The surgery seemed routine. The 62-year-old patient was prepped and draped according to protocol. The hair around his soon-to-be tracheotomy incision was shaved. Duraprep surgical solution was applied and allowed to dry for at least three minutes. But when the electrocautery tool was activated, “there was an immediate, audible ‘whoosh,’” wrote Mark Wax, MD, professor of otolaryngology/head and neck surgery at Oregon Health and Sciences University in an article about a surgery gone awry (Head Neck. 2006;28(7):649-652).
Explore this issue:April 2012
The flash fire was out almost as soon as it started, but the patient suffered first- and second-degree burns to his neck and shoulder, and Dr. Wax was motivated to “look back and try and define what were the events that led up to the fire,” he said.
Ultimately, Dr. Wax and his team concluded that the patient’s “very hairy body habitus” may have contributed to the fire by soaking up some of the Duraprep. In a 2006 Head and Neck article, he recommended increased pre-op shaving and/or the avoidance of Duraprep when working with particularly hairy patients (2006;28(7):649-652). But today, Dr. Wax stresses that “it’s never just one thing. In the majority of cases like this, physicians are following procedures, but there may be something that’s unaccounted for. Suddenly, one more grain of sand is added to the pile and the whole thing collapses.”
While surgical fires are exceedingly rare—the ECRI Institute estimates that 550 to 650 surgical fires occur annually—they can have devastating consequences. That’s why the U.S. Food and Drug Administration (FDA) and a coalition of health care providers recently launched an initiative to help physicians manage the risk of surgical fire.
The Preventing Surgical Fires Initiative is designed to “increase awareness of surgical fires, to disseminate surgical fire prevention tools and to promote the adoption of risk reduction practices through the healthcare community,” said Cindi Fitzpatrick, BSN, Safe Use Initiative Project Lead for Preventing Surgical Fires.
A High-Risk Field
The risk of a surgical fire is higher than normal during most head and neck surgeries, simply because the elements needed to start and sustain a fire are all within close proximity.
“As an otolaryngologist, you have to be particularly concerned because when you are working around the head and neck area, your oxidizer is very close by, you are using an ignition source and there are fuels all around,” said Soham Roy, MD, an associate professor of otorhinolaryngology and director of pediatric otolaryngology at the University of Texas Medical School at Houston, where he is also a member of the Preventing Surgical Fires Committee.
Certain procedures are more likely to result in a fire than others. According to a survey conducted by Dr. Roy and Lee Smith, MD, a pediatric otolaryngologist at North Shore Long Island Jewish Health System, surgical fires in otolaryngology are most commonly reported during endoscopic airway surgery, oropharyngeal surgery, cutaneous or transcutaneous surgery and tracheostomy (Am J Otolaryngol. 2011;32(2):109-114).
Otolaryngologists can minimize the risk of surgical fires by tweaking certain surgical elements:
Oxygen supplementation. Dr. Wax’s patient, who was undergoing an awake tracheotomy, was receiving high flow oxygen via face mask at the time of the flash fire, despite the fact that the patient’s oxygen saturation levels were well within normal limits during the immediate pre-op period. In his Head and Neck article, Dr. Wax wrote, “We would recommend, if tolerated, the delivery of oxygen by nasal cannula either into the nasal or oral cavity … Oxygen delivery should be titrated to the patient’s oxygenation status, and the unnecessary use of high flow oxygen would be avoided” (2006;28(7):649-652).
A task force of the American Society of Anesthesiologists recommends keeping the fraction of inspired oxygen (FiO2) as low as possible and basing decisions regarding O2 delivery on patients’ actual oxygenation status as measured by pulse oximetry (Anesthesiology. 2008;108:786-801). The ECRI Institute recommends that supplemental O2 be kept at or under 30 percent when performing head, face, neck or upper chest surgery. A metal suction cannula should be used to scavenge leaking oxygen and nitrous oxide from surgical sites (Health Devices. 2009;38(10):319).
Surgical tools. Monopolar electrosurgical units and lasers are involved in over 90 percent of surgical fires (Am J Otolaryngol. 2011:32(2):109-114). The ECRI Institute recommends activation of such units only when the tip is in view and needed at the surgical site (Health Devices. 2009;38(10):319). Surgeons should refrain from activating an electrical or laser device when oxygen is being increased, and should consider blunt dissection over electrocautery in the “rare case” of unavoidable oxygen delivery to the surgical field (Head Neck. 2006;28(7):649-652). Whenever practical, consider radiofrequency ablation. In an experiment conducted by Dr. Roy, radiofrequency ablation wands were found incapable of igniting a fire, even in the presence of 100 percent oxygen (Am J Otolaryngol. 2010;31(5):356-359).
Surgical materials. Polypropylene drapes are much less likely to catch fire than cellulose-based drapes (Am J Otolaryngol. 2011:32(2):109-114). Keep light cords away from drapes; while they may not ignite polypropylene drapes, the cords still get quite hot and could burn a patient (Am J Otolaryngol. 2011:32 (2):109-114). Cuffed polyvinyl chloride endotracheal tubes (ETTs) may help decrease the risk of fire. Polyvinyl ETTs have a low flammability index; cuffed tubes prevent oxygen leakage into the surgical area (Int J Pediatr Otorhinolaryngol. 2008;72(7):1013-1021).
“A cuffed endotracheal tube is passed below where you’re working and prevents oxygen from coming up the trachea into your field,” said Gresham Richter, MD, associate professor of pediatric otolaryngology at the University of Arkansas for Medical Sciences in Little Rock. “Theoretically, you could burn something in the oral cavity with electrocautery without risk of fire, because there’s no fuel source to ignite a fire.” Use saline-moistened instead of dry sponges in the surgical field when necessary (Health Devices. 2009;38(10):319).
A planned defense. Coat patients’ head hair and facial hair with water-soluble lubricating jelly to render it non-flammable (Health Devices. 2009;38(10):319). Keep saline on hand, in case it’s needed to douse a surgical fire.
Communication. “Coordination within the team is absolutely critical,” Dr. Roy said. “Before any type of procedure takes place, have a surgical timeout. Confirm the site and procedure and discuss any safety concerns. Talk about the fire risks and devise a plan. You want an open forum for communication so you can effectively work together as a team to minimize the involved risks.”