashi MM, Abbasivash E, Hassani E, Pirnejad H. Fatal respiratory thermal injury following accidental administration of carbon dioxide using the circle system for a cesarean delivery. International Journal of Obstetric Anesthesia. 2009; 18 (4): 400-402. doi: 10.1016/j.ijoa.2009.02.020.
  8. Rapp C, Gaines R. Fire in the operating room: A previously unreported ignition source. The American Journal of Orthopedics. 2012; 41 (8): 378-379.
  9. Mundinger GS, Rozen SM, Carson D, Greenberg RS, Redett RJ. Full-thickness forehead burn over indwelling titanium hardware resulting from an aberrant intraoperative electrocautery circuit. Eplasty. 2007; 8: e1.
  10. Lai TT, Bearer CF. Iatrogenic environmental hazards in the neonatal intensive care unit. Clinics in Perinatology. 2008; 35 (1). 163-168. doi: 10.1016/j.clp.2007.11.003.
  11. Raqqad N, Liu C. Mascara: A cause of thermal burn after cautery for eye lid lesion excision; A case report. Journal of Clinical & Experimental Opthamology. 2010; 1: 105. doi:10.4172/2155-9570.1000105. 
  12. Kim JB, Jung HJ, Im KS. Operating room fire using an alcohol-based skin preparation but without electrocautery. Canadian Journal of Anesthesia. 2013; 60 (4): 413-414. doi: 10.1007/s12630-013-9891-0.
  13. Mehta SP, Bhananker SM, Posner KL, Domino KB. Operating room fires: A closed claims analysis. Anesthesiology. 2013; 118 (5): 1133-1139. doi: 10.1097/ALN.0b013e31828afa7b.
  14. Ellsworth WA, Iverson RE. Patient safety in the operating room. Seminars in Plastic Surgery. 2006; 20 (4): 214-218. 
  15. Sabzi F, Niazi M, Ahmadi A. Rare case-series of electrocautery burn following off-pump coronary artery bypass grafting. Journal of Injury and Violence Research. 2014; 6 (1): 44-49. doi: 10.5249/jivr.v6i1.456. 
  16. Jones DB, Brunt LM, Feldman LS, Mikami DJ, Robinson TN, Jones SB. Safe energy use in the operating room. Current Problems in Surgery. 2015; 52 (11): 447-468. doi: 10.1067/j.cpsurg.2015.08.004. 
  17. Boyle PK, Badal JJ, Boeve JW. Severe cast burn after bunionectomy in a patient who received peripheral nerve blocks for postoperative analgesia. Local and Regional Anesthesia. 2011; 4: 11-13. doi: 10.2147/LRA.S14073.
  18. Abdulrasheed I, Lawal AM, Eneye AM. Surgical fires: An ongoing intra-operative challenge. Archives of International Surgery. 2013; 3 (1): 1-5.
  19. Goel L, Murdeshwar G, Bharne S. Surgical site fire during cesarean section. Journal of Obstetric Anaesthesia and Critical Care. 2013; 3 (1): 40-43. doi:10.4103/2249-4472.114293. 
  20. Bunker DLJ, Kumar R, Martin A, Pegg SP. Thermal injuries caused by medical instruments: A case report of burns caused by a pulse oximeter. Journal of Burn Care & Research. 2014; 35 (2): e132-134. doi: 10.1097/BCR.0b013e31828a8d5a.
  21. Patti MG. Thinking in three's: Changing surgical patient safety practices in the complex modern operating room. World Journal of Gastroenterology. 2012; 18 (46): 6712-6719. doi: 10.3748/wjg.v18.i46.6712. 
  22. Ellanti P, Hurson C. Tourniquet-associated povidone-iodine-induced chemical burns. BMJ Case Reports. 2015; doi: 10.1136/bcr-2014-208967. 

Hempel S, Maggard-Gibbons M, Nguyen D.K., et al. Wrong-site surgery, retained surgical items, and surgical fires: A systemic review of surgical never events. JAMA Surgery. 2015; 150 (8): 796-805. doi: 10.1001/jamasurg.2015.0301.